Meaningful feedback through a sociocultural lens

Understanding students' feedback use in medical progress testing: A qualitative interview study

BACKGROUND

Active engagement with feedback is crucial for feedback to be effective and improve students' learning and achievement. Medical students are provided feedback on their development in the progress test (PT), which has been implemented in various medical curricula, although its format, integration and feedback differ across institutions. Existing research on engagement with feedback in the context of PT is not sufficient to make a definitive judgement on what works and which barriers exist. Therefore, we conducted an interview study to explore students' feedback use in medical progress testing.

METHODS

All Dutch medical students participate in a national, curriculum-independent PT four times a year. This mandatory test, composed of multiple-choice questions, provides students with written feedback on their scores. Furthermore, an answer key is available to review their answers. Semi-structured interviews were conducted with 21 preclinical and clinical medical students who participated in the PT. Template analysis was performed on the qualitative data using a priori themes based on previous research on feedback use.

RESULTS

Template analysis revealed that students faced challenges in crucial internal psychological processes that impact feedback use, including 'awareness', 'cognizance', 'agency' and 'volition'. Factors such as stakes, available time, feedback timing and feedback presentation contributed to these difficulties, ultimately hindering feedback use. Notably, feedback engagement was higher during clinical rotations, and students were interested in the feedback when seeking insights into their performance level and career perspectives.

CONCLUSION

Our study enhanced the understanding of students' feedback utilisation in medical progress testing by identifying key processes and factors that impact feedback use. By recognising and addressing barriers in feedback use, we can improve both student and teacher feedback literacy, thereby transforming the PT into a more valuable learning tool.

How is feedback perceived by Brazilian students and faculty from a nursing school?

AIM

This study aims to explore the perceptions of feedback among undergraduate students and faculty members at a Brazilian private nursing school.

BACKGROUND

Feedback plays a crucial role in the socioemotional development of learners, with its interpretation varying across different sociocultural contexts. Student evaluations frequently express dissatisfaction regarding both the quality and quantity of feedback received. Conversely, delivering feedback poses a challenge for faculty, requiring the establishment of an empathetic connection that fosters trust and credibility. Brazil, being a developing country characterized by social disparities and economic challenges, presents a unique backdrop for examining feedback dynamics.

DESIGN

Qualitative research, employing Inductive Content Analysis, was used to understand feedback perceptions in Brazilian nursing education. Symbolic interactionism was adopted as methodological framework and guided data interpretation.

METHODS

We carried out five virtual focus groups composed of a group of teachers (n=5) and four of students (n=34). Semi-structured interviews guided data collection. The recorded sessions were subsequently analyzed to identify key themes and codes. Symbolic interactionism was employed as a framework to derive meaning from qualitative data.

RESULTS

Content analysis generated two categories that reveal the perception of teachers and students in the feedback process. The first, called "Feedback in Education: Sociocultural Influences for Students and Teachers", expresses the beliefs and interpretations of students and teachers within the shared feedback environment. The second called "Challenging resonance, transformative construction: Navigating the dualities of feedback for teachers and students", which elucidated how relational dynamics shape behaviors and attitudes, promoting the development of social skills and learning. Faculty's previous feedback experiences significantly influence their self-perception and behavior with students. As a result of the resonance of these past interactions, we recognize that the teaching self also plays a crucial role in the quality and perception of feedback. Furthermore, students construct social reality with similar beliefs and values, they believe in the learning potential generated by feedback. Our findings also corroborate that perceptions of feedback are deeply influenced by the sociocultural context and the narratives corroborate previous findings indicating that, in Brazil, honest feedback can be implicitly perceived as criticism rather than an opportunity for growth.

CONCLUSIONS

Faculty members often draw on their past experiences when providing feedback, highlighting the adaptive nature of feedback interactions. Additionally, the feedback process is consistently influenced by the commitment to maintaining positive relationships with students. Students recognize the constructive dimension of feedback as a valuable tool for learning and personal growth.

Learning in the workplace: Development of a simple language statement assessment tool that supports second-level nurse practice

AIM

To focus learning through clarity of the enrolled nurse (EN) role (a second tier nurse position) through development of a user-friendly workplace performance assessment tool commensurate with EN standards for practice.

