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Rogers SL, Van Winkle L, Michels N, Lucas C, Ziada H, Da Silva EJ, Jotangia A, Gabrielsson S, Gustafsson S, Priddis L. Further development of the reflective practice questionnaire. PeerJ 2024; 12:e16879. [PMID: 38344297 PMCID: PMC10859078 DOI: 10.7717/peerj.16879] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/21/2023] [Accepted: 01/11/2024] [Indexed: 02/15/2024] Open
Abstract
Background This article provides an update of the Reflective Practice Questionnaire (RPQ). The original RPQ consisted of 40-items with 10-sub-scales. In this article, the RPQ is streamlined into a 10-item single reflective practice construct, and a 30-item extended version that includes additional sub-scales of confidence, uncertainty/stress, and work satisfaction. Methods A total of 501 university students filled out an online questionnaire that contained the original Reflective Practice Questionnaire, and two general measures of reflection: The Self-Reflection and Insight Scale, and the Rumination-Reflection Questionnaire. Results Based on factor analysis, the RPQ was streamlined into a brief 10-item version, and an extended 30-item version. Small positive correlations were found between the RPQ reflective practice measure and the two measures of general reflection, providing discriminant validity evidence for the RPQ. The RPQ was found to be sensitive to differences among industries, whereas the general measures of reflection were not. Average reflective practice scores were higher for health and education industries compared to retail and food/accommodation industries.
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Affiliation(s)
- Shane L. Rogers
- Psychology, Edith Cowan University, Perth, Western Australia, Australia
| | - Lon Van Winkle
- Medical Humanities, Rocky Vista University, Denver, Colorado, United States of America
| | - Nicole Michels
- Medical Humanities, Rocky Vista University, Denver, Colorado, United States of America
| | - Cherie Lucas
- Pharmacy, University of Technology Sydney, Sydney, New South Wales, Australia
| | - Hassan Ziada
- Dental Medicine, University of Nevada, Las Vegas, Nevada, United States of America
| | | | | | | | - Silje Gustafsson
- Health, Education and Technology, Lulea University of Technology, Lulea, Sweden
| | - Lynn Priddis
- Law School, The University of Western Australia, Perth, Western Australia, Australia
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Khoshgoftar Z, Barkhordari-Sharifabad M. Translation and psychometric evaluation of the reflective capacity scale in Iranian medical education. BMC MEDICAL EDUCATION 2023; 23:809. [PMID: 37891530 PMCID: PMC10604778 DOI: 10.1186/s12909-023-04791-3] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 12/27/2022] [Accepted: 10/19/2023] [Indexed: 10/29/2023]
Abstract
BACKGROUND Examining the reflective capacity in medical students is a principal step for the development of effective educational strategies to improve it. Reflection scales available in Iran are inadequate due to the lack of focus on students' willingness and tendency to participate in reflection. This study aimed at translation and psychometric evaluation of "Reflective Capacity Scale" in Iranian medical education. METHODS This methodological research was completed in two parts: translation and psychometric evaluation. After getting permission from the main developer of the tool, the translation process was done based on Polit and Yang model in Persian language. Then, face validity and content validity of the tool were established using a qualitative method. Construct validity was surveyed with exploratory and confirmatory factor analysis via completing the questionnaire by 320 medical students, who were selected using convenience sampling. The reliability of the tool was also checked with two methods of internal consistency and stability. The gleaned data were analyzed with SPSS20 and AMOS. RESULTS "Reflective Capacity Scale" includes 16 items that were retained after cross-cultural translation. Face validity and content validity were acceptable. By performing exploratory factor analysis, four factors were identified that accounted for 63.79% of the total variance. In the confirmatory factor analysis, the values of the fit indices confirmed the appropriate fit of the model. The internal consistency reliability of the whole tool was equal to 0.83 and the intra-class correlation coefficient was equal to 0.98. CONCLUSION The translated and validated "Reflective Capacity Scale" provides a robust tool for assessing reflective capacity among Iranian medical students. Its validity and reliability underscore its potential for measuring the reflective capacity of medical students.
