Context matters when striving to promote active and lifelong learning in medical education

Physicians' lifelong learning journeys: A narrative analysis of continuing professional development struggles

INTRODUCTION

Despite tenacious efforts of continuing professional development (CPD) developers and educators, physician engagement in CPD is fraught with challenges. Research suggests that these educational interventions and the maintenance of professional competence systems that mandate them are often seen as impractical, decontextualized and check-box activities by participants. This study explores physicians' learning post graduate medical education (GME) training across their CPD journey to understand how they (a) conceive of themselves as learners and (b) engage in lifelong learning across the course of their professional careers.

METHODS

Using narrative inquiry and holistic narrative analysis situated within a social constructivist orientation, we carried out individual interviews with physicians from across a large children's hospital network including academic hospitals, community hospitals and primary care practices. Timelines and story arcs were used to support the narrative analysis's re-storying.

RESULTS

Twelve physicians from six different sub-specialties were interviewed. We identified three noteworthy challenges as particularly salient across participants' re-storied narratives: (i) train-on-a-track to treading water, (ii) learning takes a backseat, and (iii) learning through foraging or hunting and gathering. Participants described significant change when transitioning from GME to CPD learning. While participants identified as learners, they described the disorienting impact of losing GME's formal supports and structures. They articulated that patient care trumped learning as their top priority. They lamented having limited insight into their learning needs (e.g. little feedback data) and so resorted to engaging in CPD activities that were readily at hand-but not necessarily relevant-and to finding learning resources that might not be formally recognised for CPD credit.

CONCLUSIONS

Physicians' learning journeys post-GME are challenging, and the systems created to support that learning are ill equipped to meet the needs of physicians transitioning from GME to CPD. To encourage meaningful learning, the complex interplay of factors impeding CPD engagement should inform future innovations.

Assessment during clinical education among nursing students using two different assessment instruments

BACKGROUND

Assessment of undergraduate students using assessment instruments in the clinical setting is known to be complex. The aim of this study was therefore to examine whether two different assessment instruments, containing learning objectives (LO`s) with similar content, results in similar assessments by the clinical supervisors and to explore clinical supervisors' experiences of assessment regarding the two different assessment instruments.

METHOD

A mixed-methods approach was used. Four simulated care encounter scenarios were evaluated by 50 supervisors using two different assessment instruments. 28 follow-up interviews were conducted. Descriptive statistics and logistic binary regression were used for quantitative data analysis, along with qualitative thematic analysis of interview data.

RESULT

While significant differences were observed within the assessment instruments, the differences were consistent between the two instruments, indicating that the quality of the assessment instruments were considered equivalent. Supervisors noted that the relationship between the students and supervisors could introduce subjectivity in the assessments and that working in groups of supervisors could be advantageous. In terms of formative assessments, the Likert scale was considered a useful tool for evaluating learning objectives. However, supervisors had different views on grading scales and the need for clear definitions. The supervisors concluded that a complicated assessment instrument led to limited very-day usage and did not facilitate formative feedback. Furthermore, supervisors discussed how their experiences influenced the use of the assessment instruments, which resulted in different descriptions of the experience. These differences led to a discussion of the need of supervisor teams to enhance the validity of assessments.

CONCLUSION

The findings showed that there were no significant differences in pass/fail gradings using the two different assessment instruments. The quantitative data suggests that supervisors struggled with subjectivity, phrasing, and definitions of the LO´s and the scales used in both instruments. This resulted in arbitrary assessments that were time-consuming and resulted in limited usage in the day-to-day assessment. To mitigate the subjectivity, supervisors suggested working in teams and conducting multiple assessments over time to increase assessment validity.

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.

Learning in context: Undergraduate students' knowledge and the content retention of anatomy between discipline-specific and integrated course approaches

Undergraduate introductory human anatomy and human physiology courses are either taught as discipline-specific or integrated anatomy and physiology (A&P) sequences. An institution underwent a curricular revision to change the course approach from discipline-specific Human Anatomy and Human Physiology to an integrated A&P I and II sequence, allowing the unique opportunity to explore the potential role of contextual learning in academic achievement and content retention. Mediation and moderation analysis was used to evaluate lecture examinations, laboratory practical examinations, and anatomical content retention between the different course approaches. Undergraduate students in the integrated A&P I course approach performed significantly better on lecture assessments and had a higher anatomy content retention rate at the end of the year than students enrolled in the standalone Human Anatomy course. The lecture examination averages between Human Physiology and A&P II (the second course in the sequence), as well as the anatomy laboratory practical examinations, were not significantly different between discipline-specific and integrated course approaches. The results suggest contextual learning-providing physiological context to anatomical structures-increases the anatomical content retention and academic achievement overall.

Learning strategies for the advanced trainee in specialist training

BACKGROUND

A significant factor of clinicians' learning is based on their ability to effectively transfer acquired knowledge, skills, and attitudes from specialty-specific clinical courses to their working environment.

MATERIAL AND METHOD

We conducted semi-structured interviews with 20 anaesthesiologist trainees (i.e. residents) in four group and five individual interviews using SRL principles as sensitizing concepts. Data were collected and analyzed iteratively using thematic analysis.

RESULTS

Advanced trainees are highly motivated to explore what they have learned in specialty-specific courses, but they often face several barriers in implementing their learning in the workplace environment. Four themes emerged from the interview data: 'Be ready to learn', "Take the 'take-home-messages' home', "Be ready to create your own opportunities', and "Face it, it's not entirely up to you'. Understanding the challenges regarding transferring knowledge from courses to the working environment is an important lesson for assisting trainees set their learning goals, monitor their progress, and re-evaluate their SRL processes.

CONCLUSION

Even for advanced trainees, successfully transferring knowledge from specialty-specific courses often requires adequate commitment and support. Medical supervisors and other relevant stakeholders must be aware of their shared responsibility for creating individual environments that support opportunities for trainees to self-regulate their learning.

Effects of (de)motivating supervision styles on junior doctors' intrinsic motivation through basic psychological need frustration and satisfaction: an experimental vignette study

In clinical practice, junior doctors regularly receive supervision from consultants. Drawing on Basic Psychological Needs Theory, consultants' supervision styles are likely to affect junior doctors' intrinsic motivation differently in terms of psychological need frustration and psychological need satisfaction. To examine the effects of (de)motivating supervision styles, we conducted two experimental vignette studies among junior doctors. In Study 1 (N = 150, 73.3% female), we used a 2 (need support: high vs. low) x 2 (directiveness: high vs. low) between-subjects design and, in Study 2, a within-subjects design with the same factors (N = 46, 71.7% female). Both studies revealed a consistent positive effect of need-supportive supervision styles on psychological need satisfaction (+), need frustration (-), and intrinsic motivation (+). Particularly in Study 2, the main effect of need-supportive styles was strengthened by supervisor's directiveness. Moreover, in both studies, the effects of supervision styles on intrinsic motivation were explained through psychological need frustration and psychological need satisfaction. We discuss the implications of these findings for postgraduate clinical training.

Making goals count: A theory-informed approach to on-shift learning goals

Supervisors often ask emergency medicine trainees for their learning goals at the start of a clinical shift, though they may do so without considering the reasons for this practice. Recognizing the underlying rationale for voicing on-shift learning goals and proactively considering solutions for some of the associated challenges can help learners and supervisors employ this practice to its full potential. Goal articulation is rooted in educational principles such as self-regulated learning, targeted performance feedback, and collaborative relationships between learner and supervisor. Despite the potential for on-shift learning goals to augment learning, there are numerous barriers that make it challenging for learners and supervisors alike to create or follow up on meaningful goals. Learner-related challenges include uncertainty about how to develop goals within an unpredictable clinical environment and creating goals too narrow or broad in scope. Supervisor-related challenges include difficulties integrating direct observation into the clinical workflow and a desire to avoid negative feedback. The learning environment also presents inherent challenges, such as lack of longitudinal supervisor-learner relationships, time constraints, space limitations, and incentives for learners to conceal their knowledge gaps. The authors discuss these challenges to effective on-shift learning goals and propose solutions that target the learner's approach, the supervisor's approach, and the learning environment itself.

Pathways, journeys and experiences: Integrating curricular activities related to social accountability within an undergraduate medical curriculum

BACKGROUND

Health professions education curricula are undergoing reform towards social accountability (SA), defined as an academic institution's obligation to orient its education, service and research to respond to societal needs. However, little is known about how or which educational experiences transform learners and the processes behind such action. For example, those responsible for the development and implementation of undergraduate medical education (UGME) programs can benefit from a deeper understanding of educational approaches that foster the development of competencies related to SA. The purpose of this paper was to learn from the perspectives of the various partners involved in a program's delivery about what curricular aspects related to SA are expressed in a UGME program.

