Submitted: 4 November 2023
Accepted: 20 November 2023
Published online: 2 April, TAPS 2024, 9(2),98-100
https://doi.org/10.29060/TAPS.2024-9-2/PV3165

John Norcini

Department of Psychiatry, SUNY Upstate Medical University, United States of America

I. INTRODUCTION

Over the past 25 years, the Asia Pacific region has seen striking growth in the scholarship of health professions education, and it is poised to continue its development. A window into the past and a glimpse of the future can be found in the meetings of the Asia Pacific Medical Education Conference (APMEC), which recently celebrated its 25th anniversary. To frame my personal observations, a word cloud was created using the titles of the plenaries, keynotes, and symposia of the 2003, 2004, and 2006 conferences and another was created using the titles from 2021, 2022, and 2023. When comparing these two clouds (an exercise akin to interpreting inkblots), three themes emerged: interprofessional education and practice (IPEP), the scholarship of teaching and learning (SoTL), and the growing role of technology.

Interprofessional Education and Practice. In the first three conferences, the most common word was ‘medical’ and in the last three it was ‘education’. This parallels developments in the field, which started with a focus entirely on medical education, expanded to all the health professions, and in its most recent iteration, turned to interprofessional education. The reason for this latest development is research showing that interprofessional practice results in better patient outcomes, improved efficiency of care, and increased satisfaction among providers (Reeves et al., 2017).

One of the biggest barriers to IPEP is social closure, defined by Mackert (2012) as the “process of drawing boundaries, constructing identities, and building communities in order to monopolize scarce resources for one’s own group, thereby excluding others from using them.” (Mackert, 2012). Each profession has an educational model that encompasses as much of practice as possible, and they compete over ownership at the boundaries. This limits interprofessional cooperation and the opportunity for joint training.

Social closure has been institutionalised through the regulatory processes (i.e., accreditation and licensure/registration) used in many countries. These fix the boundaries of the professions and the nature of training and practice. Regulation ensures initial competence but makes it challenging to develop shared competencies across the professions. Moreover, there are few regulatory requirements for keeping up with changing practice and even fewer ways to acknowledge the acquisition of additional competencies after formal training.

Digital badges or micro-credentials are one way to approach the issue of social closure.  They are circumscribed credentials based on shorter educational experiences followed by assessment. They can be part of existing broad educational and regulatory processes, complement them, or replace them in part. These credentials can be applied across professions and throughout careers.

Micro-credentials can support the development of IPEP by increasing access and shifting the focus from what the professions can do, to what patients and healthcare systems need. The fact that different professions experience the same educational process leads to comparability across providers regardless of discipline, less siloed regulation, and increased interprofessional collaboration. Furthermore, it offers a pathway for practitioners who seek to upgrade their skills or acquire new competencies.

The scholarship of teaching and learning. The second theme that emerged from a comparison of the word clouds was the scholarship of teaching and learning (SoTL). ‘Curriculum’ and ‘assessment’ were prominent in the first APMEC conferences, but they vanished recently, with ‘learning’, ‘scholarship’, and ‘educator’ being more prominent. In my view, this shift signifies the growing role of SoTL.

The goal of SOTL is to improve student learning by identifying effective teaching practices and disseminating those practices. It is a relatively new field of scholarship that has nine attributes: “committed engagement in action, critique-based, disciplinary, context-oriented, critical enquiry process, continuous deep reflection, dynamic process, shared publicly, and learning focused.” (Mirhosseini et al., 2018).

A recent edition of the Asia Pacific Scholar exemplifies this work (Lee & Norcini, 2023). It included studies that addressed topics such as community based interprofessional education, cultural awareness training in the emergency room, approaches to vaccine hesitancy, innovative oral exams for occupational therapy students, and coaching programs for faculty members.

Technology. The third theme that emerged from the comparison of the word clouds was technology.  ‘eLearning’, prevalent in the early days of the conference, has disappeared to be replaced by ‘technology’. In my view, this signifies its growing role in health professions education and assessment. To pursue this further, Bard (Google’s AI chatbot) was asked, “What effect will technology have on education in the health professions?” Below is Bard’s response, edited for British spelling and for length by removing examples.

“Technology is already having a significant impact on education in the health professions, and this trend is only going to accelerate in the coming years. Here are some of the key ways in which technology is transforming health professions education

• Increased use of e-learning and simulation provides students access to high-quality educational resources and experiences, regardless of location or time constraints.
• Technology can be used to create personalised learning experiences for each student.
• Technology can be used to facilitate interprofessional collaboration between students and healthcare professionals from different disciplines.
• Technology can be used to collect and analyse data on student learning and performance.

Overall, technology is making health professions education more accessible, personalised, and effective.

Here are some of the potential benefits of using technology in health professions education:

• Improved access to education: Technology can help to break down barriers to access to education, such as distance, time constraints, and financial resources.
• Increased student engagement: Technology can be used to create more engaging and interactive learning experiences.
• Improved learning outcomes: Technology can be used to personalise learning, provide feedback, and track student progress.
• Better preparation for practice: Technology can be used to simulate real-world clinical scenarios and help students to develop the skills they need to be successful practitioners.