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Affiliation(s)
- Zohreh Khoshgoftar
- School of Medical Education and Learning Technologies, Shahid Beheshti University of Medical Sciences, Tehran, Iran
| | - Maasoumeh Barkhordari-Sharifabad
- School of Medical Education and Learning Technologies, Shahid Beheshti University of Medical Sciences, Tehran, Iran.
- School of Medical Sciences, Yazd Branch, Islamic Azad University, Yazd, Iran.
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Thompson J, Bujalka H, McKeever S, Lipscomb A, Moore S, Hill N, Kinney S, Cham KM, Martin J, Bowers P, Gerdtz M. Educational strategies in the health professions to mitigate cognitive and implicit bias impact on decision making: a scoping review. BMC MEDICAL EDUCATION 2023; 23:455. [PMID: 37340395 DOI: 10.1186/s12909-023-04371-5] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 01/28/2023] [Accepted: 05/17/2023] [Indexed: 06/22/2023]
Abstract
BACKGROUND Cognitive and implicit biases negatively impact clinicians' decision-making capacity and can have devastating consequences for safe, effective, and equitable healthcare provision. Internationally, health care clinicians play a critical role in identifying and overcoming these biases. To be workforce ready, it is important that educators proactively prepare all pre-registration healthcare students for real world practice. However, it is unknown how and to what extent health professional educators incorporate bias training into curricula. To address this gap, this scoping review aims to explore what approaches to teaching cognitive and implicit bias, for entry to practice students, have been studied, and what are the evidence gaps that remain. METHODS This scoping review was guided by the Joanna Briggs Institute (JBI) methodology. Databases were searched in May 2022 and included CINAHL, Cochrane, JBI, Medline, ERIC, Embase, and PsycINFO. The Population, Concept and Context framework was used to guide keyword and index terms used for search criteria and data extraction by two independent reviewers. Quantitative and qualitative studies published in English exploring pedagogical approaches and/or educational techniques, strategies, teaching tools to reduce the influence of bias in health clinicians' decision making were sought to be included in this review. Results are presented numerically and thematically in a table accompanied by a narrative summary. RESULTS Of the 732 articles identified, 13 met the aim of this study. Most publications originated from the United States (n=9). Educational practice in medicine accounted for most studies (n=8), followed by nursing and midwifery (n=2). A guiding philosophy or conceptual framework for content development was not indicated in most papers. Educational content was mainly provided via face-to-face (lecture/tutorial) delivery (n=10). Reflection was the most common strategy used for assessment of learning (n=6). Cognitive biases were mainly taught in a single session (n=5); implicit biases were taught via a mix of single (n=4) and multiple sessions (n=4). CONCLUSIONS A range of pedagogical strategies were employed; most commonly, these were face-to-face, class-based activities such as lectures and tutorials. Assessments of student learning were primarily based on tests and personal reflection. There was limited use of real-world settings to educate students about or build skills in biases and their mitigation. There may be a valuable opportunity in exploring approaches to building these skills in the real-world settings that will be the workplaces of our future healthcare workers.
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Affiliation(s)
- John Thompson
- Department of Nursing, Faculty of Medicine, Dentistry and Health Sciences, The University of Melbourne, Level 6, Alan Gilbert Building, 161 Barry Street, Victoria, 3010, Australia.