METHODS

We undertook a qualitative descriptive study at a francophone Canadian university. Through purposive convenience and snowball sampling, we conducted 16 focus groups (virtual) with the following partners: (a) third- and fourth-year medical students, (b) medical teachers, (c) program administrators (e.g., program leadership), (d) community members (e.g., community organisations) and (e) patient partners. We used inductive thematic analysis to interpret the data.

RESULTS

The participants' perspectives organised around four key themes including (a) the definition of a future socially accountable physician, (b) socially accountable educational activities and experiences, (c) characteristics of a socially accountable MD program and (d) suggestions for curriculum improvement and implementation.

CONCLUSIONS

We extend scholarship about curricular activities related to SA from the perspectives of those involved in teaching and learning. We highlight the relevance of experiential learning, engagement with community members and patient partners and collaborative approaches to curriculum development. Our study provides a snapshot of what are the sequential pathways in fostering SA among medical students and therefore addresses a gap between knowledge and practice regarding what contributes to the implementation of educational approaches related to SA. We emphasise the need for educational innovation and research to develop and align assessment methods with teaching and learning related to SA.

Nursing students' readiness towards the 'new normal' in clinical practice: a distributed cognition qualitative perspective

BACKGROUND

Clinical practicums are a core component of baccalaureate nursing education. Following the coronavirus pandemic, there have been extensive changes in the workforce environment that may potentially affect nursing students' experience and readiness for clinical practicums.

METHODS

A qualitative study was conducted to explore final-year nursing students' experiences and readiness for their final clinical practicum before becoming a registered nurse. A purposive sample of 24 final-year baccalaureate nursing students was included in this study. Individual semi-structured interviews were conducted face-to-face via Zoom. The data was analysed using an inductive thematic analysis approach.

RESULTS

Three themes depicting students' experiences and clinical readiness were elucidated. The themes included: (1) Experiencing multiple concerns, (2) requiring a network of support, and (3) easing the transition to professional practice. Students considered the final clinical practicum as challenging and demanding which evoked numerous concerns.

CONCLUSIONS

Considering the stress that final-year nursing students experience, it will be important to devise strategies ranging from personal, relational, and environmental protective factors to enable their successful transition and completion of clinical practice.

How does guided group reflection work to support professional identity formation in postgraduate medical education: A scoping review

PURPOSE

In postgraduate medical education, guided group reflection is often applied to support professional identity formation. However, little is known about how guided group reflection is shaped and how it works. Our scoping review synthesizes existing evidence about various approaches for guided group reflection, their aims, components and potential working mechanisms.

METHODS

We conducted a scoping review using JBI (Joanna Briggs Institute) guidelines for conducting scoping reviews. We searched PubMed, PsycINFO, EMBASE and ERIC databases for all research articles published in English or Dutch in an iterative team approach. The articles were extracted and summarized quantitatively and qualitatively.

RESULTS

We included 71 papers (45 primary research papers and 26 non-empirical papers including program descriptions, theoretical concepts and personal experiences). We identified a diversity of approaches for guided group reflection (e.g. Balint groups, supervised collaborative reflection and exchange of experiences), applied in a variety of didactic formats and aims. We distilled potential working mechanisms relating to engagement in reflection, group learning and the supervisor's role.

CONCLUSIONS

There are significant knowledge gaps about the aims and underlying mechanisms of guided group reflection. Future systematic research on these topics is needed to understand the effectiveness of educational methods, that can help facilitate learning conditions to best shape professional identity formation (PIF) in educational curricula.

A scoping review and theory-informed conceptual model of professional identity formation in medical education

INTRODUCTION

Professional identity formation (PIF) is a central tenet of effective medical education. However, efforts to support, assess and study PIF are hindered by unclear definitions and conceptualisations of what it means to 'think, act, and feel like a physician'. Gaps in understanding PIF, and by extension, its support mechanisms, can predispose individuals towards disengaged or unprofessional conduct and institutions towards short-sighted or reactionary responses to systemic issues.

METHODS

A Systematic Evidence-Based Approach-guided systematic scoping review of PIF theories was conducted related to medical students, trainees and practising doctors, published between 1 January 2000 and 31 December 2021 in PubMed, Embase, ERIC and Scopus databases.

RESULTS

A total of 2441 abstracts were reviewed, 607 full-text articles evaluated and 204 articles included. The domains identified were understanding PIF through the lens of pivotal theories and characterising PIF by delineating the underlying factors that influence it and processes that define it.

CONCLUSIONS

Based on regnant theories and frameworks related to self-concepts of identity and personhood, the relationships between key PIF influences, processes and outcomes were examined. A theory-backed integrated conceptual model was proposed to delineate the interconnected relationships among these, aiming to untangle some of the complexities inherent to PIF, to shed light on existing practices and to identify shortcomings in our understanding so as to develop mechanisms in support of its multifaceted, interlinked components.

Promotion of self-directed learning abilities among Chinese medical students through preparing for career calling and enhancing teaching competencies in medical education: a cross-sectional study

BACKGROUND

Medical students face a heavy burden as they are tasked with acquiring a vast amount of medical knowledge within a limited time frame. Self-directed learning (SDL) has become crucial for efficient and ongoing learning among medical students. However, effective ways to foster SDL ability among Chinese medical students are lacking, and limited studies have identified factors that impact the SDL ability of medical students. This makes it challenging for educators to develop targeted strategies to improve students' SDL ability. This study aims to assess SDL ability among Chinese medical students and examine the effects of career calling and teaching competencies on SDL ability, as well as the possible mechanisms linking them.

METHODS

Data were collected from 3614 respondents (effective response rate = 60.11%) using cross-sectional online questionnaires and analyzed using IBM SPSS Statistics 22.0. The questionnaire comprised a Demographic Characteristics Questionnaire, Self-directed Learning Ability Scale (Cronbach's alpha = 0.962), Teaching Competencies Scale, and Career Calling Scale.

RESULTS

The average SDL ability score of Chinese medical students was 3.68 ± 0.56, indicating a moderate level of SDL ability. The six factors of the Self-directed Learning Ability Scale-self-reflection, ability to use learning methods, ability to set study plans, ability to set studying objectives, ability to adjust psychological state, and willpower in studying-accounted for 12.90%, 12.89%, 12.39%, 11.94%, 11.34%, and 8.67% of the variance, respectively. Furthermore, career calling was positively associated with SDL learning ability (β = 0.295, p < 0.001), and SDL learning ability was positively associated with teaching competencies (β = 0.191, p < 0.01). Simple slope analysis showed that when the level of teaching competencies was higher, the influence of career calling on SDL ability was stronger.

CONCLUSIONS

Chinese medical students' SDL ability has room for improvement. Medical students could strengthen their willpower in studying by setting milestones goals with rewards, which could inspire their motivation for the next goals. Teachers should guide students to learn experience to improve students' reflective ability. Educators play a crucial role in bridging the gap between career calling education and SDL ability enhancement, highlighting the significance of optimal teaching competencies. Colleges should focus on strengthening teachers' sense of career calling and teaching competencies.

Does 'summative' count? The influence of the awarding of study credits on feedback use and test-taking motivation in medical progress testing

Despite the increasing implementation of formative assessment in medical education, its' effect on learning behaviour remains questionable. This effect may depend on how students value formative, and summative assessments differently. Informed by Expectancy Value Theory, we compared test preparation, feedback use, and test-taking motivation of medical students who either took a purely formative progress test (formative PT-group) or a progress test that yielded study credits (summative PT-group). In a mixed-methods study design, we triangulated quantitative questionnaire data (n = 264), logging data of an online PT feedback system (n = 618), and qualitative interview data (n = 21) to compare feedback use, and test-taking motivation between the formative PT-group (n = 316), and the summative PT-group (n = 302). Self-reported, and actual feedback consultation was higher in the summative PT-group. Test preparation, and active feedback use were relatively low and similar in both groups. Both quantitative, and qualitative results showed that the motivation to prepare and consult feedback relates to how students value the assessment. In the interview data, a link could be made with goal orientation theory, as performance-oriented students perceived the formative PT as not important due to the lack of study credits. This led to low test-taking effort, and feedback consultation after the formative PT. In contrast, learning-oriented students valued the formative PT, and used it for self-study or self-assessment to gain feedback. Our results indicate that most students are less motivated to put effort in the test, and use feedback when there are no direct consequences. A supportive assessment environment that emphasizes recognition of the value of formative testing is required to motivate students to use feedback for learning.