BACKGROUND

Internationally, the nursing workforce comprises regulated and unregulated staff. In Australia, similar to other western countries, there are two tiers of regulated workforce, namely Registered Nurses (RNs) and Enrolled Nurses (ENs). Differences in RN and EN standards based on the education preparation are not always clearly differentiated in workplace practice. Roles are often seen as interchangeable: Improved clarity of both regulated and unregulated roles, when numbers of healthcare workers are burgeoning, assists performance assessment that guides further learning and safe practice.

DESIGN

Two phase sequential, non-experimental design.

METHODS

Phase one used focus groups (n=48), expert reference panel (n=8) and end-users (n=16) to develop simple language statements. Phase two involved field testing of the statements.

FINDINGS

A 30-item, criterion-based workplace performance tool was developed. Principal component analysis of completed tools indicated work could be organised around three key areas of practice, namely, higher order thinking and problem solving, routine daily activities of care and personal and social attributes.

DISCUSSION

Participants reported the statement items assisted in determining suitable activities and accompanying cues in discussing learning needs. Analysis assisted with discriminating broader elements of EN workplace performance.

CONCLUSIONS

Workplace learning is important for nurses to continue to build their capacity to deliver optimum care. Assessment tools that describe professional capability in plain language statements and provide examples of supportive behavioural cues help guide on-going learning through improving the validity and thereby consistency of assessment processes. Furthermore, comprehensible and meaningful statements and cues can readily be adopted by students and educators to target learning and feedback thereby enhancing clarity of the EN role, to distinguish from other nursing roles.

Applying simulation learning theory to identify instructional strategies for Generation Z emergency medicine residency education

Introduction

Generation Z learners are entering emergency medicine (EM) residency training, bringing unique learning preferences that influence their engagement with residency education. To optimally teach and motivate this incoming generation of learners, EM educators must understand and adapt to the changing instructional landscape.

Methodology

The Simulation Leaders Advancing the Next Generation in Emergency Medicine (SLANG-EM) Workgroup was created to identify effective educational strategies for Generation Z learners entering EM. Members were faculty in the Society for Academic Emergency Medicine (SAEM) Simulation Academy, well versed in learning theory supporting simulation-based education (SBE) and actively involved in EM residency education.

Unique treatment/analysis

Through primary and secondary literature searches, the SLANG-EM Workgroup identified four distinctive learning preferences of Generation Z learners: (1) individualized and self-paced learning, (2) engaging and visual learning environments, (3) immediate and actionable feedback, and (4) combined personal and academic support. Workgroup members evaluated these learning preferences using a novel conceptual framework informed by the theoretical principles underpinning SBE, recommending instructional strategies for Generation Z EM residency learners across multiple educational environments.

Implications for educators

Instructional strategies were described for the didactic, simulation, and clinical learning environments. In the didactic environment, identified instructional strategies included meaningful asynchronous education, interactive small-group learning, and improved multimedia design. In the simulation environment, educational innovations particularly suitable for Generation Z learners included learner-centered debriefing, rapid-cycle deliberate practice, and virtual simulation. In the clinical environment, described instructional strategies involved setting learner-centered goals and delivering facilitative feedback in the context of an educational alliance. Overall, these instructional strategies were clustered around themes of student-centered education and the educator as facilitator, which align well with Generation Z learning preferences. These findings were synthesized and presented as an advanced workshop, "Delivering Effective Education to the Next Generation," at the 2023 SAEM Annual Meeting.

The 'Kidney' model for optimising feedback in undergraduate clinical communication: A meta-ethnographic systematic review

OBJECTIVES

Feedback frameworks/models focus on certain aspects of the feedback process, but a coherent and systematic model is lacking. A meta-ethnography was conducted to identify and synthesise guidance for optimising feedback interactions in undergraduate clinical communication simulations.

METHODS

A systematic search of 4 electronic databases and grey literature was conducted. Following Noblit and Hare's seven phases for conducting meta-ethnography, key themes and concepts were synthesised to provide new interpretations of components in effective feedback interactions.

RESULTS

373 publications were identified and 14 included for the final synthesis, which informed the development of a new Feedback Kidney Model. The Model illustrates the interconnections of various components that allow for effective feedback interactions. The main processes include preparation, proactivity, analysis and feedback information, reception and response, and influencing factors.