| | - Helena Bujalka
- Department of Nursing, Faculty of Medicine, Dentistry and Health Sciences, The University of Melbourne, Level 6, Alan Gilbert Building, 161 Barry Street, Victoria, 3010, Australia
| | - Stephen McKeever
- Department of Nursing, Faculty of Medicine, Dentistry and Health Sciences, The University of Melbourne, Level 6, Alan Gilbert Building, 161 Barry Street, Victoria, 3010, Australia
- Royal Children's Hospital, Parkville, Australia
| | - Adrienne Lipscomb
- Department of Nursing, Faculty of Medicine, Dentistry and Health Sciences, The University of Melbourne, Level 6, Alan Gilbert Building, 161 Barry Street, Victoria, 3010, Australia
| | - Sonya Moore
- Department of Physiotherapy, Melbourne School of Health Sciences, University of Melbourne, Melbourne, Australia
| | - Nicole Hill
- Department of Social Work, Melbourne School of Health Sciences, University of Melbourne, Melbourne, Australia
| | - Sharon Kinney
- Department of Nursing, Faculty of Medicine, Dentistry and Health Sciences, The University of Melbourne, Level 6, Alan Gilbert Building, 161 Barry Street, Victoria, 3010, Australia
- Royal Children's Hospital, Parkville, Australia
| | - Kwang Meng Cham
- Department of Optometry and Vision Sciences, Melbourne School of Health Sciences, University of Melbourne, Melbourne, Australia
| | - Joanne Martin
- Department of Nursing, Faculty of Medicine, Dentistry and Health Sciences, The University of Melbourne, Level 6, Alan Gilbert Building, 161 Barry Street, Victoria, 3010, Australia
| | - Patrick Bowers
- Department of Audiology and Speech Pathology, School of Health Sciences, University of Melbourne, Melbourne, Australia
| | - Marie Gerdtz
- Department of Nursing, Faculty of Medicine, Dentistry and Health Sciences, The University of Melbourne, Level 6, Alan Gilbert Building, 161 Barry Street, Victoria, 3010, Australia
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Royce CS, Morgan HK, Baecher-Lind L, Cox S, Everett EN, Fleming A, Graziano SC, Sims SM, Morosky C, Sutton J, Sonn T. The time is now: addressing implicit bias in obstetrics and gynecology education. Am J Obstet Gynecol 2022; 228:369-381. [PMID: 36549568 DOI: 10.1016/j.ajog.2022.12.016] [Citation(s) in RCA: 6] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/05/2022] [Revised: 10/29/2022] [Accepted: 12/13/2022] [Indexed: 12/24/2022]
Abstract
Obstetrician-gynecologists can improve the learning environment and patient care by addressing implicit bias. Accumulating evidence demonstrates that racial and gender-based discrimination is woven into medical education, formal curricula, patient-provider-trainee interactions in the clinical workspace, and all aspects of learner assessment. Implicit bias negatively affects learners in every space. Strategies to address implicit bias at the individual, interpersonal, institutional, and structural level to improve the well-being of learners and patients are needed. The authors review an approach to addressing implicit bias in obstetrics and gynecology education, which includes: (1) curricular design using an educational framework of antiracism and social justice theories, (2) bias awareness and management pedagogy throughout the curriculum, (3) elimination of stereotypical patient descriptions from syllabi and examination questions, and (4) critical review of epidemiology and evidence-based medicine for underlying assumptions based on discriminatory practices or structural racism that unintentionally reinforce stereotypes and bias. The movement toward competency-based medical education and holistic evaluations may result in decreased bias in learner assessment. Educators may wish to monitor grades and narratives for bias as a form of continuous educational equity improvement. Given that practicing physicians may have little training in this area, faculty development efforts in bias awareness and mitigation strategies may have significant impact on learner well-being.
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Affiliation(s)
- Celeste S Royce
- Department of Obstetrics and Gynecology, Beth Israel Deaconess Medical Center, Boston, MA; Department of Obstetrics, Gynecology, and Reproductive Biology, Harvard Medical School, Boston, MA.