Innovative Self-directed, Problem-oriented, Lifelong learning, Integrated Clinical case Exercise (SPLICE) modules promote critical thinking skills, early clinical exposure, and contextual learning among first professional-year medical students

Medical education is undergoing various transformations to promote a more personalized and contextual way of learning. In light of this, the innovative "Self-directed, Problem-oriented, Lifelong learning, Integrated Clinical case Exercise" (SPLICE) modules were designed, implemented, and evaluated for medical students in the first professional year as a strategy for early clinical exposure in a collaborative and self-directed way of learning. This is a mixed methods study involving first-year medical students. Students were divided randomly into the control and the intervention groups. Six SPLICE modules were administered to the intervention while the control group followed the traditional curricula. The educational outcome was compared using an end-of-module assessment. In addition, 13-item and 8-item questionnaires were administered to students to evaluate the SPLICE and plenary sessions on a 5-point Likert scale. Furthermore, students' feedback was obtained on a 10-point rating scale and in in-depth small-group interviews. The majority of students perceived that the SPLICE module improved their communication and encouraged meaningful, active learning. Students found the plenary sessions to be well organized, with sufficient interaction with professionals. Students also gave excellent scores for feedback on SPLICE modules, demonstrating the effectiveness of the innovation. In terms of test scores used in assessing learning outcomes, the intervention group outperformed the control group (P < 0.0001). The innovative SPLICE curriculum facilitated early clinical exposure and active self-directed learning. Students perceived SPLICE modules to be highly helpful in terms of promoting meaningful learning and the future application of knowledge.NEW & NOTEWORTHY The very essence of this innovative "Self-directed, Problem-oriented, Lifelong learning, Integrated Clinical case Exercise" (SPLICE) curriculum is the team-based learning of integrated pre-, para-, and clinical learning objectives right from the first professional year of study serving as an early clinical exposure. This unique way of learning creates a holistic educational environment by combining both academic and professional development thereby empowering the next generation of physician leaders to take autonomy of their own learning strategies and emerge as competent lifelong learners.

Basic psychological needs satisfaction as a mediator between clinical learning climate, self-regulated learning and perceived learning in the nursing education context

PURPOSE

Self-regulated learning (SRL) can enhance students' learning process. Students need support to effectively regulate their learning. However, the effect of learning climate on SRL behavior, its ultimate effect on learning and the underlying mechanisms have not yet been established. We explored these relationships using self-determination theory.

MATERIALS AND METHODS

Nursing students (N = 244) filled in questionnaires about SRL behavior, perceived learning, perceived pedagogical atmosphere and Basic Psychological Needs (BPN) satisfaction after their clinical placement. Structural equation modelling was used to test a model in which perceived pedagogical atmosphere affects SRL behavior and subsequent perceived learning through BPN satisfaction.

RESULTS

The tested model had an adequate fit (RMSEA = 0.080, SRMR = 0.051; CFI = 0.972; TLI = 0.950). A positively perceived pedagogical atmosphere contributed to SRL behavior, which was fully explained by BPN satisfaction. SRL partially mediated the contribution of pedagogical atmosphere/BPN to perceived learning.

CONCLUSIONS

A learning climate that satisfies students' BPN contributes to their SRL behavior. SRL behavior plays a positive but modest role in the relationship between climate and perceived learning. Without a culture that is supportive of learning, implementation of tools to apply SRL behavior may not be effective. Study limitations include reliance on self-report scales and the inclusion of a single discipline.

An exploratory study of goal orientations of traditional block and longitudinal integrated clerkship students

BACKGROUND

Achievement goal theory links goal setting, motivation, and learning and describes three orientations: 'mastery' (seeking learning), 'performance' (seeking positive judgments), and 'performance-avoidance' (avoiding negative judgments). Mastery orientation is considered most adaptive. The authors investigated goal orientations of traditional block clerkship (TBC) and longitudinal integrated clerkship (LIC) students.

METHODS

This was an exploratory study conducted at one US medical school. Three hundred and twenty students completed an anonymous survey consisting of three tools with validation evidence: Patterns of Adaptive Learning Survey, Task-choice Goal Measures, and Questionnaire Goal Choice Items. The authors analyzed the data using regression analyses, Chi-square, and Wilcoxon's rank-sum tests.

RESULTS

While all students rated mastery items most highly on the five-point Likert scale (mean 4.58/5.00), LIC students rated performance-orientation lower (β = -0.36, p = .04), chose personal mastery-orientation items more frequently (92% vs. 64.4%, p = .005), and perceived their learning environment as promoting less performance (β = -0.60, p = .002) and performance-avoidance (β = -0.78, p < .001) compared to TBC students.

CONCLUSIONS

LIC and TBC students differed in their report of personal and clerkship goal orientations. These differences may inform educational design and future research to promote students' mastery orientation.

Developing research skills in medical students online using an active research study

BACKGROUND

Developing research skills and scholarship are key components of medical education. The COVID-19 pandemic necessitated that all teaching be delivered online. We introduced an approach to small group teaching in the academic year 2020-2021 online which involved students in an active (ongoing) research study to develop their research skills.

METHODS

We acquired student feedback to evaluate their perspectives quantitatively on development of research and scholarship skills, teaching content and format, and tutor performance using this teaching approach. In addition, we captured free text responses from both students and tutors on the positives and negatives of our course, and their suggested improvements. We also compared summative assessment marks for the online/active research course (2020-2021) with those obtained from previous (2017-2019) and subsequent (2021-2023) teaching sessions.

RESULTS

Students were largely positive about most aspects of the online course utilising an active research study (n = 13). Students agreed that they were able to acquire research skills, particularly related to data analysis, transferable skills, and giving scientific presentations. A one-way ANOVA revealed no significant difference for assessment marks across all five teaching years (two years prior and two years following the online/active research course), indicating that the course achieved the learning outcomes. Students enjoyed the convenience of online teaching and the availability of course resources, but least liked the lack of in-person interaction and laboratory training. Tutors enjoyed the collaborative aspects of online teaching, but least liked the lack of face-to-face interactions with students.

CONCLUSIONS

Our study demonstrates that delivering online teaching which involves students in active research engages and motivates them to develop their research and scholarship skills. We recommend that educators consider incorporating a current research study in their undergraduate courses as this can enhance the student learning experience as well as the research project itself.

The effects of job characteristics on physicians' orientation toward lifelong learning

With the rapidly growing body of medical knowledge, physicians must engage in lifelong learning. Physicians' orientation toward lifelong learning is of crucial importance. This study aimed to explore the effects of job characteristics on physicians' lifelong learning. A multicenter study collecting data from physicians from three medical centers in Taiwan was performed. A total of 321 physicians were surveyed with the Chinese version of the Job Content Questionnaire (C-JCQ) and the revised Jefferson Scale of Physician Lifelong Learning (JeffSPLL) to assess their job characteristics (i.e., job demands, job control, social support) and orientation toward lifelong learning. Exploratory factor analysis was employed to validate both questionnaires. Hierarchical regression was utilized to explore the relationship of job characteristics and predictors with physicians' lifelong learning. The results revealed that job demands (β = 0.10), job control (β = 0.19), social support from supervisors (β = 0.16), the interaction of job demands × job control (β =  - 0.11) and the interaction of job demands × social support from colleagues (β = 0.13) were significantly (p < .05, p < .001) related to lifelong learning. Moreover, physicians in the active group (high demand, high control) possessed a stronger orientation toward lifelong learning (mean = 3.57) than those in the low-strain group (mean = 3.42), high-strain group (mean = 3.39) and passive group (mean = 3.20). In conclusion, examining physicians' job demands, job control and social support helps us to understand their orientation toward lifelong learning and may provide insight to improve educational strategies.

"Learning to learn" in the Extended Inverted Classroom: An evaluation of the effects of interactive teaching on knowledge and cognitive regulation in medical students

INTRODUCTION

The evidence regarding the effects of the Inverted Classroom on students' metacognitive skills is limited. This study evaluates these effects on student perceptions about knowledge and cognitive regulation during a surgical course.

METHODS

We measured student perceptions before and after a conventional Inverted Classroom in surgery using the Metacognitive Awareness Inventory. We evaluated the mean differences between the scores of the two measurements using Student's t-test (p < 0.05), and the size of the effect on knowledge and cognitive regulation using Cohen's d test (95%CI).