CONCLUSIONS

This meta-ethnography moves beyond providing an up-to-date synthesis of feedback guidance to proposing the brand-new Feedback Kidney Model, which can guide medical education and future research into how feedback is co-constructed and utilised to promote learning.

PRACTICE IMPLICATIONS

Clinical communication should incorporate meta-cognitive training and using this Model will help students better utilise on-site face-to-face feedback to enhance their learning and improve future communication with patients.

Challenges and opportunities in cultivating medical students' competencies: Participatory action research from a hierarchical cultural setting

BACKGROUNDS

Research concerning student-centered learning (SCL) recommends a comprehensive assessment of medical students' competencies including their personal and professional characters. Accordingly, nurturing future doctors should be in a continuous mentorship program. However, in a hierarchical culture, communication is one-way with limited feedback and reflection. We aimed to explore challenges and opportunities for SCL implementation in medical schools in this cultural setting necessary for a globally interdependent world.

METHODS

Two cycles of participatory action research (PAR) were conducted, involving medical students and teachers in Indonesia. A national conference on SCL principles was conducted between the cycles, also the SCL modules were developed for each institution and feedback was shared. Twelve focus group discussions were conducted (before and after the module development), with 37 medical teachers and 48 medical students from 7 faculties of medicine across Indonesia at various levels accreditation. Following verbatim transcriptions, a thematic analysis was conducted.

RESULTS AND DISCUSSIONS

In cycle 1 PAR, some challenges in implementing SCL were identified: lack of constructive feedback, overloaded content, summative-based assessment, hierarchical culture environment, and teachers' dilemma of committed time between patient-care and education. In cycle 2, several opportunities to approach the SCL were proposed: a faculty development program on mentorship, students' reflection guides and training, a more longitudinal assessment system, also a more supportive government policy on the human resources system.

CONCLUSIONS

The main challenge of fostering student-centered learning revealed in this study was a teacher-centered learning tendency in the medical curriculum. The weighting towards summative assessment and the national educational policy drive the curriculum like a 'domino effect', away from the expected student-centered learning principles. However, using a participative method, students and teachers could identify opportunities and articulate their educational needs, i.e., a partnership-mentorship program, as a significant step toward student-centered learning in this cultural context.

Undergraduate Learners' Receptiveness to Feedback in Medical Schools: A Scoping Review

Feedback from educators to learners is considered an important element of effective learning in medical school. While early studies were focused on the processes of providing feedback, recent work has showed that factors related to how learners receive feedback seems to be equally important. Considering that the literature on this topic is new in medical education, and studies are diverse and methodologically variable, we sought to conduct a scoping review to map the articles on receptiveness to feedback, to provide an overview of its related factors, to identify the types of research conducted in this area, and to document knowledge gaps in the existing literature. Using the Joanna Briggs Institute scoping review methodology, we searched four databases (CINAHL, Ovid, PubMed, and Web of Science) and screened 9120 abstracts, resulting in 98 articles for our final analysis. In this sample, 80% of studies on the feedback receiver were published in the last 10 years, and there is a vast variation in the studies' methodologies. The main factors that affect medical students' receptiveness to feedback are students' characteristics, feedback content, educators' credibility, and the learning environment. Feedback literacy is a very recent and rarely used term in medical education; therefore, an important area for further investigation. Lastly, we identified some gaps in the literature that might guide future research, such as studying receptiveness to feedback based on academic seniority and feedback literacy's long-term impacts on learning.

Supplementary Information

The online version contains supplementary material available at 10.1007/s40670-023-01858-0.

Feedback conversations: First things first?

OBJECTIVE

This study explores medical students' perceptions regarding the order in which feedback is given and its impact on how that feedback is received.

METHODS

Medical students were interviewed regarding their feedback experiences during medical school and preferred order in which to receive feedback. Thematic analysis was applied to interview transcripts to identify salient themes in students' comments related to feedback order.

RESULTS

Twenty-five students entering their second, third, and fourth years of medical school participated in the study. Students indicated that the order in which feedback was conveyed influenced their receptivity to its content, but varied in their specific order preferences. Most students indicated that they preferred feedback conversations that started with positive observations. Only the most senior students expressed a preference for feedback based on self-assessment.

