The clinical educator and complexity: a review

Fostering the clinician as teacher: A realist review

BACKGROUND

Clinician-teachers, physicians with educational responsibilities in either classroom or clinical setting, are assumed to add value by virtue of their dual role. The clinical responsibilities are often prioritised over the educational tasks. How and under which circumstances clinician-teachers are able to perform their educational role and create added value for different stakeholders is currently unclear.

OBJECTIVES

To identify for whom, how and under which circumstances educational activities executed by CTs by virtue of their dual role add value to others.

SCOPE

CTs activities linking the system of education and clinical practice beyond direct patient interactions and purposefully executed.

METHODS

A realist review was conducted. Databases were searched in two stages: a narrow conventional search, followed by a comprehensive artificial intelligence-aided search. Studies concerning clinician-teachers' dual role were included. Realist analysis was applied to identify in which contexts resource mechanisms triggered reasoning mechanisms, which led to specific outcomes for different stakeholders.

RESULTS

Sixty-six studies were included. In contexts where clinician-teachers' dual role was formally recognised and valued, clinician-teachers benefitted from the credibility and legitimacy bestowed on them, making the transfer of domain-specific knowledge more impactful. In contexts where sociocultural differences between both systems existed, CTs were able to mediate and adjust recommendations aligned with stakeholders' perceived relevance. Also, contexts organised to support both roles made resource mechanisms more impactful. Clinician-teachers added value to students' clinical competency and learning environment, and to educational organisations' curricular innovation. In their clinical workspace, clinician-teachers added value by enhancing colleague physicians' teaching expertise, implementing educational innovations and recruiting students for scarce specialisms.

CONCLUSION

Clinician-teachers add value to students, colleague physicians and the clinical and educational contexts at large. Domain-specific knowledge of both systems was important to gain credibility and achieve added value. Openness, formal recognition and allocated time for both roles in educational and clinical contexts towards the dual role are important to strengthen the impact of the dual role.

Examining the nexus between medical education and complexity: a systematic review to inform practice and research

BACKGROUND

Medical education is a multifarious endeavour integrating a range of pedagogies and philosophies. Complexity as a science or theory ('complexity') signals a move away from a reductionist paradigm to one which appreciates that interactions in multi-component systems, such as healthcare systems, can result in adaptive and emergent outcomes. This examination of the nexus between medical education and complexity theory aims to discover ways that complexity theory can inform medical education and medical education research.

METHODS

A structured literature review was conducted to examine the nexus between medical education and complexity; 5 databases were searched using relevant terms. Papers were included if they engaged fully with complexity as a science or theory and were significantly focused on medical education. All types of papers were included, including conceptual papers (e.g. opinion and theoretical discussions), case studies, program evaluations and empirical research. A narrative and thematic synthesis was undertaken to create a deep understanding of the use of complexity in medical education.

RESULTS

Eighty-three papers were included; the majority were conceptual papers. The context and theoretical underpinnings of complexity as a relevant theory for medical education were identified. Bibliographic and temporal observations were noted regarding the entry of complexity into medical education. Complexity was relied upon as a theoretical framework for empirical studies covering a variety of elements within medical education including: knowledge and learning theories; curricular, program and faculty development; program evaluation and medical education research; assessment and admissions; professionalism and leadership; and learning for systems, about systems and in systems.

DISCUSSION

There is a call for greater use of theory by medical educators. Complexity within medical education is established, although not widespread. Individualistic cultures of medicine and comfort with reductionist epistemologies challenges its introduction. However, complexity was found to be a useful theory across a range of areas by a limited number of authors and is increasingly used by medical educators and medical education researchers. This review has further conceptualized how complexity is being used to support medical education and medical education research.

CONCLUSION

This literature review can assist in understanding how complexity can be useful in medical educationalists' practice.

Supporting health professional educators in the workplace: A scoping review

PURPOSE

Clinical educators frequently request additional support for educating pre-qualification health professions students despite having access to professional development programs to build education knowledge and skills. The breadth of 'additional support' options remains unclear. The aim of this review is to explore what is known about support options for health professional educators in the workplace through the lens of learning organisations.