| | - Helen Kang Morgan
- Department of Obstetrics and Gynecology, University of Michigan, Ann Arbor, MI
| | - Laura Baecher-Lind
- Department of Obstetrics and Gynecology, Tufts Medical Center, Boston, MA
| | - Susan Cox
- Department of Medical Education, The University of Texas at Tyler School of Medicine, Tyler, TX
| | - Elise N Everett
- Department of Obstetrics, Gynecology and Reproductive Sciences, Robert Larner College of Medicine, The University of Vermont, Burlington, VT
| | - Angela Fleming
- Department of Obstetrics and Gynecology, Michigan State University College of Osteopathic Medicine, East Lansing, MI
| | - Scott C Graziano
- Department of Obstetrics and Gynecology, Stritch School of Medicine, Loyola University Chicago, Maywood, IL
| | - Shireen Madani Sims
- Department of Obstetrics and Gynecology, University of Florida College of Medicine, Gainesville, FL
| | - Christopher Morosky
- Department of Obstetrics and Gynecology, University of Connecticut School of Medicine, Farmington, CT
| | - Jill Sutton
- Department of Obstetrics and Gynecology, Brody School of Medicine, East Carolina University, Greenville, NC
| | - Tammy Sonn
- Department of Obstetrics and Gynecology, Washington University in St. Louis, St. Louis, MO
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Van Winkle LJ, Thornock BO, Schwartz BD, Horst A, Fisher JA, Michels N. Critical reflection on required service to the community propels prospective medical students toward higher empathy, compassion, and bias mitigation but are these gains sustainable? Front Med (Lausanne) 2022; 9:976863. [PMID: 36160142 PMCID: PMC9500161 DOI: 10.3389/fmed.2022.976863] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/23/2022] [Accepted: 08/25/2022] [Indexed: 11/23/2022] Open
Abstract
Purpose We observed increased cognitive empathy and reflective capacity scores when prospective medical students wrote critical reflections on mandatory team service-learning in a Medical Humanities course, but these findings did not include a control group. Here we compare these survey results in similar courses with and without required service-learning. Methods Forty-three prospective medical students completed a Medical Humanities course requiring critical reflection on team service-learning. In comparison, 32 students finished a similar course in which service to the community was not mandatory. Before starting the courses, students completed reliable surveys of their cognitive empathy and reflective capacity, and more than 93% of the students completed the same surveys after finishing the courses. Results Students' cognitive empathy and reflective capacity scores increased significantly when service-learning was required, but the scores did not increase significantly when service to the community was not required. The effect size for the empathy increase was of crucial practical importance (r = 0.50), whereas it was of moderate practical importance for the increase in reflective capacity (r = 0.34). Conclusions These and prior findings strongly support the conclusion that students' critical reflection on mandatory team service-learning fosters development of their cognitive empathy and reflective capacity. We present a model program to incorporate critical reflection on service to the community throughout the curricula of all healthcare professions trainees.
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Affiliation(s)
- Lon J. Van Winkle
- Department of Medical Humanities, Rocky Vista University, Parker, CO, United States
- Department of Biochemistry, Midwestern University, Downers Grove, IL, United States
- *Correspondence: Lon J. Van Winkle
| | - Bradley O. Thornock
- Department of Medical Humanities, Rocky Vista University, Ivins, UT, United States
| | - Brian D. Schwartz
- Department of Medical Humanities, Rocky Vista University, Parker, CO, United States
| | - Alexis Horst
- Department of Medical Humanities, Rocky Vista University, Parker, CO, United States
| | - Jensen A. Fisher
- Department of Medical Humanities, Rocky Vista University, Parker, CO, United States
| | - Nicole Michels
- Department of Medical Humanities, Rocky Vista University, Parker, CO, United States
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Vela MB, Erondu AI, Smith NA, Peek ME, Woodruff JN, Chin MH. Eliminating Explicit and Implicit Biases in Health Care: Evidence and Research Needs. Annu Rev Public Health 2022; 43:477-501. [PMID: 35020445 PMCID: PMC9172268 DOI: 10.1146/annurev-publhealth-052620-103528] [Citation(s) in RCA: 62] [Impact Index Per Article: 31.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/02/2022]
Abstract
Health care providers hold negative explicit and implicit biases against marginalized groups of people such as racial and ethnic minoritized populations. These biases permeate the health care system and affect patients via patient–clinician communication, clinical decision making, and institutionalized practices. Addressing bias remains a fundamental professional responsibility of those accountable for the health and wellness of our populations. Current interventions include instruction on the existence and harmful role of bias in perpetuating health disparities, as well as skills training for the management of bias. These interventions can raise awareness of provider bias and engage health care providers in establishing egalitarian goals for care delivery, but these changes are not sustained, and the interventions have not demonstrated change in behavior in the clinical or learning environment. Unfortunately, the efficacy of these interventions may be hampered by health care providers’ work and learning environments, which are rife with discriminatory practices that sustain the very biases US health care professions are seeking to diminish. We offer a conceptual model demonstrating that provider-level implicit bias interventions should be accompanied by interventions that systemically change structures inside and outside the health care system if the country is to succeed in influencing biases and reducing health inequities.