However, there are also some potential challenges associated with the use of technology in health professions education, such as:

• Cost: Technology can be expensive to purchase and maintain
• Digital divide: Not all students have equal access to technology resources
• Technical challenges: Technology can be complex and difficult to use
• Quality control: It is important to ensure that technology-enhanced learning resources are high-quality and effective

Overall, the benefits of using technology in health professions education outweigh the challenges. However, it is important to use technology thoughtfully and strategically to ensure that it is used to enhance learning, not replace it.” (Bard, 10/30/2023)

This is an impressive performance by Bard, and it offers a small preview of what technology may do. The ideas are not novel, but a wide range of thinking was summarised in a systematic fashion within seconds. This is just the beginning for generative artificial intelligence but it is clear that technology will reshape educational practice and scholarship. It also raises important questions about how we interact with it going forward.

II. SUMMARY

APMEC’s history provides a means of describing the dramatic growth in health professions education in the Asia Pacific region. The past 25 years have seen the focus of research expand from its start in medical education through all the health professions to IPEP. To drive this growth, new forms of scholarship have taken root. With its strong emphasis on context, SoTL enhances the relevance of this research to the cultures and practices of the region. Finally, technology, and our relationship with it, will have profound effects going forward. Taken together, these trends lay the groundwork for future work that will serve the needs of the region and have sizeable influences beyond it.

Note on Contributor

John Norcini wrote the paper.

Funding

No funding was involved.

Declaration of Interest

There are no conflicts to declare.

References

Lee, S. S., & Norcini, J. (2023). Celebrating excellence in the scholarship of teaching and learning. The Asia Pacific Scholar, 8(2), 1-3. https://doi.org/10.29060/TAPS.2023-8-2/EV8N2

Mackert, J. (2012). Social Closure. Oxford University Press.

Mirhosseini, F., Mehrdad, N., Bigdeli, S., Peyravi, H., Khoddam, H. (2018). Exploring the concept of scholarship of teaching and learning (SoTL): Concept analysis. Medical Journal of The Islamic Republic of Iran, 32(1), 553-560. https://doi.org/10.14196/mjiri. 32.96

Reeves, S., Pelone, F., Harrison, R., Goldman, J., & Zwarenstein, M. (2017). Interprofessional collaboration to improve professional practice and healthcare outcomes. Cochrane Database of Systematic Reviews, 6. https://doi.org/10.1002/14651858.CD0000 72.pub3

*John Norcini
Upstate University Hospital
750 East Adams Street
Syracuse, NY 13210
Email: John.norcini@gmail.com

Submitted: 30 June 2023
Accepted: 19 October 2023
Published online: 2 April, TAPS 2024, 9(2), 95-97
https://doi.org/10.29060/TAPS.2024-9-2/PV3075

Gabriel Tse Feng Chong^1,2

¹Singapore Armed Forces HQ Medical Corps, Singapore; ²Dental Specialist Accreditation Committee (Dental Public Health), Singapore

There is growing awareness of the need to include humanities in educating dental students at the undergraduate/pre-doctoral level (Marti et al., 2019). However, there appears to be no literature discussing or advocating the inclusion of humanities for the training of dental specialists. Dental Public Health (DPH) is one such dental specialty where its trainees and practitioners would benefit from an inclusion of humanities in its pedagogy.

This author opines that exposure to humanities (which includes, but is not limited to, literature – both fiction and non-fiction, art, history, narrative dentistry/medicine, philosophy, ethics, and medical anthropology) that touch on dental themes can make a DPH trainee/practitioner more rounded; able to empathise better with the individuals that his/her policies and programs would affect; become even more persuasive in health promotion efforts; and more articulate in their advocacy efforts with stakeholders and policy makers.

Unfortunately, the curriculum of most DPH training programs (in English speaking jurisdictions) do not include humanities apart from the inclusion of ethics in North American programs. Perhaps the roots of this problem can be traced back to the dental undergraduate/pre-doctoral level where the typical training is predominately focused on biomedical subjects. The result is “few dental schools have implemented humanities in their dental education” and where humanities are taught, ethics tend to form the bulk (Marti et al., 2019). At the postgraduate specialty-training level, this traditional segregation between what are considered ‘sciences’ on one hand, and ‘humanities’ on the other hand, are already ingrained for most dental specialties. However, the DPH curriculum is different from the sister dental specialties because the trainee is required to understand for instance: sociology, health-related behaviors, the interactions of social, cultural and political variables (including age, gender, socioeconomic status, culture, religion, ethnicity and globalisation) on public health, health inequities, and the provision of health services. In essence, the DPH curriculum aims to re-orientate the trainee from a biomedical model of care to a biopsychosocial model of care. As such, the DPH curriculum is a natural starting point for the inclusion of humanities in the training of dental specialists.

There are some foreseeable barriers to implement humanities in the DPH training curriculum – (i) the possible lack of DPH educators and practitioners who are well-versed or at least comfortable with humanities and this itself may be a barrier to even commencing the addition of humanities into the pedagogy, and (ii) finding the time and space to include humanities into the voluminous curriculum that the DPH trainee is expected to cover in a relatively short amount of time. One suggestion to resolve the former barrier is cross-disciplinary training, where dental and/or public health schools can reach across to educators and researchers in the humanities departments to co-develop the DPH-humanities curriculum and training materials. The latter barrier can perhaps be tackled by infusing readings and discussions on humanities into the DPH curriculum that already require the trainee to adopt a biopsychosocial approach to healthcare and where humanities would be natural additional skillsets for inclusion in the DPH trainees’/practitioners’ toolbox.