RESULTS

A total of 158 students (pre-intervention) and 155 students (post-intervention) were included in the analysis. Significant differences were found (p < 0.05) in, as well as positive effects on, the students' abilities to know their own learning (declarative knowledge) (d = 0.24; 95%CI, 0.02-0.47), to use learning strategies (procedural knowledge) (d = 0.19; 95%CI, -0.02 to 0.41) and to understand when and why to use these strategies (conditional knowledge) (d = 0.20; 95%CI, -0.01 to 0.42), in addition to the abilities to plan (d = 0.31; 95%CI, 0.09-0.53) and to evaluate their learning (d = 0.31; 95%CI, 0.08-0.53).

CONCLUSIONS

The Inverted Classroom has positive effects on metacognitive skills according to students' perceptions. Further studies are required that compare these effects with other methodologies for teaching in the classroom and the workplace.

Navigating Challenging Conversations: The Interplay Between Inquiry and Knowledge Drives Preparation for Future Learning

Introduction

While some physicians hone their skills through informal learning in clinical practice, others do not. There is a lack of understanding of why some physicians seek improvement and how they use the workplace context to build their capabilities. Because physicians rarely pursue formal professional development activities to improve communication skills, examining physician-patient communication offers a powerful opportunity to illuminate important aspects of preparation for future learning in the workplace.

Methods

This qualitative observational study involved over 100 hours of observation of eight pediatric rehabilitation physicians as they interacted with patients and families at an academic teaching hospital in 2018-2020. Detailed field notes of observations, post-observation interviews, and exit interviews were the data sources. Data collection and analysis using a constructivist grounded theory approach occurred iteratively, and themes were identified through constant comparative analysis.

Results

Through their daily work, experienced physicians employ 'habits of inquiry' by constantly seeking a better understanding of how to navigate challenging conversations in practice through monitoring and attuning to situational and contextual cues, taking risks and navigating uncertainty while exploring new and varied ways of practicing, and seeking why their strategies are successful or not.

Discussion

Engaging in communication challenges drives physician learning through an interplay between habits of inquiry and knowledge: inquiry into how to improve their communication supported by existing conceptual knowledge to generate new strategies. These 'habits of inquiry' prompt continual reinvestment in problem solving to refine existing knowledge and to build new skills for navigating communication challenges in practice.

Is there ever a single best answer (SBA): assessment driving certainty in the uncertain world of GP?

Uncertainty is inherent in all areas of medical practice, not least in primary care, which is defined by its acceptance of uncertainty and complexity. Single best answer (SBA) questions are a ubiquitous assessment tool in undergraduate medical assessments; however clinical practice, particularly in primary care, challenges the supposition that a single best answer exists for all clinical encounters and dilemmas. In this article, we seek to highlight several aspects of the relationship between this assessment format and clinical uncertainty by considering its influence on medical students' views of uncertainty in the contexts of their medical education, personal epistemology, and clinical expectations.

Stakes of Assessments in Residency: Influence on Previous and Current Self-Regulated Learning and Co-Regulated Learning in Early Career Specialists

Introduction

Assessments drive learning but the influence of the stakes of the assessments on self-regulated (SRL) during and after residency are unknown. As early career specialists (ECS) must continue learning independently, the answer to this is important as it may inform future assessments with the potential to promote life-long learning after graduation.

Methods

We utilized constructivist grounded theory to explore the perspectives of eighteen ECS on the influence of stakes of assessments within residency on their SRL during training and in current practice. We conducted semi-structured interviews.

Results

We initially set out to examine the influence of the stakes of assessments on SRL during residency and after graduation. However, it was apparent that learners increasingly engaged with others in co-regulated learning (CRL) as the perceived stakes of the assessments increased. The individual learner's SRL was embedded in CRL in preparation for the various assessments in residency. For low-stakes assessments, the learner engaged in less CRL, taking less cues from others. As stakes increased, the learner engaged in more CRL with peers with similar intellectual level and supervisors to prepare for these assessments. SRL and CRL influenced by assessments in residency had a knock-on effect in clinical practice as ECS in: 1) developing clinical reasoning, 2) improving doctor-patient communication and negotiation skills, and 3) self-reflections and seeking feedback to deal with expectations of self or others.

Discussion

Our study supported that the stakes of assessments within residency reinforced SRL and CRL during residency with a continued effect on learning as ECS.

Medical Residents' Informal Learning from Pharmacists in the Clinical Workplace

Workplace-based interactions between residents and pharmacists, though relatively underexplored, might contribute substantially to learning. This international study sought to investigate the affordances residents use for informal learning about medications, their interactions with pharmacists and patterns of resident-pharmacist engagement, as well as residents' perceived impact of these interactions on their learning. Contextual differences between US and Dutch residency training and electronic health record (EHR) may impact informal learning about medications. We conducted a cross-sectional, online, 25-item survey study, including closed-format and open-response questions among current resident physicians (post-graduate years 1-6, from a variety of residency programs n = 803) from the University of California San Francisco, the University of Minnesota, and the University Medical Center Utrecht. Responses from 173 residents in both countries revealed that these physician trainees were afforded opportunities to engage in a wide variety of pharmacotherapy-related activities but engaged differently with social and environmental resources for support. Residents from the United States (US) utilized pharmacists and Up-To-Date, whereas Dutch residents preferentially utilized the online Dutch medication information site and EHR-embedded medication resources. US residents interacted with pharmacists significantly more frequently than Dutch residents. Pharmacists provided residents with a wide range of useful information, much of which is integrated into the medication resources in the Dutch EHR-based decision-support system. While US residents reported overwhelmingly that informal interactions with pharmacists contribute to their learning about medications, Dutch residents' responses did not confirm this. Intentionally designing residents' training to include opportunities for interactions with pharmacists could potentially positively impact residents' informal workplace learning.

Supplementary Information

The online version contains supplementary material available at 10.1007/s40670-023-01784-1.

Digital feedback during clinical education in the emergency medical services: a qualitative study

BACKGROUND

Clinical education is essential for students' progress towards becoming registered nurses (RN) in Sweden. Assessment of caring skills in the Emergency Medical Services (EMS) is complex due to the ever-changing scenarios and the fact that multiple supervisors are involved in the student's education. Currently, assessments of student's skills are summative and occur twice during the six weeks of clinical education. A digitalized assessment tool (DAT) with an adaptation for formative assessment is a new approach to assessment of nursing skills in the EMS. Since new technologies and changes in procedures are likely to affect both students and supervisors, our aim in this study is to describe students' and clinical supervisors' experience of formative assessments using DAT in the EMS.

METHOD

This study is qualitative, using semi-structured group interviews (N = 2) with students and semi-structured individual telephone interviews (N = 13) with supervisors. The data was analysed according to Graneheim and Landman's method for content analysis. This analysis generated 221 codes organized into 10 categories within which three themes were identified. The students in this study were nursing students in their last semester and all supervisors were experienced RNs.

RESULTS

The results showed that students and supervisors had mainly positive views of the DAT and the formative assessment stating that the information they provided while using the DAT offered opportunities for reflection. The DAT supported the students' learning by visualizing strengths and areas of improvement, as well as displaying progress using a Likert scale. The application improved communication, but additional features linking the assessment tool with the university were requested. The application contributed to transparency in the assessments and was seen as preferable to the traditional 'pen and paper' method.

CONCLUSION

A digital system was described in a positive manner, and the assessment using the DAT facilitated reflection and formative assessment. The use of a Likert scale was considered positive in order to demonstrate progression which with advantage could be demonstrated visually.

How does portfolio use support self-regulated learning during general practitioner specialty training? A qualitative focus group study

OBJECTIVES

Portfolios are used to support self-regulated learning (SRL), but the research literature is still inconclusive on their effectiveness. This study explored experiences with portfolio use among different stakeholders, to answer the research question: How does portfolio use support SRL during general practitioner (GP) specialty training?

DESIGN

We used a qualitative research design, based on phenomenology.

SETTING

Three of the eight training institutes of Dutch GP specialty training participated in this study.

PARTICIPANTS

The three stakeholder groups that use the portfolio were included in nine homogenous focus groups: trainees (n=16), supervisors (n=16) and faculty (n=17). All participants had at least 6-month experience with portfolio use.

RESULTS

Three themes were identified: SRL with(out) the portfolio, stakeholder dynamics and ambiguities. Respondents were doubtful about the learning benefits of portfolio use, as most trainees used their portfolio to 'check off' what was considered required. Stakeholder dynamics contributed to checking off behaviour in two ways. First, trainees experienced documenting learning activities to be superfluous, since the close relationship with their supervisor already supported SRL sufficiently. Second, faculty often (unintentionally) took portfolio ownership away from trainees, as they instructed trainees to deliver portfolio content that was valuable for assessment. Without ownership, trainees struggled to use the portfolio for SRL. Besides, ambiguities related to portfolio use amplified checking off behaviour.