MATERIALS AND METHODS

A scoping review was conducted searching Ovid Medline, CINAHL, ProQuest and PsycINFO electronic databases from 1 January 2005 up to 21 October 2020 for studies that identified support strategies for clinical educators of pre-qualification students in the workplace. Relevant data were charted, summarised thematically and synthesised with reference to support type and implementation level.

RESULTS

Fifty relevant records related to medicine, nursing and allied health clinical education were included. Twelve support themes and five cross-cutting support categories were identified across four implementation levels of healthcare systems.

CONCLUSIONS

A diversity of support for clinical educators beyond professional development was identified. Future research combined with leadership and commitment from the healthcare and education sectors is needed to better understand the applicability, efficacy and resourcing of any newly integrated support to ensure it is sustainable and improves clinical educator capability.

Learning on the run - a qualitative, longitudinal study of pharmacy educators' experiences implementing a hospital pharmacy residency program

BACKGROUND

A hospital pharmacy foundation residency training program has been introduced in Australia, modelled on residency programs established in other countries. The program aims to support the professional development of early-career hospital pharmacists, in both clinical and non-clinical roles. Pharmacy educators are usually tasked with the implementation and maintenance of this program. This qualitative, longitudinal study aimed to investigate hospital pharmacy educators' expectations, perceptions and experiences with implementing and developing their residency program.

METHODS

Qualitative data were collected at two timepoints, approximately 24 months apart, using either focus groups or interviews with pharmacy educators who were directly involved in the implementation of the residency program at their respective hospitals. During the early phases of implementation, and approximately 24 months later, participants were asked about their experiences and expectations of the residency program as well as any changes that had occurred within the residency program over time.

RESULTS

Four focus groups and three semi-structured interviews were held with pharmacy educators and senior pharmacists from different hospital settings. These were audio recorded and transcribed verbatim. Transcripts were inductively analysed via thematic analysis. Fifteen hospital pharmacy educators and senior hospital pharmacists participated in the initial focus groups and interviews, and seven educators were retained for follow-up. Four main themes were established from the discussions: participants had great expectations of a positive impact of the residency on their workplace and residents' professional development; substantial effort, support and resources were needed to implement and maintain a residency program; self-motivation and engagement is needed by residents to succeed and experience timely completion and career acceleration; and lastly a balance between standardisation, consistency and flexibility in delivering the residency needs to be found. The role of educators changed with the implementation of a residency, with the addition of more managerial and supervisory aspects.

CONCLUSION

The Australian hospital pharmacy foundation residency program is a complex workplace training program with multiple factors and prerequisites influencing its implementation, development and outcomes. Pharmacy educators are central to the successful implementation and ongoing sustainability of a residency program. They may benefit from formal training and qualifications to support their role.

Clinical educators can supervise students without increased stress: a study of interacting factors using insights from complexity theory

Supervising students in healthcare settings is complex and can be stressful for clinical educators. However, it is unclear how to design student placements without clinical educator stress. Using complexity theory as a lens, fuzzy set Qualitative Comparative Analysis (fsQCA) was used to explore factors associated with no increased stress for clinical educators during speech pathology (SP) placements. Factor selection was informed by the Demand- Control- Support model and existing literature. No single factor was necessary for clinical educators to experience no increased stress. Varied combinations of all factors were found in 10 paths to no increased stress. These combinations often had passing student(s); however, multiple paths included other factors that could be adjusted by clinical educators prior to placement. For example, having more than one workday per week without students was a factor in four paths to no increased stress despite other potential challenges such as a higher caseload throughput. More experienced educators, who had other supporting factors (e.g. lower caseload throughput or workplace engagement such as support from colleagues and managers), also perceived no increased stress in four paths. Student placements without increased stress for clinical educators require consideration of multiple interacting factors. Principles of complexity theory provide insight into how clinical educators uniquely respond to their individual circumstances, resulting in different experiences of student placement impact even within similar workplaces. FsQCA has highlighted practical ways clinical educators supervise students without increased stress. However, any changes for an individual clinical educator need to be considered in combination with other factors given the complexity of clinical education and healthcare settings.