CONCLUSION

Feedback conversations are complicated interactions. Students' responses to feedback are influenced by a variety of factors, including the order in which feedback is delivered.

PRACTICE IMPLICATIONS

Educators should recognize that students' feedback needs may be influenced by a variety of factors, and should aim to tailor feedback and the order of its delivery to the learner.

Ready for practice? National recommendations for emergency medicine transition to practice curriculum

BACKGROUND

Transition from residency to unsupervised practice represents a critical stage in learning and professional identity formation, yet there is a paucity of literature to inform residency curricula and emergency department transition programming for new faculty.

OBJECTIVE

The objective of this study was to develop consensus-based recommendations to optimize the transition to practice phase of emergency medicine training.

METHODS

A literature review and results of a survey of emergency medicine (EM) residency program directors informed focus groups of recent (within 5 years) EM graduates. Focus group transcripts were analyzed following conventional content analysis. Preliminary recommendations, based on identified themes, were drafted and presented at the 2022 Canadian Association of Emergency Physicians (CAEP) Academic Symposium on Education. Through a live presentation, symposium attendees representing the Canadian national EM community participated in a facilitated discussion of the recommendations. The authors incorporated this feedback to construct a final set of 14 recommendations, 8 targeted toward residency training programs and 6 specific to department leadership.

CONCLUSION

The Canadian EM community used a structured process to develop 14 best practice recommendations to enhance the transition to practice phase of residency training as well as the transition period in the career of junior attending physicians.

Exploring the Impact of Entrustable Professional Activities on Feedback Culture: A Qualitative Study of Anesthesiology Residents and Attendings

PURPOSE

Entrustable professional activities (EPAs) were introduced as a potential way to optimize workplace-based assessments. Yet, recent studies suggest that EPAs have not yet overcome all of the challenges to implementing meaningful feedback. The aim of this study was to explore the extent to which the introduction of EPAs via mobile app impacts feedback culture as experienced by anesthesiology residents and attending physicians.

METHOD

Using a constructivist grounded theory approach, the authors interviewed a purposive and theoretical sample of residents (n = 11) and attendings (n = 11) at the Institute of Anaesthesiology, University Hospital of Zurich, where EPAs had recently been implemented. Interviews took place between February and December 2021. Data collection and analysis were conducted iteratively. The authors used open, axial, and selective coding to gain knowledge and understanding on the interplay of EPAs and feedback culture.

RESULTS

Participants reflected on a number of changes in their day-to-day experience of feedback culture with the implementation of EPAs. Three main mechanisms were instrumental in this process: lowering the feedback threshold, change in feedback focus, and gamification. Participants felt a lower threshold to feedback seeking and giving and that the frequency of feedback conversations increased and tended to be more focused on a specific topic and shorter, while feedback content tended to focus more on technical skills and more attention was given to average performances. Residents indicated that the app-based approach fostered a game-like motivation to "climb levels," while attendings did not perceive a game-like experience.

CONCLUSIONS

EPAs may offer a solution to problems of infrequent occurrence of feedback and invite attention to average performances and technical competencies, but may come at the expense of feedback on nontechnical skills. This study suggests that feedback culture and feedback instruments have a mutually interacting influence on each other.

Debriefing or Feedback: Exploring the Impact of Two Post-Scenario Discussion Methods in the Acquisition and Retention of Non-Technical Skills

INTRODUCTION

There is a paucity of quantitative studies objectively comparing debriefing and feedback as methods for post-scenario discussion and its impact on healthcare teams' acquisition and retention of non-technical skills. The main purpose of this study is to provide some insight on this research question, using a sample of medical students. A secondary objective explores students' opinion and preference on the post-scenario discussion.

MATERIAL AND METHODS

Forty-five medical students were distributed among 15 teams, and randomly allocated to two groups. Each team participated in three different simulated scenarios, with similar levels of difficulty and opportunities to apply specific non-technical skills: leadership, communication, and task management. To assess the acquisition and retention of skills, scenarios occurred on days one (baseline), two (acquisition) and 20 (retention). Team performance was objectively evaluated by an observer, using scenario recordings. Students individually assessed different aspects of debriefing and feedback.