CONCLUSIONS

Portfolio use did not support SRL in our setting. The multipurpose use of the portfolio (for the support of SRL and assessment) was identified as the primary obstacle. Underlying is a conflict that is often present in current medical curricula: agency versus accountability. If the support of SRL is considered a valuable and attainable purpose of portfolio use, it is important to realise that deliberate attention for this purpose is required during the design, guidance, assessment and evaluation of the portfolio.

Diving into debate: Comparing discussion-based and single-presenter journal club formats in a large PM&R department

BACKGROUND

Journal clubs in physical medicine and rehabilitation (PM&R) advance the educational mission by uniting colleagues to learn of literature updates, consider clinical applications, practice critical thinking, and engage in lively dialogue and community. Although discussion-based journal clubs have been shown to enhance quality, a model for their application across a large and clinically diverse department of PM&R has not been described, nor has one been evaluated in comparison to a single-speaker podium format.

OBJECTIVE

To develop a discussion-based PM&R department-wide journal club, present elements of the journal club model in a manner that would enable replication, and assess effectiveness as perceived by participants, compared to the prior (podium-based, single-speaker) format. It was hypothesized that a discussion-based journal club would more effectively achieve educational goals and would be perceived by participants to be of greater quality and value.

DESIGN

Pre-post educational intervention study, using surveys of PM&R resident and faculty participants. Survey items used a 5-point Likert scale. Unpaired 2-tailed t-tests were used to compare the formats.

SETTING

A large academic PM&R department.

PARTICIPANTS

PM&R faculty, residents, fellows: 26 respondents (preintervention) and 26 respondents (postintervention) out of a total of 94 and 98 people invited to participate, respectively.

INTERVENTIONS

A discussion-based departmental journal club was designed and implemented, replacing the previous single-speaker, podium-based journal club.

MAIN OUTCOME MEASURES

Pre- and post- intervention respondent ratings of (a) journal club quality and value, and (b) effectiveness in achieving specific educational goals.

RESULTS

Compared to the traditional format, the discussion-based format more effectively met the educational objectives, was of higher quality and value as perceived by respondents, and increased desire to attend the activity.

CONCLUSIONS

This discussion-based journal club format can serve as a model for academic PM&R programs looking to enhance the educational value of journal club.

Comparison of simulation-based interprofessional education and video-enhanced interprofessional education in improving the learning outcomes of medical and nursing students: A quasi-experimental study

BACKGROUND

Use of interprofessional education has greatly expanded and is widely used to foster interprofessional collaborative practice competency in health professionals, especially during medical emergencies. Identifying the interprofessional education delivery mode that can maximize learning outcomes within available resources is crucial for achieving the sustainability of an interprofessional education program.

OBJECTIVES

To examine the learning outcomes of simulation-based interprofessional education and video-enhanced interactive discussion interprofessional education modules and to analyze the variable costs between these two interprofessional education modules.

DESIGN

A prospective quasi-experimental study.

SETTING

A medical university in Northern Taiwan.

PARTICIPANTS

24 medical students and 48 nursing students enrolled in a 4-week simulation-based interprofessional education or video-enhanced interactive discussion interprofessional education program.

METHODS

Students' medical task performance, critical medical task performance, team behavior performance, and interprofessional collaboration attitude were examined at the pretest and posttest by using an objective structured checklist and team performance rating scale with a hands-on simulation model and structured questionnaires. The variable costs for simulation-based interprofessional education and video-enhanced interactive discussion interprofessional education were estimated upon the completion of the course.

RESULTS

All learning outcomes significantly improved for both the groups from the pretest to posttest. After the intervention, the simulation-based interprofessional education group exhibited significantly higher scores in medical task performance, critical medical task performance and team behavior performance than the video-enhanced interactive discussion interprofessional education group at the posttest. No significant difference was noted in interprofessional collaboration attitude between the groups. Cost analysis revealed that the simulation-based interprofessional education program was approximately two times more expensive in terms of staffing costs and required 1.3 times greater space charges than the video-enhanced interactive discussion interprofessional education program.

CONCLUSION

Both simulation-based interprofessional education and video-enhanced interactive discussion interprofessional education modules effectively improved medical and nursing students' medical task performance, critical medical task performance and team behavior performance. The simulation-based interprofessional education group had more favorable learning outcomes, but the associated costs were higher. Educators should consider both learning outcomes and cost when choosing a design strategy simulation-based interprofessional education vs. video-enhanced interactive discussion interprofessional education for interprofessional education module development.

Work station learning activities (WSLA) through the ICAP framework: a qualitative study

BACKGROUND

Engaging, student-centered active learning activities, such as team-based learning (TBL) and laboratory practices, is beneficial to integrate knowledge, particularly in Medicine degree. Previously, we designed and implemented workstation learning activities (WSLA) inspired by TBL, which proved effective for learning requiring higher-order thinking skills. We now hypothesize that WSLA may also have the potential to be framed into a theoretical model that stratifies learning into interactive, constructive, active and passive modes (ICAP hypothesis).

METHODS

An interpretive qualitative research study was conducted to evaluate this idea. Semi-structured interviews were conducted with students enrolled in health science programs after WSLA sessions, consisting of a series of activities accompanying a traditional lecture. Interviews were analyzed according to a deductive approach. Theoretical themes and subthemes driving the analysis were organized around the ICAP modes: passive, active, constructive, and interactive. An inductive approach was applied to provide additional insights.

RESULTS

Students valued preparatory lectures as well as corresponding WSLA activities as highly motivating, especially for the ability to integrate concepts. Although previous research shows that not all activities require high levels of cognitive engagement, students appreciated the opportunity the WSLA provided to discuss and clarify concepts as a group. Furthermore, feedback from professors and peers was highly appreciated, and helped students to construct new knowledge.

CONCLUSION

In this work, by focusing in understanding the student's experience, we have evaluated for the first time the WSLA approach in relation to the ICAP model. We found that not only the activity type determines the learning mode, but also the environment accompanying WSLA is a determining factor. Our findings can guide future development of the WSLA approach, which represents an interactive learning methodology with strong potential within the ICAP framework.

TRIAL REGISTRATION

Not applicable.

The blacksmith approach: a strategy for teaching and learning in the medical anatomy course (a qualitative study)

BACKGROUND

Anatomy is a symbolic, essential core topic and one of the fundamental pillars of medical and paramedical knowledge. Nevertheless, few exploratory data analyses have focused on how students approach learning anatomy. This study examined how students perceive their learning experience during anatomy lessons and how to make a model which promotes their meaningful learning and professional identity.

METHODS

Using purposive sampling with maximum variation, we conducted a qualitative content analysis at the Shiraz University of Medical Sciences in Iran (2020 to 2021). Twenty-four medical students and twelve faculty members of Iran's medical science universities were enrolled in the study. The data were collected through semi-structured interviews and analyzed according to the theme.

RESULTS

A conceptual model emerged from the data analysis with the main theme called the blacksmith approach, which included Three sub-themes: (1) making a new forge (adequate preparation and mindful beginning), (2) heating the students' hearts (considering supporting systems that learners need) and (3) using Sledgehammer's approach (teaching anatomy by using more active methods and engaging all neuroanatomical regions) and (Using fun for enjoyable learning). All the concepts were related to each other.

CONCLUSION

Medical students experience a challenging fundamental evolution into professional doctors. Educational systems focus primarily on teaching and learning, while students' transition can be facilitated by a three-step model called the Blacksmith Approach. It best serves as an educational framework for any pivotal, preclinical course capable of helping students acquire new roles and tackle challenges. Further research should be conducted to confirm how hard work leads to satisfying results with the opportunity to create enjoyable learning.

Continuing professional development challenges in a rural setting: A mixed-methods study

INTRODUCTION

Health professionals in rural settings encounter a wide range of medical conditions requiring broad knowledge for their clinical practice. This creates the need for ongoing continuing professional development (CPD). In this study, we explored the barriers that health professionals in a rural healthcare context faced participating in CPD activities and their preferences regarding educational strategies to overcome these challenges.

METHODS

This mixed-methods (exploratory sequential) study in a community hospital in rural Mexico includes 22 interviews, 3 focus groups, 40 observational hours, and a questionnaire of healthcare staff.

