Resident learning trajectories in the workplace: A self-regulated learning analysis

Ready, Set, Goal: A Mixed Methods Study of a Goal-Setting Intervention on 2 Competency-Based Geriatric Medicine Rotations

Background More research is required to understand the effects of implementing structured goal-setting on trainee engagement in competency-based clinical learning environments. Objective To explore how residents experienced a rotation-specific goal-setting intervention on geriatric medicine rotations at 2 hospitals. Methods All rotating residents were expected to complete the intervention, consisting of a SMART-based (Specific, Measurable, Achievable, Relevant, and Time-Bound) goal-setting form and feedback sessions with teaching faculty. From November 2019 to June 2021, we recruited a convenience sample of rotating residents. Study participants completed pre- and postrotation 35-item Dutch Residency Educational Climate Test (D-RECT) questionnaires to compare scores from their rotation before the geriatric rotation and a postrotation semistructured interview, which we transcribed and analyzed using principles of constant comparison and reflexive thematic analysis. Results We interviewed 12 of 58 (20.7%) residents participating in the goal-setting intervention, 11 of whom completed both D-RECT questionnaires. Participants' D-RECT scores favored the geriatric medicine rotation versus the immediately preceding clinical rotation (M=4.29±0.37; M=3.84±0.44, P=.002). Analyses of interview transcripts yielded 3 themes on how participants perceived the intervention influenced their learning experience: (1) structured forms and processes mediate, inform, and constrain goal selection; (2) interactions with faculty, patients, and system factors influenced goal enactment; and (3) unstructured assessments led to uncertainty around goal achievement. Challenges included time restrictions and unpredictable clinical opportunities. Conclusions Goal-setting appeared to help many residents direct their learning efforts and engage in collaborative processes with teaching faculty. We identified challenges limiting residents' engagement with the goal-setting intervention, which may inform the practical implementation of goal-setting in other competency-based curricula.

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.

Nurses' self-regulated learning in clinical wards: Important insights for nurse educators from a multi-method research study

Central in nurse education curricula stands the preparation of future nurses to work in quickly evolving, dynamic, clinical wards. Learning in the flow of work plays a pivotal role in initial nurse education, but also during continuous professional development. To drive their ongoing development, nurses need competency in self-regulation of learning (SRL). Despite the importance of SRL in the clinical workplace for all (future) healthcare professionals, research on self-regulated workplace learning (SRwpL) of nurses and future nurses in clinical wards is underdeveloped. This study aims to enhance the conceptual understanding of SRwpL strategies and practices in clinical nursing wards and to offer insights for designing effective educational interventions supporting the facilitation and development of (future) nurses' SRwpL in the clinical ward. A multi-actor, multi-method perspective was adopted to qualitatively investigate SRwpL strategies nurses engaged in. Nurses were observed and interviewed, but also professionals responsible for ongoing development in clinical wards (the ward's head nurses and learning counselors) were interviewed. The data collection took place before the COVID pandemic. Results reveal self-regulatory strategies conditional for SRwpL in addition to strategies initiating, progressing, and evaluating the learning process. Head nurses and learning counselors report a lack of these conditional strategies and little variation, and sporadic engagement in all other self-regulatory strategies. To enhance (future) nurses' SRwpL, we suggest that clinical supervisors from educational institutions could exert a lasting influence by not only educating student nurses, but also fostering further professional development of counselors and head nurses to scaffold the SRwpL processes of future nurses in clinical wards.

Relinquishing control? Supervisor co-regulation may disrupt students' self-regulated learning during simulation-based training

When uncertain, medical trainees often seek to co-regulate their learning with supervisors and peers. Evidence suggests they may enact self-regulated learning (SRL) strategies differently when engaged in self- versus co-regulated learning (Co-RL). We compared the impacts of SRL and Co-RL on trainees' acquisition, retention, and preparation for future learning (PFL) of cardiac auscultation skills during simulation-based training. In our two-arm, prospective, non-inferiority trial, we randomly assigned first- and second-year medical students to the SRL (N = 16) or Co-RL conditions (N = 16). Across two learning sessions separated by two-weeks, participants practiced and were assessed in diagnosing simulated cardiac murmurs. We examined diagnostic accuracy and learning trace data across sessions, and conducted semi-structured interviews to explore participants' understandings of their underlying choices and learning strategies. SRL participants' outcomes were non-inferior to Co-RL participants on the immediate post-test and retention test, but not on the PFL assessment (i.e., inconclusive). Analyzing interview transcripts (N = 31) generated three themes: perceived utility of initial learning supports for future learning; SRL strategies and sequencing of murmurs; and perceived control over learning across sessions. Co-RL participants regularly described relinquishing control of learning to supervisors and regaining it when on their own. For some trainees, Co-RL seemed to interfere with their situated and future SRL. We posit that transient clinical training sessions, typical in simulation-based and workplace-based settings, may not allow the ideal processes of Co-RL to unfold between supervisor and trainee. Future research must examine how supervisors and trainees can share accountability to develop the shared mental models that underlie effective Co-RL.