RESULTS

Both debriefing and feedback groups showed similar overall increase in objective scores, with significant increase between days one and two (acquisition), and a smaller increase between days two and 20 (retention). Students indicated debriefing as the preferred discussion method.

CONCLUSION

Debriefing and feedback are effective post-scenario discussion methods, promoting acquisition and retention of non-technical skills, by undergraduate students. Allying debriefing reflexive practice with feedback directive style, and shifting appropriately between facilitation and instruction, can be a good compromise to achieve a timely and educationally meaningful discussion.

The Development and Implementation of a National Veterinary Graduate Development Programme (VetGDP) to Support Veterinarians Entering the UK Workforce

The UK veterinary profession is facing significant challenges, including high rates of veterinarians leaving the profession amidst workforce shortages, alongside high levels of dissatisfaction, stress, and poor mental health. The highest rates of attrition are associated with veterinarians who have recently graduated and are at an early stage in their careers. Although there may be many contributory factors, a lack of adequate support during the transition from vet school into their first professional role following graduation may be one important cause. Consequently, it has never been more important to develop an effective system for supporting new graduates, which is accessible to all. A new Veterinary Graduate Development Programme (VetGDP) has been developed, using a framework of professional activities that are sufficiently flexible to create a bespoke, individualized program for each graduate depending on the role they enter. Each new graduate is assigned a dedicated coach (Adviser) within their workplace, who has been trained to provide effective support and has committed to doing so throughout the program. VetGDP has been implemented on a national scale in the UK; engagement is assured through the RCVS Code of Professional Conduct and quality assurance is in place. VetGDP has been developed using established educational, sociocultural, and behavioral theories, and the latest research in coaching and feedback within medical education. These methods, which aim to ensure there is the best possible impact on graduates' professional development, and the creation of a positive learning culture within the workplace, are taught to all Advisers via an e-learning package.

Beyond Competency: A Student Perspective on Growth Through Clerkship Feedback

This article proposes a paradigm shift from the competency-based model of clerkship feedback using checklists to a coaching-based, action plan-oriented process that centers on individualized student-oriented goals. Using a student perspective, the authors examine the feedback literature and put forward a proposal to use an impact model whose emphasis is to improve the learning climate for students. Several techniques are reviewed which include goal generation and creation of dynamic action plans. By intentionally focusing on coaching relationships as a platform for feedback, the learners and mentors share goals and the result of feedback becomes action-based behaviors which may help negate personal attribution and bias in the feedback process.

Narrative Assessments in Higher Education: A Scoping Review to Identify Evidence-Based Quality Indicators

PURPOSE

Narrative comments are increasingly used in assessment to document trainees' performance and to make important decisions about academic progress. However, little is known about how to document the quality of narrative comments, since traditional psychometric analysis cannot be applied. The authors aimed to generate a list of quality indicators for narrative comments, to identify recommendations for writing high-quality narrative comments, and to document factors that influence the quality of narrative comments used in assessments in higher education.

METHOD

The authors conducted a scoping review according to Arksey & O'Malley's framework. The search strategy yielded 690 articles from 6 databases. Team members screened abstracts for inclusion and exclusion, then extracted numerical and qualitative data based on predetermined categories. Numerical data were used for descriptive analysis. The authors completed the thematic analysis of qualitative data with iterative discussions until they achieved consensus for the interpretation of the results.

RESULTS

After the full-text review of 213 selected articles, 47 were included. Through the thematic analysis, the authors identified 7 quality indicators, 12 recommendations for writing quality narratives, and 3 factors that influence the quality of narrative comments used in assessment. The 7 quality indicators are (1) describes performance with a focus on particular elements (attitudes, knowledge, skills); (2) provides a balanced message between positive elements and elements needing improvement; (3) provides recommendations to learners on how to improve their performance; (4) compares the observed performance with an expected standard of performance; (5) provides justification for the mark/score given; (6) uses language that is clear and easily understood; and (7) uses a nonjudgmental style.

CONCLUSIONS

Assessors can use these quality indicators and recommendations to write high-quality narrative comments, thus reinforcing the appropriate documentation of trainees' performance, facilitating solid decision making about trainees' progression, and enhancing the impact of narrative feedback for both learners and programs.