Moving beyond solutionism: Re-imagining placements through an activity systems lens

INTRODUCTION

Clinical placements are central to the process of preparing future health professionals for practice. Health care environments are increasingly complex and demanding with clinical placements often being perceived as a burden on busy health professionals giving rise to a service-education tension. This tension creates a situation ripe for simplistic solutionist approaches. For example, characterising the problem of clinical placements as students negatively impacting on service productivity results in a reductionist solution such as universities compensating health services for student education. Challenges faced by placement seekers and placement providers are multifaceted and complex requiring a more sophisticated understanding and response to the challenges of involving students in the workplace to prepare them for the future workforce.

RE-CONCEPTUALISATION

We argue that the health and education systems have become de-coupled. Learning and working are seen as distinct activities that are at odds with one another. Re-imagining the purposes and practices of clinical placements for the mutual benefit of patients, health services and students may fruitfully address this disconnect.

WORKED EXAMPLE

We present a worked example using the conceptual and analytical tools of cultural-historical activity theory to articulate what we have learnt about this health-education disconnect. Our worked example draws on research involving a series of clinical education case studies within acute care contexts.

CONCLUSION

Through the lens of cultural-historical activity theory, we highlight that solutionist approaches are entrenched in a de-coupling of health from education where the shared object of preparing the future workforce is fragmented. Successful re-coupling requires a partnership that is founded on a shared commitment to preparing the future workforce; recognises that learning and practice are inseparable; and understands that both activity systems are fluid and that collaboration to stay focused on the shared object of preparing the future workforce is complex, challenging and ongoing work.

Health Professions Educators' System-Oriented Roles as Educational Advocate, Quality Improver, and Broker

INTRODUCTION

Health professionals have many facets to their educational role. Although the teaching and student support dimensions of health professionals' educational role are highly visible in the literature, other nontraditional elements are not. This study presents a broader conceptualization of health professionals' educational role, with a focus on the strategic dimensions of their role.

METHODS

Participants were health professionals from different clinical backgrounds and teaching settings, with a formal role in education. Data were collected using a survey (n = 41) and interviews (n = 9), and this article focuses on reporting the qualitative findings of this study. Thematic analysis was used for data interpretation.

RESULTS

Health professionals have three strategic dimensions to their educational role. The first strategic dimension is educational advocacy, which is aimed at championing education at different levels and parts of the educational system and building educational capacity. The second strategic dimension is educational quality improvement which is focused on shifting narratives around education and educational change in health service settings and leveraging educational evidence. The final strategic dimension is educational brokerage which is oriented at connecting clinical and educational communities and building trust and consensus.

DISCUSSION

Beyond the microlevel of learning and teaching, health professionals engage in strategic work that is focused on the broader educational mission within health. Continuing professional development initiatives can empower health professionals to optimize these strategic and system-focused educational roles and responsibilities.

Embedding and sustaining motivational interviewing in clinical environments: a concurrent iterative mixed methods study

BACKGROUND

Motivational interviewing (MI) is internationally recognised as an effective intervention to facilitate health-related behaviour change; although, how it is best implemented and maintained in everyday clinical practice is not so clear. The aim of this study is to understand how MI as an intervention can be embedded and sustained in the clinical practice and learning environments.

METHODS

A concurrent iterative mixed methodology was utilised. Data collection occurred in two parts: a scoping review to identify reported barriers and enablers to embedding and sustaining MI in healthcare settings, and a survey of health professionals at an international clinical educator workshop on the topic. Results from both methods were integrated at the analysis phase ('following a thread') to understand how MI is embedded and the fidelity sustained in the clinical environments. Complexity theory as a conceptualising framework was utilised.

RESULTS

Eleven studies were included, and 30 health professionals were surveyed. Sustainability of MI at micro-clinical levels can be fostered through use of enabling technology, focus on patient-centred care, personnel development and process improvement. At the meso-organisational level, developing shared vision, creating opportunities and an organisational culture supportive of continuous learning are relevant issues. At the macro levels, adopting systems thinking and a learning organisation approach is important for sustaining MI.

CONCLUSIONS

In addressing the recognised barriers to embedding and sustaining MI in health service provisions, clinical educators could potentially play a central role as change agents within and across the complex clinical system.