Oral health inequities exist in most, if not all, societies. The burden and resultant impact of dental caries is largely borne by those who are disadvantaged and underserved. This is true even of an affluent country in Asia-Pacific like Singapore with a highly educated populace with very good healthcare system, infrastructure, and policies. Singapore enjoys (i) an universal community water fluoridation program covering 100% of Singapore’s population, (ii) public health education to increase awareness and health literacy by actors, such as, the Ministry of Health (MOH) and Health Promotion Board (HPB), (iii) free dental care to school children up to 18 years of age, and (iv) an extensive network of dental clinics in the private and public sector (Chong & Tseng, 2011). Despite all these benefits, the burden of poor oral health is mainly carried by members of lower socioeconomic groups and certain racial groups (Chong & Tseng, 2011).

Humanities can also challenge the lens through which a DPH trainee/practitioner views oral health problems. For instance, even the current epidemiological trends of dental caries was not always the case. For example, if we were to go back in time to about the late 18th century, dental caries in Europe was largely a disease of the affluent. This is even mentioned in a gastronomical literature text ‘The Physiology of Taste’, written by Brillat-Savarin (published in 1825), in which the author describes the poor oral health of his fellow diners. He writes “what then if the mouth is neither fresh nor pretty? And what shall be said of those monstrous chasms which open up to reveal pits that would seem bottomless, if it were not for the sight of shapeless, time-corroded stumps?” (Chong, 2012).

What caused the epidemiological shift such that dental caries was no longer a disease of the affluent but became one of the poor? This is because until about the late 18^th century, sugar was not yet widely available to the masses for consumption frequently and/or in large quantities so as to cause widespread decay. For example, in England, the annual consumption of sugar per capita increased from almost zero in the 17^th century to 1.8kg in 1704 to 8.2kg in 1800, and finally to 40.8kg by the mid-19^th century (Chong, 2012). Several factors have been identified as the causes of increased consumption of sugar during this period: increased disposable income due to the industrial revolution; the availability of processed foods and beverages; and the change in dietary habits to add sugar as a sweetener to tea and coffee (Chong, 2012). 

This historical trend is important for the modern DPH trainee/practitioner because it approximates ecological studies and supports our modern understanding that the intake of dietary sugars is the most important risk factor for developing dental caries. This should focus DPH trainees’/practitioners’ efforts to tackle the Social Determinants of Health (including the commercial determinants, such as the health risks posed by the sugar and fast-food industries). Furthermore, the 180-degree shift in the epidemiology of dental caries should serve as a reminder that what is the norm of today can be changed drastically in the future, and therefore improvements at a societal-level are possible.

Despite being the most prevalent chronic disease condition globally, dental caries is seldom reported in the news save for the rare occasions where it is extremely headlines worthy, such as the case where a 12-year old American boy (Deamonte Driver) passed away because of an untreated tooth abscess arising from dental caries (Otto, 2017). In this regard, DPH trainees and practitioners can utilise the humanities (in the form of literature, narrative dentistry, and art) as useful media to showcase the plight of the poor and the injustice of oral health inequities. This is needful because sometimes key stakeholders and policy makers (who usually do not have healthcare backgrounds) may not quite comprehend or relate to quantitative data, whereas the narrative aspects such as the description of the individuals’ experience can be very emotive to nudge those stakeholders and policy makers towards the right direction. Editors and reporters of traditional media channels are more likely to publish articles and editorial pieces that are deemed ‘headlines worthy’ with a compelling story to tell.

To highlight the potential power of humanities in telling a story, the author would like to quote a passage from the novel ‘Les Miserables’ by Victor Hugo (originally published in 1862), that depicts the emotional and physical pain of those who were forced to sell their teeth out of dire economic circumstances; which was a fairly common practice in European society of that time.

Excerpt from Les Miserables (Hugo, 1982, p. 177 – 178):

He was an itinerant dentist selling sets of false teeth, opiates, powders, and elixirs… seeing Fantine laugh, the dentist cried:

‘You’ve got a fine set of teeth, my lass. If you’d care to sell me your two incisors I’ll pay you a gold napoleon for each.’

‘What are my incisors?’

‘Your two top front teeth.’

‘How horrible!’ exclaimed Fantine.

‘Two napoleons,’ grumbled a toothless old woman standing near. ‘She’s in luck!’

Fantine fled, covering her ears to shut out the man’s hoarse voice as he shouted after her:

‘Think it over, my girl. Two napoleons are worth having. If you change your mind you’ll find me this evening at the Tillac d’argent.’…

When Marguerite entered Fantine’s room next morning… she found her seated cold and shivering on her bed… and it seemed that she had aged ten years overnight.

‘Lord preserve us!’ cried Marguerite, ‘What’s the matter with you?’

‘Nothing is the matter with me,’ said Fantine, ‘I’m happy. My baby isn’t going to die of that dreadful disease for lack of medicine.’

She pointed to two napoleons that lay gleaming on the table.

‘A fortune,’ murmured Marguerite. ‘A fortune! Where did you get them?’

‘I earned them,’ said Fantine.

She smiled as she said it, and the candle lighted her face. It was a bloodstained smile. There were flecks of blood at the corners of her mouth and a wide gap beneath her upper lip.  

Notes on Contributors

The author conceived the ideas stated in this personal review article and wrote the manuscript.

Funding

The author declares that no financial support was received for this personal view article.

Declaration of Interest

The author declares that there is no potential conflict of interest.   