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.

Exploring mentorship in surgery: An interview study on how people stick together

OBJECTIVE

The objective is to explore the processes contributing to how and why mentors and mentees initiate, maintain and grow in their mentorship relationships in surgery.

BACKGROUND

To explore the processes contributing to how and why mentors and mentees initiate, maintain and grow their mentorship relationships in surgery. Evidence suggests that mentorship has a positive impact on physicians' success. Consequently, mentorship programmes have been incorporated into many medicine environments, albeit with variable success.

METHODS

We designed an interview-based study using a constructivist grounded theory approach to explore the dynamics of mentorship between junior and experienced surgeons. Recruited mentees were asked to nominate a senior surgeon they identified as a mentor. Both mentee and mentors were then interviewed separately. Transcripts were analysed using constant comparison to a create a final coding framework and to generate themes.

RESULTS

We interviewed nine faculty mentors and 10 junior faculty mentees. Our analysis identified key themes describing how to initiate, maintain and grow a mentorship relationship. Mentorship starts with ensuring a 'good fit', persists through satisfying a reciprocal loop with timely communication and deepens the relationship through cycles of mutual investment, learning, and success. Participants also discussed how to navigate through tensions to avoid relationship breakdown, balancing formality and friendship, knowing when to transition a relationship to a new dynamic and finding areas of realistic contribution.

CONCLUSIONS

We found that successful mentorship relationships are viewed as dynamic and thus require active investment and shared responsibility between mentees and mentors. Our results also emphasise the value of co-regulation in the relationship, where cycles of mutual investment can contribute to mutual learning and growth.

Workplace-based learning opportunities in a South African family medicine training programme

BACKGROUND

Workplace-based learning (WBL) provides authentic learning opportunities to develop fit-for-practice healthcare workers. Different types of WBL opportunities have been described in high-income countries, but the opportunities in the district health systems of sub-Saharan Africa have not been characterised.

AIM

This study explored family physicians' (FPs) and registrars' perceptions of WBL opportunities in a decentralised postgraduate family medicine registrar training programme.

SETTING

The study was conducted at five decentralised training sites across two provinces affiliated with the University of the Witwatersrand in South Africa.

METHODS

This instrumental case study involved semi-structured qualitative interviews with 11 FPs and 11 registrars purposively sampled across the training sites. The verbatim transcripts were thematically analysed using Braun and Clark's six-step approach.

RESULTS

Workplace-based learning opportunities were grouped into four themes: Learning from interpersonal interactions, learning from district activities, self-directed learning and contextual influences on learning opportunities. Registrars learnt from patients, peers, FPs and other professionals. Feedback, self-reflection, portfolio use, involvement in various district events, such as student and staff teaching, and continuous medical education augmented learning. Contextual influences originated from health facilities, resource availability, district management and university support, excessive workload and a need for standardised district learning opportunities.

CONCLUSION

Registrars are exposed to several types of WBL opportunities in district health systems. Effective engagement with available opportunities and addressing contextual challenges could enhance registrar learning.Contribution: Maximising learning opportunities to promote registrars' acquisition of required skills and competencies to efficiently address community needs in a middle-income country such as South Africa.

Experience-based learning during the final year - quantitative content analyses of students' self-reports

PURPOSE

The final year offers students the opportunity to explore their future role as a physician in different environments. Learning success depends in large part on how students experience these assignments. The aim of this study is to analyze students' self-reported experiences to derive factors that promote experience-based learning in the transition phase during the final year of medical school in order to optimally prepare students for professional practice.

METHOD

Data were collected from 2013 to 2019 via written survey after each assignment in the final year. Students were asked to report their pleasant and unpleasant experiences in free-text fields. The text material was analyzed using quantitative content analysis.

RESULTS

The authors included 1762 questionnaires for analysis. They formed 12 main categories from the text material, equally covering pleasant and unpleasant experiences. Supervisors and teamwork played a central role in both questions, responsibility and working areas frequently led to positive experiences, and working conditions to negative ones.

CONCLUSION

This study confirms the great importance of supervision. Above all, successful collaboration serves as a door opener into a feeling of security which students need to take on responsibility. The authors adapted Dornan's model of experience-based learning to the transition phase to help medical schools establish tailored conditions for students' successful entry into professional practice.

Residents' and supervisors' experiences when using a feedback-model in post-graduate medical education

BACKGROUND

Supervisors play a key part as role models and supporting the learning during residents' post-graduate medical education, but sometimes lack sufficient pedagogic training and are challenged by high demands in today's healthcare. The aim of this study was to describe the strengths and areas for improvement identified in the supervision process by residents and supervisors in post-graduate medical education.

METHODS

This study included supervisors and residents working at departments and health centres who have used a web-based questionnaire, as a part of the Evaluation and Feedback For Effective Clinical Teaching (EFFECT) model, during the period 2016-2019. Descriptive statistics and content analysis were used to analyse ratings and comments to describe strengths and areas for improvement in the supervision process.