RESULTS

Despite low engagement with CPD activities (67% not motivated), all participants expressed interest and acknowledged the importance of learning for their practice. Barriers to participating include a disparity between strategies used (lecture-based) and their desire for practical learning, institutional barriers (poor leadership engagement, procedural flaws, and lack of resources), and collaboration barriers (adverse interprofessional education environment, ineffective teamwork, and poor communication). Additional barriers identified were inconvenient scheduling of sessions (75%), inadequate classrooms (65%), high workload (60%), ineffective speakers (60%), and boring sessions (55%). Participants' preferred learning strategies highlighted activities relevant to their daily clinical activities (practical workshops, simulations, and case analysis). The questionnaire had an 18% response rate.

DISCUSSION

The barriers to CPD in this rural setting are multifactorial and diverse. A strong interest to engage in context-specific active learning strategies highlighted the need for leadership to prioritize interprofessional education, teamwork, and communication to enhance CPD and patient care. These results could inform efforts to strengthen CPD in other rural contexts.

Identifying residents' educational needs to optimising postgraduate medical education about shared decision-making

OBJECTIVE

To investigate how to optimise resident engagement during workplace learning of shared decision-making (SDM) by understanding their educational needs.

METHODS

A qualitative multicentre study was conducted using video-stimulated interviews with 17 residents in General Practice. Video recordings of residents' recent clinical encounters were used to facilitate reflection on their educational needs.

RESULTS

Data analysis resulted in five themes regarding residents' educational needs for learning SDM: acquiring knowledge and skills needed to perform SDM; practising SDM; reflection and feedback; longitudinal and integrated training; and awareness and motivation for performing SDM.

CONCLUSION

Residents expressed a need for continuous attention to be paid to SDM during postgraduate medical education. That would help them engage in two parallel learning processes: acquiring the knowledge and skills necessary to perform SDM, and practising SDM in the clinical workplace. Alignment between the educational curriculum, workplace learning and resident learning activities is essential to operationalise SDM attitude, knowledge and skills into clinical performance.

PRACTICE IMPLICATIONS

The identified educational needs provide ingredients for fostering the development of SDM proficiency. The findings suggest that residents and clinical supervisors need parallel training to bridge the gap between education and clinical practice when learning SDM.

Enhancing trainee clinical scientists' self-regulated learning in the workplace

Background

Trainee health professionals must be competent self‐regulated learners, particularly when learning in busy, unpredictable clinical settings. Whilst research indicates self‐regulated learning (SRL) is influenced both by learners' individual actions and their interactions with others, how these combine to foster SRL requires further exploration. We have used Zimmerman's learner‐focused SRL model and the situative perspective of communities of practice (CoPs) to investigate how UK trainee clinical scientists regulate their learning. Our aims were to develop a holistic understanding of SRL in the clinical workplace incorporating both individual and social aspects and to suggest ways of maximising learning for trainee clinical scientists and other health professionals.

Methods

Semi‐structured interviews were conducted with 13 trainees on the Scientist Training Programme. Transcripts were analysed both inductively and deductively (abductively) using Zimmerman's model and CoPs to explore how trainees regulate their learning.

Results

Thematic analysis yielded four themes: approach to learning, engagement and execution of tasks in practice; self‐reflection and reaction; and autonomy and role construction. Themes linked concepts from Zimmerman's model and CoPs, as illustrated by our trainee–workplace congruence model. Our model suggests optimal conditions for SRL, and we highlight the importance of trainers in supporting trainee development.

Conclusions

Our trainee–workplace congruence model links concepts from Zimmerman's model and CoPs to provide a framework for understanding how trainee clinical scientists regulate their learning and navigate its social aspects. Whilst trainees must take responsibility for their learning, trainers can facilitate SRL through attention to trainee‐workplace ‘fit’ and encouraging trainee participation in communities of practice.

Navigating Affordances for Learning in Clinical Workplaces: A Qualitative Study of General Practitioners' Continued Professional Development

Medical specialists' lifelong learning is essential for improving patients' health. This study identifies affordances for learning general practitioners (GPs) engage in, and explores what influences engagement in those affordances. Eleven GPs were interviewed and the interview transcripts were analysed thematically. Stephen Billett's theoretical framework of workplace participatory practices was used as an analytical lens to explore the topic. Challenging patient cases were identified as the main trigger for engagement in learning. Local, national and international colleagues from the same and other specialties, were found to be an important affordance for learning, as was written material such as websites, journals and recommendations. Other inputs for learning were conferences and courses. Workplace aspects that were essential for GPs to engage in learning related to: place and time to talk, relevance to work, opportunity for different roles, organisation of work and workload, and working climate. Importantly, the study identifies a need for a holistic approach to lifelong learning, including spontaneous and structured opportunities for interaction over time with colleagues, establishment of incentives and arenas for exchange linked to peer learning, and acknowledgement of the workplace as an important place for learning and sufficient time with patients. This study contributes with a deepened understanding of how GPs navigate existing affordances for learning both within and outside their workplaces.

Feasibility Study of a Fully Synchronous Virtual Critical Care Elective Focused on Learner Engagement

Background: The COVID-19 pandemic disrupted clinical education for medical students. With the rise of variants, meaningful in-person clinical experiences remain threatened. This report describes the design, implementation, and evaluation of a fully synchronous virtual critical care elective for medical students focused on learner engagement.

Methods: The two-week elective was offered during June and July 2020 in the COVID-19 extracorporeal membrane oxygenation (ECMO) unit. Medical students remotely participated in multidisciplinary rounds with the attending physician connected from the bedside via a head-mounted camera providing the first-person video view. Other team members connected outside the negative pressure area. Learners electronically completed daily intensive care unit (ICU) goals sheet (GS) for each patient. The daily completion percentage of the GS assessed the learner engagement, and the learners evaluated the experience with a five-point Likert scale survey.

Results: Nine medical students participated in two separate cohorts. Cohort A had 53 patient encounters, and Cohort B had 45 patient encounters totaling 301.5 total hours of supervised virtual patient interaction. The mean completion percentage of the daily ICU GS for the combined cohorts was 77.8%, (with a standard deviation of 9.6%), with sustained or increased completion from start to finish for all learners. All medical students agreed that the daily ICU GS was helpful for following rounds, organizing patient assessments and plans, and participating in patient care. The majority (88.9%) agreed that the elective increased their comfort in caring for critically ill patients.

Conclusions: During the COVID-19 pandemic, a fully synchronous virtual critical care elective successfully utilized the first-person view and daily ICU GS to promote and assess learner engagement.

Beyond the Classroom: Inspiring Medical and Health Science Students to Learn Surface Anatomy

This qualitative and quantitative study offered students the opportunity to participate in engaging and inspiring activities "outside the classroom", to extend their experience and knowledge of surface anatomy. Medical and health science students benefit from studying surface anatomy as it is relevant to their future professions that deal with patients and clients. Surface anatomy is an essential part of the learning process that allows students an opportunity to identify anatomical structures on living people and to develop their palpation and tactile skills for physical examinations of patients. Body painting is a student-centred, engaging, and motivating approach to learn surface anatomy in anatomy practical classes. In this study, anatomy learning was extended "beyond the classroom" through extra-curricular body painting projects. These projects were run by student teams consisting of a student model, student artists (4-5), and a student photographer, under the direction of the chief investigator. A total of sixteen body painting projects were carried out from 2010 to show the skeletal system, the muscular system, pregnancy, respiratory and gastrointestinal systems, and the neurovascular systems of the entire body. A SurveyMonkey of 31/41 active participants suggested that participants enjoyed the projects (94-100%), found them relevant to their future profession (80-87%), and considered them to assist with deeper understanding (94%) and long-term memory (93%) of anatomy. Learning anatomy outside the classroom through extra-curricular body painting projects was a successful way to engage, motivate, and inspire participants and first year anatomy students to study surface anatomy and to develop their physical examination skills.

How medical students co-regulate their learning in clinical clerkships: a social network study

BACKGROUND

Self-regulated learning is a key competence to engage in lifelong learning. Research increasingly acknowledges that medical students in clerkships need others to regulate their learning. The concept of "co-regulated learning" captures this act of regulating one's learning by interacting with others. To effectively cultivate such skills in students, we need to increase our understanding of co-regulated learning. This study aimed to identify the purposes for which students in different phases of clinical training engage others in their networks to regulate their learning.

METHODS

In this social network study, we administered a questionnaire to 403 medical students during clinical clerkships (65.5% response rate). The questionnaire probed into the composition of students' co-regulatory networks and the purpose for which they engaged others in specified self-regulated learning activities. We calculated the proportion of students that engaged others in their networks for each regulatory activity. Additionally, we conducted ANOVAs to examine whether first-, second-, and third-year students differed in how they used their networks to support self-regulation.