References

Chong, G. T. F. (2012). Jean-Anthelme Brillat-Savarin’s 1825 treatise on the mouth and ingestion. Singapore Dental Journal, 33(1), 31-36. https://doi.org/10.1016/j.sdj.2012.10.002

Chong, G. T. F., & Tseng, P. (2011). A review of the uses of fluoride and outcomes of dental caries control in Singapore. Singapore Dental Journal, 32(1), 14-18. https://doi.org/10.1016/ S0377-5291(12)70011-1

Hugo, V. (1982). Les Miserables. Penguin Classics.

Marti, K. C., Mylonas, A. I., MacEacher, M., & Gruppen, L. (2019). Humanities in predoctoral dental education: A scoping review. Journal of Dental Education, 83(10), 1174-1198. https://doi.org/10.21815/JDE.019.126

Otto, M. (2017, June 13). How can a child die of toothache in the US? The Guardian. https://www.theguardian.com/inequality/2017 /jun/13/healthcare-gap-how-can-a-child-die-of-toothache-in-the-us

*Gabriel Chong
Singapore Armed Forces HQ Medical Corps,
701 Transit Rd,
Singapore 778910
Email: g.chong@mail.com

Submitted: 6 May 2023
Accepted: 12 September 2023
Published online: 2 April, TAPS 2024, 9(2), 92-94
https://doi.org/10.29060/TAPS.2024-9-2/PV3054

Bhuvan KC¹ & Pathiyil Ravi Shankar²

¹School of Clinical Sciences, Faculty of Health, Queensland University of Technology, Australia; ²IMU Centre for Education, International Medical University, Malaysia

I. INTRODUCTION

Learning spaces can be physical, virtual, or hybrid spaces where students engage with the learning material and interact with peers and facilitators. Traditionally, learning spaces used to be classrooms, lecture halls, laboratories, and libraries and would include a teacher and students working inside a fixed space using a blackboard/whiteboard, PowerPoint projector, boards, and flexible/fixed seating arrangements.  With the advancement in educational methodologies and incorporation of technology and newer applications, learning spaces now include simulated laboratories, online learning platforms, and virtual and augmented reality-based platforms. Using virtual spaces students can interact and learn from wherever they are living/staying.

The healthcare sector has a demand for personalised and precision medicine, teleconsultation, artificial intelligence (AI)-assisted devices and programs, health/clinical applications, health informatics, and robotics along with the need for healthcare and clinical services and medicines. However, there has not been enough research and discussion around the built-in environment i.e., learning spaces in health sciences education and the activities of teaching and learning (Temple, 2007). Against this backdrop, we need to examine how students use learning spaces to interact and engage with the learning material in our current environment and think about how we can optimise the learning spaces for active learning and make them more impactful and future-ready.

II. LEARNING SPACES

Learning spaces in health sciences must consider the unique needs of these subjects in terms of teaching and learning activities, student engagement, and hands-on sessions. Learning spaces design are domain specific and must cater to the teaching and learning needs of the discipline. Designing learning spaces for health sciences is challenging. Learning space can have a significant impact on teaching and learning experiences. A well-designed learning space can help students in many ways:

• It can promote student engagement, is always inviting and comfortable, and stimulating for students. They can sit together and discuss a case or work on a project (Wilson & Randall, 2012).

• A nice and comfortable multi-purpose space can help students engage in project work. They can move the seating to suit their group’s needs, write on the table surface, and whiteboards and discuss, charge their laptops, and use the internet to interact in virtual spaces. Interactive classrooms could make instruction more efficient and effective. More research is needed on the effect of learning space design on students’ engagement and the outcomes of teaching and learning. Health sciences students engage in formal and informal learning, peer support and discussion, clinical case practice and use different diagnostic equipment.

• A well-designed and well-equipped classroom can allow teachers to design workshops and activities that engage students in groups. A flexible learning space can help teachers be more creative and innovative in their approach. Flexible learning spaces provide pedagogical opportunities and support innovative practices that are not easily provided by traditional learning spaces (Benade, 2019). Health Sciences schools must think of ways to design and use learning spaces to promote active learning and help students learn clinical decision-making, required skills, therapeutic reasoning, clinical examinations, and other important practical skills.

• A well-designed learning space can promote collaboration and enhance creativity among the students. A learning space where students can interact face to face, bring their devices, and use tables, boards, and other tools will promote better collaboration and learning. However, one significant challenge is to have enough collaborative learning rooms to accommodate students; multipurpose tables, boards, and other teaching aids and devices are important given that space is at a premium, especially in urban centres (Jamieson, 2003; Van Joolingen et al., 2005). Hybrid learning spaces may partly address this problem.

III. DESIGNING A COLLABORATIVE LEARNING SPACE

To design a collaborative learning space for health sciences we must examine how learning occurs. Active learning plays an important role. There is extensive use of technology in learning. We use interactive whiteboards, create personalised learning environments, wireless networks and the internet, interactive software such as PollEverywhere, Slido and MyDispense, games, applications, etc. to engage with learners in a physical, virtual, or hybrid environment. So, our first consideration is to have a learning space that is flexible, accommodative, supports technologies used for teaching and learning, and is sustainable. Some steps that we can include in our planning and design of learning space can be:

1) Define the learning objectives: The first key consideration while designing a learning space is to look at the programme learning objective. We need to evaluate what students want to achieve in terms of learning outcomes and what skills do they need to acquire for that programme/subject. For campuses running multiple programmes collaboration across the discipline is needed during the planning stage to look at learning spaces that can work for multiple disciplines. Health sciences students gain specialised skills for patient care, including clinical competence, interdisciplinary collaboration, ethics, cultural sensitivity, and patient communication.