A qualitative study of medical students' perceptions of resident feedback

CONTEXT

Residents play a pivotal role in medical students' clinical education. From a feedback lens, the near-peer relationship between student and resident holds the potential to foster an educational alliance that could influence learning. We undertook the current qualitative study to explore medical students' perceptions of feedback experiences with residents, addressing when, how and why (and conversely when not and why not) resident feedback plays a role in their clinical education.

METHODS

Our methodology was qualitative interpretive description, informed by phenomenology. We conducted 24 semi-structured interviews with third and fourth year medical students at one institution. The interviews aimed to foster rich discussion about students' feedback experiences with residents during clinical rotations. Data collection and analysis proceeded iteratively. Initial interviews were independently open-coded by three investigators and then collaboratively refined. Codes were applied to subsequent interviews, and new codes were developed. During the final stages of analysis, we organised our themes by drawing on a sociocultural perspective to examine students' perceptions of relationship-building with residents and when and how this influenced feedback and learning.

RESULTS

From the students' perspectives, when residents contributed to building interpersonal relationships with students, this in turn influenced students' receptivity to both encouraging and constructive feedback conversations. In the context of resident-student relationships that were perceived as supportive, resident feedback influenced how students approached learning and working in the clinical environment, as well as students' visions of their future selves. In unsupportive relationships, students were less inclined to engage in feedback with residents and students noted resident behaviours that they wanted to avoid in themselves.

CONCLUSION

Residents are uniquely positioned to create a strong educational alliance with students in which feedback conversations can flourish. Focusing educational efforts on resident feedback conversations has the potential to significantly impact the feedback culture of our clinical environments.

Teacher Feedback and Student Learning-The Students' Perspective

INTRODUCTION

Feedback from teachers to students plays an important role in informing students about the outcome of their assessments. It contributes to students' ongoing learning. The aim of this study was to investigate dental students' perceptions of the feedback given to them by their teachers in Europe.

MATERIALS & METHODS

An online questionnaire was completed by dental students throughout Europe in this quantitative study. Data were collected via Google Forms, transferred to an excel spreadsheet and analysed using SPSS software Version 24.

RESULTS

234 students studying in 9 different European countries completed the questionnaire. These students were born in 36 different countries within and beyond Europe. 84% (n=197) were undergraduate students. 20.3% (n=48) students reported receiving feedback following summative assessments. 81.2% (n=190) students reported constructive criticism as their preferred mode of receiving feedback. 11.3% (n=26) students did not know who delivered the feedback to them. 71% (n=166) students felt that the feedback they received had a significant impact on their future learning.

CONCLUSION

It would appear that there is some diversity in dental students' perceptions of: i) who delivers feedback, ii) when feedback is given, iii) the consistency of feedback received, and iv) the style of feedback they preferred compared to that delivered by tutors. Feedback is being provided to dental students in an appropriate and helpful manner, although there is still room for improvement. Students were aware of the significance of feedback and its impact on future learning.

The Senior Medical Resident's New Role in Assessment in Internal Medicine

PURPOSE

With the introduction of competency-based medical education, senior residents have taken on a new, formalized role of completing assessments of their junior colleagues. However, no prior studies have explored the role of near-peer assessment within the context of entrustable professional activities (EPAs) and competency-based medical education. This study explored internal medicine residents' perceptions of near-peer feedback and assessment in the context of EPAs.

METHOD

Semistructured interviews were conducted from September 2019 to March 2020 with 16 internal medicine residents (8 first-year residents and 8 second- and third-year residents) at the University of Toronto, Toronto, Ontario, Canada. Interviews were conducted and coded iteratively within a constructivist grounded theory approach until sufficiency was reached.

RESULTS

Senior residents noted a tension in their dual roles of coach and assessor when completing EPAs. Senior residents managed the relationship with junior residents to not upset the learner and potentially harm the team dynamic, leading to the documentation of often inflated EPA ratings. Junior residents found senior residents to be credible providers of feedback; however, they were reticent to find senior residents credible as assessors.