RESULTS

Students used others within their co-regulatory networks to support a range of self-regulated learning activities. Whom students engaged, and the purpose of engagement, seemed to shift as students progressed through clinical training. Over time, the proportion of students engaging workplace supervisors to discuss learning goals, learning strategies, self-reflections and self-evaluations increased, whereas the proportion of students engaging peers to discuss learning strategies and how to work on learning goals in the workplace decreased. Of all purposes for which students engaged others measured, discussing self-reflections and self-evaluations were consistently among the ones most frequently mentioned.

CONCLUSIONS

Results reinforce the notion that medical students' regulation of learning is grounded in social interactions within co-regulatory networks students construct during clerkships. Findings elucidate the extent to which students enact self-regulatory learning within their co-regulatory networks and how their co-regulatory learning behaviors develop over time. Explicating the relevance of interactions within co-regulatory networks might help students and supervisors to purposefully engage in meaningful co-regulatory interactions. Additionally, co-regulatory interactions may assist students in regulating their learning in clinical workplaces as well as in honing their self-regulated learning skills.

'Everyone is trying to outcompete each other': A qualitative study of medical student attitudes to a novel peer-assessed undergraduate teamwork module

The centrality of teamwork in ensuring the effective functioning of institutions across all sectors is undeniable. However, embedding teamwork into higher education has been hampered due to a range of deeply entrenched practices associated broadly with the foregrounding of knowledge, beliefs about the place of skill training and routines of assessment. As a result, despite an urgent need to address teamwork, little progress has been made with respect to progressing teamwork education. We have designed and evaluated a novel teamwork module delivered to fourth‐year undergraduate medical students involving placements, a cocreated piece of work, reflection and summative peer assessment. This paper aimed to investigate whether the module increased students’ insight into teamwork, including their own skill development, and whether their perceptions of teamwork changed. Throughout the evaluation, students played a key role, with four final‐year medical students working alongside others in the multidisciplinary project team. Five distinct themes emerged from our in‐depth, semi‐structured interviews: (a) importance and meaning; (b) insight into skill development; (c) transferability; (d) peer assessment; and (e) resistance to teamwork education. Themes had positive and negative components, and student perceptions changed in multiple ways after experiencing a longitudinal educational opportunity to develop their teamwork skills. Before practice, students focused on superficial explanations and on where they might improve. In contrast, after practice, students conveyed deeper insights, contextualisation, focus on how they might improve, and shared structured reflection.

Future Problem-Solving Practiced During COVID-19: Implications for Health Management Students' E-Health Literacy Identity

The current study describes the implementation of an online Future Problem Solving (FPS) program in the field of Health education and set out to explore its contribution to students' eHealth Literacy identity, by using two levels of teacher guidance: minimal vs. frequent. FPS was employed in two groups of Health students. In the research group, frequent weekly guidance was provided to the students centered on the enhancement of eHealth Literacy skills, whereas in the control group minimal guidance was offered by the lecturer. Data for the analysis were gathered from 113 Israeli undergraduate students of a Management of Health Service Organizations program, of whom 62 comprised the research group. Data were gathered twice, pre- and post-program implementation from both groups. Findings showed significant differences between the tests only for the research group, with increased levels of eHealth Literacy skills detected between the tests. The perception of the FPS program as meaningful contributed to students' perceived eHealth Literacy skills only in the research group whereas non-significant results were shown for the control group. This study mainly shows that the enhancement of skills in online educational environments requires frequent and personalized guidance. Faculty must recognize the role of the instructor as a facilitator of learning and design successful scaffolding strategies to nurture students' lifelong learning skills during distance learning.

Relationships between medical students' co-regulatory network characteristics and self-regulated learning: a social network study

INTRODUCTION

Recent conceptualizations of self-regulated learning acknowledge the importance of co-regulation, i.e., students' interactions with others in their networks to support self-regulation. Using a social network approach, the aim of this study is to explore relationships between characteristics of medical students' co-regulatory networks, perceived learning opportunities, and self-regulated learning.

METHODS

The authors surveyed 403 undergraduate medical students during their clinical clerkships (response rate 65.5%). Using multiple regression analysis, structural equation modelling techniques, and analysis of variance, the authors explored relationships between co-regulatory network characteristics (network size, network diversity, and interaction frequency), students' perceptions of learning opportunities in the workplace setting, and self-reported self-regulated learning.

RESULTS

Across all clerkships, data showed positive relationships between tie strength and self-regulated learning (β = 0.095, p < 0.05) and between network size and tie strength (β = 0.530, p < 0.001), and a negative relationship between network diversity and tie strength (β = -0.474, p < 0.001). Students' perceptions of learning opportunities showed positive relationships with both self-regulated learning (β = 0.295, p < 0.001) and co-regulatory network size (β = 0.134, p < 0.01). Characteristics of clerkship contexts influenced both co-regulatory network characteristics (size and tie strength) and relationships between network characteristics, self-regulated learning, and students' perceptions of learning opportunities.

DISCUSSION

The present study reinforces the importance of co-regulatory networks for medical students' self-regulated learning during clinical clerkships. Findings imply that supporting development of strong networks aimed at frequent co-regulatory interactions may enhance medical students' self-regulated learning in challenging clinical learning environments. Social network approaches offer promising ways of further understanding and conceptualising self- and co-regulated learning in clinical workplaces.

Coproducing the Learning Environment: Lessons Learned from a Year of Near-Peer Teaching

PURPOSE

Few medical schools offer electives with the goal of teaching medical students to be effective teachers prior to residency. We developed a novel year-long, longitudinal course, the Clinical Teaching Elective (CTE), that develops fourth-year medical students as student teachers within Clinical Skills (CS).

APPROACH/METHODS

The elective was designed by Clinical Skills (CS) Course Directors and two fourth-year medical students (M4) as a longitudinal elective. The elective involves teaching in the Simulation Center where M4 student instructors teach first and second-year medical students. Each session, in addition to simulated patient case topics, emphasizes application of a key topic within medical education (ie clinical reasoning, reflective practice, dual process reasoning).

DISCUSSION

Six "teaching takeaways" were crafted to summarize common themes experienced by near-peer medical student educators. Teaching is not about the destination, but rather the diagnostic journey.Students thrive when learning is co-produced.A little bit of praise goes a long way.You can't please every learner.When students struggle, there is more to teach than just the answer.Facilitating learner independent thinking promotes future autonomy.

SIGNIFICANCE

A novel CTE for fourth-year medical students that emphasizes medical education pedagogy prepares students to serve as educators in residency. The CTE provides an opportunity for medical students to develop into effective clinical educators prior to residency. The focus of our elective on medical education pedagogy furthers medical student understanding of adult learning theory and fosters professional development in teaching clinical reasoning.

Development of a veterinary emergency open standard competency framework using a competency-based model of medical education

OBJECTIVE

To address the shortage of emergency veterinarians, the profession is exploring accelerated training pathways. We sought to contribute to the solution by developing the foundation for an open standard, competency-based veterinary emergency training curriculum for use by any program. We also developed a curricular delivery, tracking, and assessment system to demonstrate how the framework can be integrated into training programs.  DESIGN: Hybrid Delphi method.  SETTING: Academia and referral practice.  ANIMALS: None.

INTERVENTIONS

None.

MEASUREMENTS AND MAIN RESULTS

An emergency veterinary competency framework was developed by adapting the human Model of the Clinical Practice of Emergency Medicine, which aligns with the Competency-Based Veterinary Education framework, to produce 4 areas of core competency: Patient Care, Interpersonal/Communication, Professionalism, and Practice-based Learning/Improvement. A comprehensive list of veterinary emergency skills was generated and organized within the framework utilizing the hybrid Delphi method. An initial survey completed by 133 emergency and critical care specialists and emergency room clinicians produced data regarding the value of specific skills. An 11-member focus group consisting of survey participants iterated upon the survey results to produce a master library of skills and cases, including 56 Patient Care, 43 Interpersonal/Communication, 11 Practice-based Learning/Improvement, and 20 Professionalism skills, as well as 155 case types. The curricular delivery system tracks and assesses case management proficiency and development of knowledge and professional skills using a patient care eLearning program and simulation training environment.  CONCLUSIONS: The increasing need for emergency veterinarians is a shared industry-wide challenge. To contribute toward a collective solution, we have undergone an evidence-based process to create the foundation for an open standard competency framework composed of a library of skills and cases. We offer this open standard framework to the veterinary profession and hope it continues to grow and evolve as we drive toward developing competency-based training programs that address the shortage of emergency veterinarians.