2) Consider the size and layout: The learning space must have adequate room to fit all the pupils in the group, necessary furnishings, and equipment. Consider the programme’s enrolment and the activities that the learners will take part in. The layout should encourage student collaboration and active learning.

3) Utilise technology: Technology plays a significant role in modern-day learning. Our subjects/programmes are managed via online platforms like Moodle, CANVAS, Blackboard, etc. Post-COVID Universities/ Schools are running their programmes in a hybrid fashion. Integrating the latest technology, especially the information and communication technology (ICT) based applications and built-in system seems to be vital when we deliver our programmes through online platforms. Tests are run via online quizzes and electronic assessment platforms.

4) Flexibility in learning spaces: Flexibility is the key consideration when designing a learning space in modern classrooms. These learning spaces must be customisable to accommodate the various learning requirements of the students in a flexible learning environment.

5) Optimise lighting and acoustics: Lighting and acoustics are critical factors that can impact learning. It is important when we want to use a virtual environment for immersive learning or play a video to demonstrate 3D- anatomical illustrations. Ensure the learning space has adequate lighting, and acoustics are optimised to minimise noise levels and distractions.

6) Emphasise sustainability: When designing the learning space, sustainability should be a top priority. To lessen the environmental impact and foster a healthy learning environment, incorporate sustainable materials and designs.

7) Encourage collaboration: Active learning requires collaboration, which is a crucial component. Think about including group tables, breakout rooms, and collaborative learning spaces.

8) Customisation of learning spaces: Learning spaces (formal or informal) must be accommodative. For example, a learning space must fit multiple activities like workshops, lectures, problem-based learning, small group discussions, simulation activities, etc. Thus, having flexible elements like collapsible walls, movable desks and chairs, computers on wheels, and foldable furniture and equipment will be ideal from a customisation perspective.

IV. CHALLENGES IN DESIGNING LEARNING SPACES

Learning space design is challenging especially for health and medical sciences programmes because of the specialisation and the complexities of the curriculum and its requirements. It is even more challenging for resource limited settings where universities and schools are struggling to deliver high quality teaching and learning even in traditional environments. These challenges are manifold:

1) Health sciences curricula are content-rich but traditionally taught didactically. Designing learning spaces, crucial for activities like problem-based learning, clinical skill practice, and immersive anatomy learning, presents challenges due to their specialised requirements. Altering spaces to these needs is complex.

2) Keeping the learning spaces human centred is another challenge given the rapidly changing teaching and learning delivery methods brought about by information technology. The pedagogy must be the priority and technology must support it and make it more efficient.

3) Designing learning spaces involves multiple priorities. There are elements like curriculum/content requirement, disability access, collaborative learning, and use of technology. Creating a learning space balancing these elements is a challenge, especially for educational institutions in low resource settings.

4) Designing adaptable learning environments that embrace evolving technologies and teaching methods is complex. A versatile collaborative space, equipped with tables, chairs, digital tools, and virtual platforms, must serve diverse students and activities. This challenge is intensified in resource-limited settings, where maintaining physical and virtual elements, costly online resources, and internet quality pose additional hurdles.

V. CONCLUSION

Learning spaces need proper focus. Health science programs are undergoing major structural transformations. Thus, our learning space must be coordinated with active learning pedagogy and philosophy. While designing learning spaces we must consider flexibility, comfort, technology, collaboration, and safety to build a collaborative and futuristic learning space that allows students to engage with their learning content and achieve the required learning outcomes.

Notes on Contributors

BKC contributed to the conceptualisation of the manuscript, wrote the first draft, revised the subsequent draft, and contributed to the final draft. PRS contributed to the conceptualisation of the manuscript and critically revised the first draft. He contributed to the subsequent revision and finalisation of the manuscript.

Funding

The authors did not receive any funding for this article.

Declaration of Interest

The authors would like to declare that they do not have any conflict of interest.

References

Benade, L. (2019). Flexible learning spaces: Designed for inclusion? New Zealand Journal of Education Studies, 54(1), 53-68.

Jamieson, P. (2003). Designing more effective on‐campus teaching and learning spaces: a  role for academic developers. International Journal for Academic Development, 8(1-2), 119-133. https://doi.org/10.1080/1360144042000277991

Temple, P. (2007). Learning spaces for the 21st century: A review of the literature. Retrieved from https://www.advance-he.ac.uk/knowledge-hub/learning-spaces-21st-century

Van Joolingen, W. R., de Jong, T., Lazonder, A. W., Savelsbergh, E. R., & Manlove, S. (2005). Co-Lab: Research and development of an online learning environment for collaborative scientific discovery learning. Computers in Human Behavior, 21(4), 671-688. https://doi.org/10.1016/j.chb.2004.10.039

Wilson, G., & Randall, M. (2012). The implementation and evaluation of a new learning space: a pilot study. Research in Learning Technology, 20(2), 14431. https://doi.org/10.3402/rlt.v20i0.14431

*Bhuvan KC
Discipline of Pharmacy, School of Clinical Sciences,
Queensland University of Technology,
2 George Street, Brisbane, Qld, Australia
Email: kc.bhuvan@qut.edu.au

Submitted: 17 August 2023
Accepted: 21 December 2023
Published online: 2 April, TAPS 2024, 9(2), 87-91
https://doi.org/10.29060/TAPS.2024-9-2/SC3114

Isharyah Sunarno^1,2, Budu Mannyu^2,3, Suryani As’ad^2,4, Sri Asriyani^2,5, Irawan Yusuf ^2,6, Rina Masadah^2,7 & Agussalim Bukhari^2,4