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Affiliation(s)
- Monica B Vela
- Department of Medicine, Section of Academic Internal Medicine, University of Illinois College of Medicine in Chicago, Chicago, Illinois, USA;
| | - Amarachi I Erondu
- Department of Internal Medicine and Pediatrics, University of California, Los Angeles Medical Center, Los Angeles, California, USA
| | - Nichole A Smith
- Department of Internal Medicine, Hospital of the University of Pennsylvania, Philadelphia, Pennsylvania, USA
| | - Monica E Peek
- Department of Medicine, Section of General Internal Medicine and Chicago Center for Diabetes Translation Research, University of Chicago, Chicago, Illinois, USA
| | - James N Woodruff
- Pritzker School of Medicine, University of Chicago, Chicago, Illinois, USA
| | - Marshall H Chin
- Department of Medicine and Chicago Center for Diabetes Translation Research, University of Chicago, Chicago, Illinois, USA
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Van Winkle LJ, Schwartz BD, Horst A, Fisher JA, Michels N, Thornock BO. Impact of a Pandemic and Remote Learning on Team Development and Elements of Compassion in Prospective Medical Students Taking a Medical Humanities Course. INTERNATIONAL JOURNAL OF ENVIRONMENTAL RESEARCH AND PUBLIC HEALTH 2021; 18:ijerph18094856. [PMID: 34063219 PMCID: PMC8124650 DOI: 10.3390/ijerph18094856] [Citation(s) in RCA: 6] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 03/15/2021] [Revised: 04/27/2021] [Accepted: 04/29/2021] [Indexed: 11/16/2022]
Abstract
INTRODUCTION We reported previously that when teams of students reflect on readings about communication, unconscious bias, and service-learning, their critical reflection, implicit bias mitigation, empathy, and compassionate behavior all increase. However, would these gains occur when intimate classroom settings, in-person team meetings, and direct interactions with people served were lost owing to the COVID-19 pandemic and remote learning? METHODS Before an online Medical Humanities course began in August 2020 and following the course in December 2020, 61 prospective medical students (54.1% female) completed reliable surveys of their reflective capacity (RC) and cognitive empathy (compassion). Students also completed surveys about their implicit biases and team community service in December 2020. RESULTS Both RC and empathy scores increased in students after they reflected on difficulties in communication, unconscious biases, and team service-learning experiences in the course. In written reflections, they reported how their compassionate behavior also grew owing to bias mitigation. Most students concurred that "unconscious bias might affect some of (their) clinical decisions or behaviors as a healthcare professional" and vowed to remain aware of these biases in clinical settings. CONCLUSIONS Compared to previous years, the pandemic and remote learning had minimal effects on the benefits of our Medical Humanities course.
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Affiliation(s)
- Lon J. Van Winkle
- Department of Medical Humanities, Rocky Vista University, 8401 S. Chambers Road, Parker, CO 80134, USA; (B.D.S.); (A.H.); (J.A.F.); (N.M.)