CONCLUSIONS

Although EPAs have formalized moments of feedback, senior residents struggled to include constructive feedback comments, all while knowing the assessment decisions may inform the overall summative decision of their peers. As a result, EPA ratings were often inflated. The utility of having senior residents serve as assessors needs to be reexamined because there is concern that this new role has taken away the benefits of having a senior resident act solely as a coach.

Moving toward Mastery: Changes in Student Perceptions of Clerkship Assessment with Pass/Fail Grading and Enhanced Feedback

ProblemClerkship grades contribute to a summative assessment culture in clerkships and can therefore interfere with students' learning. For example, by focusing on summative, tiered clerkship grades, students often discount accompanying feedback that could inform future learning. This case report seeks to explore whether an assessment system intervention which eliminated tiered grades and enhanced feedback was associated with changes in student perceptions of clerkship assessment and perceptions of the clinical learning environment. Intervention: In January 2019, our institution eliminated tiered clerkship grading (honors/pass/fail) for medical students during the core clerkship year and implemented pass/fail clerkship grading along with required twice weekly, work-based assessments for formative feedback. Context: In this single institution, cross-sectional survey study, we collected data from fourth-year medical students one year after an assessment system intervention. The intervention entailed changing from honors/pass/fail to pass/fail grading in all eight core clerkships and implementing an electronic system to record twice-weekly real-time formative work-based assessments. The survey queried student perceptions on the fairness and accuracy of grading and the clinical learning environment-including whether clerkships were mastery- or performance-oriented. We compared responses from students one year after the assessment intervention to those from the class one year before the intervention. Comparisons were made using unpaired, two-tailed t-tests or chi-squared tests as appropriate with Cohen's d for effect size estimation for score differences. Content analysis was used to analyze responses from two open-ended questions about feedback and grading. Impact: Survey response rates were similar before and after intervention (76% (127/168) vs. 72% (118/163), respectively) with no between-group differences in demographics. The after-intervention group showed statistically significant increases in the following factors: "grades are transparent and fair" (Cohen's d = 0.80), "students receive useful feedback" (d = 0.51), and "resident evaluation procedures are fair" (d = 0.40). After-intervention respondents perceived the clerkship learning environment to be more mastery-oriented (d = 0.52), less performance approach-oriented (d = 0.63), and less performance avoid-oriented (d = 0.49). There were no statistical differences in the factors "attending evaluation procedures are fair," "evaluations are accurate," "evaluations are biased," or "perception of stereotype threat." Open-ended questions revealed student recommendations to improve clerkship summary narratives, burden of work-based assessment, and in-person feedback. Lessons Learned: After an assessment system change to pass/fail grading with work-based assessments, we observed moderate to large improvements in student perceptions of clerkship grading and the mastery orientation of the learning environment. Our intervention did not improve perceptions around bias in assessment in clerkships. Other medical schools may consider similar interventions to begin to address student concerns with clerkship assessment and promote a more adaptive learning environment.

A is for advocacy: How introducing student advocacy assessment impacts longitudinal integrated clerkship students and clinical supervisors

To improve health, physicians are increasingly called to advocate. Yet medical schools have only recently focused on health advocacy skill-building. Limited work to date addresses assessing medical student advocacy on behalf of patients. We describe how students and clinical supervisors (CS) in two urban longitudinal integrated clerkships (LIC) experience patient advocacy and how introducing a new advocacy assessment impacts them. Using a thematic approach, we analyzed transcripts of focus groups during 2018-2019. Seventeen of 24 (71%) students and 15 of 21 (71%) CS participated in the focus groups. We describe how students perceive their advocacy role as they accompany the patient, amplify their voice, and facilitate connection. The rationale for advocacy assessment includes that it (1) adds a novel dimension to the written and verbal assessment, (2) drives student learning, (3) aligns with the institutional goal to promote equity, and (4) impacts CS teaching and clinical practice. Challenges are the ambiguity of expectations, pressure to 'perform,' and a moral overlay to advocacy assessment. Findings demonstrate how educational alliances between students and CS and longitudinal relationships between LIC students and patients offer a constructive opportunity for advocacy assessment. We describe suggestions to hone and expand the reach of advocacy assessment.