¹Department of Obstetrics and Gynecology, Faculty of Medicine, Hasanuddin University, Indonesia; ²Department of Medical Education, Faculty of Medicine, Hasanuddin University, Indonesia; ³Department of Ophthalmology, Faculty of Medicine, Hasanuddin University, Indonesia; ⁴Department of Clinical Nutrition, Faculty of Medicine, Hasanuddin University, Indonesia; ⁵Department of Radiology, Faculty of Medicine, Hasanuddin University, Indonesia; ⁶Department of Physiology, Faculty of Medicine, Hasanuddin University, Indonesia; ⁷Department of Pathological Anatomy, Faculty of Medicine, Hasanuddin University, Indonesia

Abstract

Introduction: The study aimed to ascertain how the faculty at the Faculty of Medicine, Hasanuddin University perceived their role as a tutor during a problem-based learning activity during the academic phase of medical education, based on the length of time they acted as a tutor.

Methods: This was prospective observational research with an explanatory sequential mixed-method design, which was performed at the Undergraduate Medical Study Program, Faculty of Medicine, Hasanuddin University, from January 2023 until May 2023. Research subjects were divided into two groups: a) the Novice group and b) the Expert group. Quantitative data were collected by giving a questionnaire containing six categories with 35 questions and distributed by Google form. An independent t-test was used to compare the faculty’s perception, with a p-value <.05 significant. Followed by Focus Group Discussion (FGD) for qualitative data, which then were analysed by thematic analysis. The last stage is integrating quantitative and qualitative data.

Results: There were statistically significant differences in seven issues between the two groups. Most of the tutors in both groups had favorable opinions, except for the expert group’s disagreement with the passive role of the tutor in the tutorial group. Eight positive and twelve negative perceptions were found in the FGD.

Conclusion: Most tutors positively perceived their role in PBL, with the expert group having more dependable opinions and well-reasoned suggestions.

Keywords:           Problem-Based Learning, Undergraduate Medical Education, Focus Group Discussion

I. INTRODUCTION

The transition from teacher-centered to student-centered learning occurs with the introduction of active learning based on the needs of the students. The majority of effective active learning activities in the classroom were created in small groups using the Problem-Based Learning (PBL) approach. PBL has no worse outcomes in terms of academic performance and is more effective than conventional methods at enhancing social and communication skills, problem-solving abilities, and self-learning abilities, and allows the students to collaborate while integrating science, theory, and practice (Trullàs et al., 2022; Wiggins et al., 2017). A tutor or a facilitator is a pertinent element for the success of tutorial activities in PBL, thus evaluating periodically their perception and understanding about PBL activities, will help determine the need for resource development at the faculty level. Based on the aforementioned background, the author is intrigued to understand how the faculty at the Undergraduate Faculty of Medicine at Hasanuddin University perceived their role as a tutor during a PBL activity based on the duration they acted as a tutor.

II. METHODS

Short-case PBL tutorial is the model being implemented in our institution. An explanatory sequential mixed-methods observational prospective design study was carried out from January 2023 to May 2023. Informed consent was obtained from all the participants (ethics approval recommendation number: 99/UN4.6.4.5.31/PP36/2022). The study was conducted in three stages (Figure 1):

A. Stage 1

Gathering quantitative data via a survey disseminated using Google form, after which the information was analysed using SPSS version 25. The Likert scale, which ranged from 1 (extremely disagree) to 5 (extremely agree), was used to evaluate the 35 items in the questionnaire that served as the study’s primary data collection tool (Table 1 which is openly available on Figshare). The validity and reliability test for the study’s questionnaire was carried out as the first step and the Pearson Correlation was used to examine the outcome; all questions were valid with Cronbach’s α .951. The next step was to collect data through convenience sampling. Inclusion criteria were lecturers who: have attended training to become PBL tutors, are actively involved in PBL activities, and are willing to participate in the research projects to completion. Exclusion criteria were lecturers who were not familiar with the Google form application. Subjects with other commitments that prevented them from finishing the research activities and with a conflict of interest in continuing the study were considered dropouts. The research participants were split into two groups: the novice group (participants who served as tutors for less than five years) and the expert group (participants who served as tutors for five years or more). The Slovin formula was used to determine the minimum sample size, and the result was 32 people for each group. Characteristics of the study subjects were presented descriptively. An independent t-test was used to compare the faculty’s perception of their role as a tutor during a problem-based learning activity, with a p-value <.05 significant.

B. Stage 2

Focus Group Discussions (FGD) were held to collect qualitative data. The participants in the FGD were divided into two groups using the identical criteria utilised for the quantitative group categorisation, and each group consisted of six subjects. Each participant received a set of open-ended questions to be discussed during the FGD. All events and discussions were recorded, and then all conversations were transcribed using the VERBATIM app. MAXQDA 2020 was then used to tag and categorise the data. Thematic analysis was used to assess qualitative data. We used an audit trail and triangulation during data collection and conducted a peer review during data analysis to ensure the validity of the qualitative data.

C. Stage 3

Integrating quantitative and qualitative data was performed by linking data, followed by integration at the interpretation and reporting level which was conducted by integration through a narrative with a weaving approach.

III. RESULTS

A. Characteristics of the Subjects

The subjects in the novice groups were all under 45 years old, but the expert group was predominately made up of older faculty members. Both groups were predominately female. At the time of the research, medical doctors dominated the novice group, but the expert group included people with a range of educational backgrounds. Characteristics of the study subjects are openly available in Table 2 on Figshare.