RESULTS

The study included 287 resident evaluations of supervisors and 78 self-evaluations by supervisors. The supervisor as a role model, being available, and, giving personal support, were the three most important strengths identified by the residents and supervisors. Residents in primary care also identified the role modelling of general practice competence as a strength, whereas residents and supervisors in hospital departments addressed supervisors as energetic and showing work was fun. The area with the need of most improvement was, Giving and receiving feedback.

CONCLUSIONS

To be able to give feedback, residents and supervisors, needed to see each other in work, and the learning environment had to offer time and space to pedagogical processes, like feedback, to improve the learning environment.

The impact of simulation-based mastery learning, booster session timing and clinical exposure on confidence in intercostal drain insertion: a survey of internal medicine trainees in Scotland

BACKGROUND

Intercostal chest drain (ICD) insertion is a skill that medical trainees lack confidence in performing. This study explores the impact of a national programme of Simulation-Based Mastery Learning (SBML) on procedural confidence, including the impact of time intervals between booster sessions and interim clinical experience.

METHODS

Internal Medicine Trainees in Scotland were surveyed about confidence and clinical experience with ICD insertion before and immediately after SBML and booster session. Data were matched and analysed using paired sample t-tests. Short interval and long interval groups were compared using Student's unpaired t-test. The impact of interim clinical experience was assessed using Analysis of Variance.

RESULTS

Mean confidence in ICD insertion rose following SBML, fell between initial and booster session, and increased again following booster session (P =  < 0.001). 33 of 74 trainees had successfully inserted an ICD between sessions. Fall in confidence was unaffected by the time interval between training sessions, but was mitigated by interim clinical experience.

CONCLUSIONS

SBML boosts trainee confidence in ICD insertion. However, there is evidence of confidence decay, possibly due to a lack of clinical experience between sessions. More research is needed to explore barriers to transfer of skills from simulated to real-world environments.

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.

Vitalizing the evaluation of curricular implementation: a framework for attending to the "how and whys" of curriculum evolution

As curricular reforms are implemented, there is often urgency among scholars to swiftly evaluate curricular outcomes and establish whether desired impacts have been realized. Consequently, many evaluative studies focus on summative program outcomes without accompanying evaluations of implementation. This runs the risk of Type III errors, whereby outcome evaluations rest on unverified assumptions about the appropriate implementation of prescribed curricular activities. Such errors challenge the usefulness of the evaluative studies, casting doubt on accumulated knowledge about curricular innovations, and posing problems for educational systems working to mobilize scarce resources. Unfortunately, however, there is long-standing inattention to the evaluation of implementation in health professions education (HPE). To address this, we propose an accessible framework that provides substantive guidance for evaluative research on implementation of curricular innovations. The Prescribed-Intended-Enacted-Sustainable (PIES) framework that is articulated in this paper, introduces new concepts to HPE-with a view to facilitating more nuanced examination of the evolution of curricula as they are implemented. Critically, the framework is theoretically grounded, integrating evaluation and implementation science as well as education theory. It outlines when, how, and why evaluators need to direct attention to curricular implementation, providing guidance on how programs can map out meaningful evaluative research agendas. Ultimately, this work is intended to support evaluators and educators, seeking to design evaluation studies that provide more faithful, useful representations of the intricacies of curricular change implementation.

Residents' transformational changes through self-regulated, experiential learning for professionalism

PURPOSE

Postgraduate trainees ('residents") are required to convey professional behaviours as they navigate complex clinical environments. However, little is known about experiential learning for professionalism. Thus, we asked residents about professionalism challenges within the clinical learning environment: 1) how challenges were identified, 2) what supported successfully addressing challenges and 3) the impact of addressing challenges to further inform resident education.

METHOD

From 2015-2016, twenty-five residents across specialties and multiple university affiliated teaching hospitals participated in appreciative inquiry informed audio-taped semi-structured interviews. Transcripts were categorized deductively for the 2015 CanMEDS Professional Role element addressed (commitment to patients, society, the profession, and physician health). A pragmatic research paradigm focussed descriptive data analysis on actions and outcomes.

RESULTS

Residents actively identify opportunities for experiential learning of professionalism within the clinical workplace- addressing conflicting priorities with interprofessional clinicians to ensure excellent patient care, providing informal feedback regarding peers' and other healthcare clinicians' professionalism lapses and by gaining self-awareness and maintaining wellness. There were no descriptions of commitment to society. Values, relationships, and reflection supported professional behaviours. Many described transformative personal and professional growth as an outcome of addressing professionalism challenges.

CONCLUSIONS

Residents self-regulated experiential learning for professionalism often results in transformational changes personally and professionally. Elucidation of how residents successfully navigate power dynamics and conflict to provide excellent patient care and feedback for professional regulatory behaviour will support professionalism education. An interprofessional research lens will be valuable to explore how best to incorporate commitment to society within clinical environments.