A review to characterise and map the growth mindset theory in health professions education

INTRODUCTION

Growth mindset is a motivation theory proposed by Carol Dweck that posits our beliefs about intelligence, and the ability to change mindsets can have impacts on how we approach challenges, respond to criticism challenges and orient our goals. This study characterised articles on growth mindset theory in health professions education to: summarise the aspects of growth mindset being researched, describe the discussed benefits of growth mindset theory and outline strategies discussed that may promote a growth mindset.

METHODS

A systematic review of the literature yielded 4927 articles-articles were reviewed and excluded if they were outside of health professions education and did not discuss Dweck's growth mindset theory. The final review yielded 14 research articles and 13 commentaries, which were characterised and analysed using content analysis.

RESULTS

The included articles were published in 2016 and beyond; the articles represented a diverse context, participant type and approach. Most research studies measured participant mindsets and evaluated the correlation with other variables (eg grit, well-being, anxiety). Articles often highlighted benefits and strategies to promote a growth mindset at the learner, educator and organisation level. The most common learner benefits were to help them be more receptive to feedback as well as increased resiliency and perseverance, educator benefits focused on supporting collaborative relationships and safe learning environments. The most prevalent strategies discussed were teaching learners about growth mindset theory, shifting faculty feedback to emphasise effort and to prioritise feedback across the organisation.

CONCLUSION

The growth mindset framework has been shown in other fields to help others manage educational challenges and enhance learning environments. Researchers are encouraged to explore how interventions such as teaching about and prioritising a growth mindset can support learners, health care professionals, educators and organisations.

Driving lesson or driving test? : A metaphor to help faculty separate feedback from assessment

Although there is consensus in the medical education world that feedback is an important and effective tool to support experiential workplace-based learning, learners tend to avoid the feedback associated with direct observation because they perceive it as a high-stakes evaluation with significant consequences for their future. The perceived dominance of the summative assessment paradigm throughout medical education reduces learners' willingness to seek feedback, and encourages supervisors to mix up feedback with provision of 'objective' grades or pass/fail marks. This eye-opener article argues that the provision and reception of effective feedback by clinical supervisors and their learners is dependent on both parties' awareness of the important distinction between feedback used in coaching towards growth and development (assessment for learning) and reaching a high-stakes judgement on the learner's competence and fitness for practice (assessment of learning). Using driving lessons and the driving test as a metaphor for feedback and assessment helps supervisors and learners to understand this crucial difference and to act upon it. It is the supervisor's responsibility to ensure that supervisor and learner achieve a clear mutual understanding of the purpose of each interaction (i.e. feedback or assessment). To allow supervisors to use the driving lesson-driving test metaphor for this purpose in their interactions with learners, it should be included in faculty development initiatives, along with a discussion of the key importance of separating feedback from assessment, to promote a feedback culture of growth and support programmatic assessment of competence.

Piloting a first-year resident-as-teacher workshop to foster evidence-based teaching

PURPOSE

Residents function as important educators of dental students; however, they often have limited training in educational best-practices. Resident-as-teacher programs have been designed and implemented in other health professions to prepare residents to teach in clinic and classroom settings. In this research, we describe the design, implementation, and evaluation of a 2-day workshop for first-year advanced dental residents.

METHODS

The program engaged residents in techniques to: (1) foster psychological safety, (2) use the cognitive apprenticeship framework, (3) deliver quality feedback, and (4) conduct effective didactic instruction. Nineteen first-year residents attended 2 four-hour workshops in July 2019. The impact of the program was evaluated using Kirkpatrick's model, which included participant reactions, learning, and self-reported behaviors.

RESULTS

Most residents (at least 83.3%) reported the value and quality of the workshop was high or very high. With regard to knowledge, residents had statistically significant higher scores after the workshop on knowledge questions about cognitive apprenticeship (P < 0.01), feedback strategies (P < 0.05), and classroom instruction techniques (P < 0.05). Resident reported self-efficacy had a statistically significantly increase (P < 0.05) after the workshop in psychological safety, cognitive apprenticeship, and most items related to providing feedback; there were few changes in self-efficacy on classroom instruction strategies.

CONCLUSION

Overall, a workshop to prepare residents as teachers can improve knowledge and self-efficacy in evidence-based educational practices.