B. Quantitative Data

Seven question items from four categories significantly differed between the novice and expert groups as shown in Table 3 which is openly available on Figshare.

C. Qualitative Data

Thematic analysis from the FGD revealed that the expert group only has negative perceptions, whereas the novice group has both negative and positive perceptions. The data are openly available in Table 4 on Figshare.

D. Integration of Quantitative and Qualitative Data

Faculty staff has the same perception about almost all concepts about the role of a PBL tutor, except for seven concepts that were statistically significantly different (Figure 1): 

1) PBL as Pedagogical Method: Q5 (group tutorials help students share experiences) and Q9 (PBL is a great tool for student learning) were significantly different, with the majority of the novice group agreeing with it while the majority of the expert group were extremely agreeable. Nevertheless, while the novice had a positive perspective shown in the discussion, the expert expressly stated that “(PBL) increased the (student’s) ability to discuss but not the depth of knowledge.”

2) Supervising Problem Processing in Tutorial Groups: Q12 (I function as a resource person in the group) and Q13 (I participate in creating a positive work environment for the group) were significantly different, with most of the novice group agreeing to the concept while the majority of the expert group were extremely agreeable. The novice group stated in the FGD that “PBL is very effective for building students’ analytical skills because the students can interact with each other to express their opinions and find key problem-solving strategies.” Both groups had the same perception that some tutors attended the PBL activities “just as a formality.” Q17 (I am sensitive to the wishes of the students regarding their need for support) was also significantly different, with most participants in both groups agreeing that tutors are sensitive to the student’s need for support, but 5.71% of the novices extremely disagreed. In contrast, none of the experts in the expert group disagreed with the concept. From the FGD results, the expert group suggested that the “tutor should give feedback and guidance to the students”.

3) Potential Barriers to Student Learning in PBL: the majority of both groups agreed that the group size is just right from a tutorial point of view (Q24), but the novice group had a wide range of responses (from extremely disagree to extremely agree), while 77.14% of the expert group agreed. “Six to eight students in one PBL group” is an elaborate suggestion made by the expert group as a result of the FGD.

4) There was a statistically significant difference between the two groups regarding the role of the tutor, which is usually passive in the tutorial group (Q29), with the expert group’s consensus on the matter being unfavorable, whereas the novice group’s responses were evenly split between neutral and disagree. The FGD’s results revealed that the novice merely stated, “If the students had a misleading concept, the tutor could not be kept silent,” whereas the expert suggested, “The tutor should be the chairman of the group discussion,” and “Questions and keywords must be made by the tutor.”

Figure 1. Integration of Quantitative and Qualitative Data

IV. DISCUSSION

PBL can be regarded as a multidisciplinary method that allows the learners to resolve real-life problems and situations in every aspect, learn how to construct new information meaningfully, put away the understanding of ready-to-use knowledge, and acquire critical thinking skills. Problem processing or facilitation is a challenging task (Aydogmus & Mutlu, 2019). Since PBL can be used in specific topics and can break up the monotony of traditional didactic teaching, it has become a popular alternative teaching strategy for undergraduate medical students. It can also be used as a method of integrated teaching. Overall, it is a great tool for students learning (Gadicherla et al., 2022).

The group size is one of the possible obstacles to students’ learning in PBL. All students will not be able to participate in a team that is too big. A team that is too small could not have enough members to address the learning objectives or enough diverse opinions to guarantee a robust discussion. The tutor should be aware of how the participants play their roles, noting those who do not contribute to debates or who are silent. Therefore, they must pay close attention to what is happening in the group process to intervene and provide feedback, promoting the participants’ individual and group progress. The tutor can assist the student in identifying their requirements through motivated evaluations and simple feedback, fostering the growth of self-confidence, autonomy, and, ultimately, integration into group dynamics. PBL teams ideally consist of 6–10 students (Dent et al., 2017).

V. CONCLUSION

Aside from seven concepts, both groups mostly had positive perceptions about their role as tutors, with the expert group having more dependable opinions and well-reasoned suggestions.

Notes on Contributors

Isharyah Sunarno made the following contributions to the study: conceptualised, created the initial draft and study design, investigated and collected data, conducted formal analysis, looked for research references, performed critical revision of the article, reviewed and edited the article, and approved the study’s final published version.

The following are the contributions Budu Mannyu made to the study: provided insights into the methodology, suggested research references, served as a peer reviewer of the study’s findings, performed critical revision of the article, and gave his approval of the final draft to be published.

Suryani As’ad contributed the following to the study: she offered insights into the methodology, proposed research references, served as a peer reviewer of the study’s findings, revised the article critically, and approved the final draft of the manuscript to be published.

The study benefited from Sri Asriyani’s efforts, which included: suggestion for research references, peer review of the study’s findings, and performed critical revision of the article.

The following contributions were made to the study by Irawan Yusuf: peer reviewing of the result, supervising the research activities, and critical editing of the publication.

The following are the contributions Rina Masadah contributed to the study: provided ideas into the original draft, supervised the research activities, and edited the publication critically.

Agussalim Bukhari made the following contributions to the study: offered insights into the methodology, oversaw the research activities, critically revised the final version of the article.

Ethical Approval

The study was approved by the Research Ethical Committee Faculty of Medicine Hasanuddin University with recommendation number: 99/UN4.6.4.5.31/PP36/ 2022.