Conceptions of clinical learning among stakeholders involved in undergraduate nursing education: a phenomenographic study

BACKGROUND

To prepare nursing students to become critical, autonomous members of the workforce, an agreement among stakeholders on how this can be achieved in the clinical setting is needed. However, a critical discussion of the clinical learning process in relation to actual and desirable outcomes is lacking in the nursing education literature. This study aimed to map conceptions of the desired process and outcomes of clinical learning among stakeholders involved in undergraduate clinical nursing education.

METHODS

Twenty-five semi-structured interviews about their understanding of clinical learning were conducted with nursing students, supervisors, clinical educators and higher education institute professionals involved in clinical nursing education in a Dutch academic medical center. Data were analyzed using a phenomenographic approach.

RESULTS

Four conceptions were identified: clinical learning as a process to 1) meet curricular demands, 2) learn to deliberately deliver patient care, 3) learn to deliver patient care within the larger (healthcare) context, and 4) become a continuously developing professional. Conceptions 3 and 4 represented a broader, more inclusive perspective on clinical learning than conception 1 and 2. Conceptions were distinguished by five dimensions: role of guidelines from the school; learning opportunities, focus of supervisor; focus of reflection; desirable outcomes of clinical learning.

CONCLUSIONS

Those directly involved in clinical learning in nursing may have qualitatively different understandings of its desired nature and outcomes. Two patterns across conceptions could be discerned: a) a shift in focus from learning as following standards, to following an individualized learning trajectory and b) a shift in focus from increasing patient load, to understanding oneself and the patient within the healthcare context. To prepare nursing students for the future workforce, a flexible, social form of self-regulated learning is warranted, as well as an understanding of one's own role within the healthcare system and a critical attitude towards healthcare. Schools and hospitals should collaborate to integrate these values in the curriculum. The current study adds different ways of applying self-regulated learning as a relevant dimension in understanding clinical learning to the literature. Through the phenomenographic approach we identified conceptions that can be a basis for training and policy development.

"Learning to Learn" in the Extended Inverted Classroom: An Evaluation of the Effects of Interactive teaching on Knowledge and Cognitive Regulation in Medical Students

INTRODUCTION

The evidence regarding the effects of the Inverted Classroom on students' metacognitive skills is limited. This study evaluates these effects on student perceptions about knowledge and cognitive regulation during a surgical course.

METHODS

We measured student perceptions before and after a conventional Inverted Classroom in surgery using the Metacognitive Awareness Inventory. We evaluated the mean differences between the scores of the two measurements using Student's t-test (p<0.05), and the size of the effect on knowledge and cognitive regulation using Cohen's d test (95%CI).

RESULTS

A total of 158 students (pre-intervention) and 155 students (post-intervention) were included in the analysis. Significant differences were found (p<0.05)in, as well as positive effects on, the students' abilities to know their own learning (declarative knowledge) (d=0.24; 95%CI, 0.02-0.47), to use learning strategies (procedural knowledge) (d=0.19; 95%CI, -0.02 to 0.41) and to understand when and why to use these strategies (conditional knowledge) (d=0.20; 95%CI, -0.01 to 0.42), in addition to the abilities to plan (d=0.31; 95%CI, 0.09-0.53) and to evaluate their learning (d=0.31; 95%CI, 0.08-0.53).

CONCLUSIONS

The Inverted Classroom has positive effects on metacognitive skills according to students' perceptions. Further studies are required that compare these effects with other methodologies for teaching in the classroom and the workplace.

Online argumentation-based learning aided by digital concept mapping during COVID-19: implications for health management teaching and learning

Purpose

The COVID-19 pandemic has affected educational systems worldwide, forcing them to abruptly shift from face-to-face to online teaching and learning. This case study illustrates how a traditional lecture-based activity for undergraduate students in a Management of Health Service Organizations program was transformed into an argumentation-based learning activity using the technique of digital concept mapping and was deployed in an online format during the COVID-19 lockdown.

Design/methodology/approach

The students were tasked with solving an ill-structured problem bearing significance for their future professional lives and connected to the contents of their course (entitled “Assimilation of service quality in health systems”). The activity was composed of two phases. In Phase 1, participants were asked to provide five arguments to establish their proposed solution to the problem by using a concept map on a digital platform (Mindomo). In Phase 2, they were asked to substantiate their arguments. Reflective journals were used to ascertain how the participants viewed the activity. Thematic analysis was used to analyze the qualitative data by searching for themes demonstrating different epistemological positions.

Findings

Six themes were inductively derived from the students' reflections: (1) transitioning from passive to active learning; (2) generating epistemic change; (3) social perspective-taking; (4) domain-based knowledge; (5) prior knowledge and experience; and (6) online collaboration with other students. Episodes, thoughts and feelings expressed by the students were reported so as to increase the reliability of the recurrent and common themes.

Originality/value

This study mainly shows that combining constructivist teaching and learning tools with advanced technology in an online course enables the development of lifelong learning capabilities among students in the health management professions.

Key considerations in planning and designing programmatic assessment in competency-based medical education

Programmatic assessment as a concept is still novel for many in clinical education, and there may be a disconnect between the academics who publish about programmatic assessment and the front-line clinical educators who must put theory into practice. In this paper, we clearly define programmatic assessment and present high-level guidelines about its implementation in competency-based medical education (CBME) programs. The guidelines are informed by literature and by lessons learned from established programmatic assessment approaches. We articulate five steps to consider when implementing programmatic assessment in CBME contexts: articulate the purpose of the program of assessment, determine what must be assessed, choose tools fit for purpose, consider the stakes of assessments, and define processes for interpreting assessment data. In the process, we seek to offer a helpful guide or template for front-line clinical educators. We dispel some myths about programmatic assessment to help training programs as they look to design-or redesign-programs of assessment. In particular, we highlight the notion that programmatic assessment is not 'one size fits all'; rather, it is a system of assessment that results when shared common principles are considered and applied by individual programs as they plan and design their own bespoke model of programmatic assessment for CBME in their unique context.

Medical students' orientation toward lifelong learning in an outcome-based curriculum and the lessons learnt

BACKGROUND

Lifelong learning (LL) is an important outcome of medical training. The objective of this study is to measure the orientation of medical students toward LL and to determine the types of self-directed learning (SDL) activities that contribute toward LL skills.

METHODS

The Jefferson Scale of Physician Lifelong Learning for medical student (JeffSPLL-MS) questionnaire was used. Factor analysis was performed, Cronbach's alpha and effect size were calculated. The types of learning activities that contribute to LL skills were identified.

RESULTS

Three-factor structure emerged from the factor analysis and were identified as learning beliefs and motivation, skills in seeking information and attention to learning opportunities. A significant increase (p < .05; ES = 0.27) in orientation toward LL with academic progression was observed. Clinical students improved significantly in the domains of 'skills in seeking information' (p < .001; ES = 0.48) and 'attention to learning opportunities' (p < .001; ES = 0.55). Problem-based learning, flipped classroom, guided reading, projects and experiential learning activities are perceived to be effective for promoting LL.

CONCLUSIONS

Medical students' LL skills develop progressively from preclinical to clinical years. Self-directed learning activities are perceived to be effective in promoting LL skills.

Understanding the lived experiences of medical learners in a narrative medicine course: a phenomenological study

BACKGROUND

Reflection and various approaches to foster reflection have been regarded as an indispensable element in enhancing professional practice across different disciplines. With its inherent potential to engage learners in reflection and improvement, narrative medicine has been adopted in various settings. However, the relevance and effectiveness of reflection remains underexplored in the context of narrative medicine, specifically in regard to the concern about variability of learner acceptance and the way learners really make sense of these reflective activities. This study aimed to explore what medical learners experience through narrative medicine and the meanings they ascribe to the phenomenon of this narrative-based learning.

METHODS

Using a transcendental phenomenology approach, twenty medical learners were interviewed about their lived experiences of taking a narrative medicine course during their internal medicine clerkship rotation. Moustakas' phenomenological analysis procedures were applied to review the interview data.

RESULTS

Six themes were identified: feeling hesitation, seeking guidance, shifting roles in narratives, questioning relationships, experiencing transformation, and requesting a safe learning environment. These themes shaped the essence of the phenomenon and illustrated what and how medical learners set out on a reflective journey in narrative medicine. These findings elucidate fundamental elements for educators to consider how narrative approaches can be effectively used to engage learners in reflective learning and practice.

CONCLUSION

Adopting Moustakas' transcendental phenomenology approach, a better understanding about the lived experiences of medical learners regarding learning in narrative medicine was identified. Learner hesitancy should be tackled with care by educators so as to support learners with strategies that address guidance, relationship, and learning environment. In so doing, medical learners can be facilitated to develop reflective capabilities for professional and personal growth.