- Correspondence:
| | - Brian D. Schwartz
- Department of Medical Humanities, Rocky Vista University, 8401 S. Chambers Road, Parker, CO 80134, USA; (B.D.S.); (A.H.); (J.A.F.); (N.M.)
| | - Alexis Horst
- Department of Medical Humanities, Rocky Vista University, 8401 S. Chambers Road, Parker, CO 80134, USA; (B.D.S.); (A.H.); (J.A.F.); (N.M.)
| | - Jensen A. Fisher
- Department of Medical Humanities, Rocky Vista University, 8401 S. Chambers Road, Parker, CO 80134, USA; (B.D.S.); (A.H.); (J.A.F.); (N.M.)
| | - Nicole Michels
- Department of Medical Humanities, Rocky Vista University, 8401 S. Chambers Road, Parker, CO 80134, USA; (B.D.S.); (A.H.); (J.A.F.); (N.M.)
| | - Bradley O. Thornock
- Department of Medical Humanities, Rocky Vista University, 255 E. Center Street, Ivins, UT 84738, USA;
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Gustafsson S, Engström Å, Lindgren B, Gabrielsson S. Reflective capacity in nurses in specialist education: Swedish translation and psychometric evaluation of the Reflective Capacity Scale of the Reflective Practice Questionnaire. Nurs Open 2021; 8:546-552. [PMID: 33570291 PMCID: PMC7877226 DOI: 10.1002/nop2.659] [Citation(s) in RCA: 6] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/26/2020] [Revised: 08/10/2020] [Accepted: 09/03/2020] [Indexed: 11/16/2022] Open
Abstract
AIM This study aimed to test the validity and reliability of the Swedish version of the Reflective Capacity Scale of the Reflective Practice Questionnaire in a nursing context. DESIGN Non-experimental and cross-sectional. METHODS The instrument was translated from English to Swedish using a translation and back-translation procedure. Data for the validity and reliability analysis were collected from Registered Nurses in specialist education (n = 156) at two Swedish universities. RESULTS The Swedish version of the Reflective Capacity Scale of the Reflective Practice Questionnaire is a valid and reliable instrument that assesses the reflective capacity of healthcare practitioners. Our findings suggest a unidimensional structure of the instrument, excellent internal consistency and good reliability. CONCLUSION The Swedish version of the Reflective Capacity Scale of the Reflective Practice Questionnaire has a degree of reliability and validity that is satisfactory, indicating that the instrument can be used as an assessment of reflective capacity in nurses.
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Affiliation(s)
- Silje Gustafsson
- Department of Health SciencesLuleå University of TechnologyLuleåSweden
| | - Åsa Engström
- Department of Health SciencesLuleå University of TechnologyLuleåSweden
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Schwartz BD, Horst A, Fisher JA, Michels N, Van Winkle LJ. Fostering Empathy, Implicit Bias Mitigation, and Compassionate Behavior in a Medical Humanities Course. INTERNATIONAL JOURNAL OF ENVIRONMENTAL RESEARCH AND PUBLIC HEALTH 2020; 17:ijerph17072169. [PMID: 32218103 PMCID: PMC7177225 DOI: 10.3390/ijerph17072169] [Citation(s) in RCA: 20] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 02/26/2020] [Revised: 03/12/2020] [Accepted: 03/23/2020] [Indexed: 12/23/2022]
Abstract
Increases in compassionate behavior improve patient outcomes and reduce burnout among healthcare professionals. We predicted that selecting and performing service-learning projects by teams of prospective medical students in a Medical Humanities course would foster students' compassion by raising their reflective capacity, empathy, and unconscious bias mitigation. In class, we discussed difficulties in communication and implicit bias. In this observational study, teams wrote individual and team critical reflections on these class discussions and their service-learning experiences, and we analyzed these reflections for dissonance, self-examination, bias mitigation, dissonance reconciliation, and compassionate behavior. Thirty-two students (53% female) completed the Reflective Practice Questionnaire and the Jefferson Scale of Empathy before the course in August 2019 and after it in December 2019. In December, students were surveyed concerning their attitudes toward team service-learning projects and unconscious bias. The students reported changes in their behavior to mitigate biases and become more compassionate, and their reflective capacity and empathy grew in association with discussions and team service-learning experiences in the course. Virtually all students agreed with the statement "Unconscious bias might affect some of my clinical decisions or behaviors as a healthcare professional," and they worked to control such biases in interactions with the people they were serving.
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