Data Availability

The authors confirm that the data supporting the findings of this study are available within the article and its Supplementary material for research instrument in https://doi.org/10.6084/m9.figshare.23646918

Acknowledgement

Authors would like to express our sincere gratitude to all the tutors who participated in this study. A special appreciation is given to Ichlas Nanang Affandi and A. Tenri Rustam from the Psychology Study Program, Faculty of Medicine, Hasanuddin University for their valuable support throughout the research process, including their role as the facilitator of the FGD. We also would like to thank Andriany Qanitha and the CRP team from Faculty of Medicine, Hasanuddin University for their support in developing the manuscript. We are also grateful to the Department of Medical Education, Faculty of Medicine, Hasanuddin University for providing us with the resources and support we needed to complete this study.

Funding

This research received no external funding.

Declaration of Interest

The authors declare no conflict of interest.

References

Aydogmus, M., & Mutlu, A. (2019). Problem-based learning studies: A content analysis. Turkish Studies-Educational Sciences, 14(4), 1615–1630. https://doi.org/10.29228/turkishstudies.23012

Dent, J. A., Harden, R. M., & Hunt, D. (2017). A practical guide for medical teachers (5th ed.). Elsevier.

Gadicherla, S., Kulkarni, A., Rao, C., & Rao, M. Y. (2022). Perception and acceptance of problem-based learning as a teaching-learning method among undergraduate medical students and faculty. Azerbaijan Medical Journal, 62(03), 975–982.

Trullàs, J. C., Blay, C., Sarri, E., & Pujol, R. (2022). Effectiveness of problem-based learning methodology in undergraduate medical education: A scoping review. BMC Medical Education, 22(1), 1–12. https://doi.org/10.1186/s12909-022-03154-8

Wiggins, B. L., Eddy, S. L., Wener-Fligner, L., Freisem, K., Grunspan, D. Z., Theobald, E. J., Timbrook, J., & Crowe, A. J. (2017). ASPECT: A survey to assess student perspective of engagement in an active-learning classroom. CBE Life Sciences Education, 16(2), 1–13. https://doi.org/10.1187/cbe.16-08-0244

*Isharyah Sunarno
Jl. Perintis Kemerdekaan Km. 11,
Faculty of Medicine, Hasanuddin University
+62411-585859
Email: isharyahsunarno@gmail.com

Submitted: 20 April 2023
Accepted: 19 October 2023
Published online: 2 April, TAPS 2024, 9(2), 70-80
https://doi.org/10.29060/TAPS.2024-9-2/OA3044

Xiang Ren Tan^1,2, Anthony J Goff¹ & Li Whye Cindy Ng^1,3

¹Health and Social Sciences, Singapore Institute of Technology, Singapore; ²Human Potential Translational Research Programme, Yong Loo Lin School of Medicine, National University of Singapore, Singapore; ³Department of Physiotherapy, Singapore General Hospital, Singapore

Abstract

Introduction: Objective structured clinical examinations have traditionally been used to assess clinical skills. However, these face-to-face clinical assessments were hindered by physical and social restrictions imposed during COVID-19. This created a need to develop novel approaches for reliable assessment of clinical skills. We explored and evaluated a virtual exercise teleconsultation assessment (VETA) to replicate a teleconsultation setting where physiotherapy students were assessed on exercise prescription and coaching skills.

Methods: We conducted a cross-sectional mixed-methods study using convenience sampling. A VETA was implemented for 172 physiotherapy students via Zoom to allow synchronous interaction with standardised patients (SPs). 67 students and 9 SPs completed two separate post evaluation surveys on themes relating to administration, support, authenticity, effectiveness, and value of the VETA. Likert-type responses were categorised as positive, neutral, or negative while coded qualitative responses were consolidated into themes by inductive content analysis.

Results: 76% of students agreed that the assessment was authentic while 93% felt that the SPs were realistic and believable. Responders also highlighted important challenges including the limited camera viewing angle, time and space constraint, adequacy of equipment and reliability of connectivity. Exploratory factor analysis of responses revealed three latent constructs: (1) clarity of assessment, (2) clinical relevance, and (3) value of assessment.

Conclusion: Despite the technical challenges, VETA demonstrated clarity and value as an alternative assessment and showed relevance to future telehealth practice, which is increasingly pervasive in clinical settings. This paper demonstrates a feasible approach for the virtual assessment of clinical competencies.

Keywords:           Health Sciences Education, Virtual Assessment, Clinical Skills, OSCE, Physiotherapy, Exercise Prescription

Practice Highlights

• The ability to assess students non-obtrusively allows for fair assessment with reduced anxiety.
• Despite several technical challenges, VETA demonstrated value as an alternative assessment.
• An appropriate context of use, content validity and authenticity of virtual assessment are crucial.
• VETA format may be used for distant learning and remote assessment of clinical competency.
• Virtual care delivery should be included as part of healthcare professionals’ formal training.

Table 1. Response frequency for Likert-type questions

IV. DISCUSSION

A. Keeping Pace with the Digital World

With the advent of technology and increasing prevalence of virtual care (Stamenova et al., 2022), there is a need to rethink conventional assessments of clinical competencies in medical and allied health education. Formal exposure, training, and assessment of clinical care delivery over virtual platforms will be important to prepare students for the digital world, beyond traditional face-to-face environments (Fickenscher & Pagliaro, 2021). Many digitally empowered patients have turned to web-based platform for telerehabilitation services (Brennan et al., 2009). This underscores the need for future healthcare professionals to demonstrate clinical competencies that complement the virtual mode of care delivery.

In our study, VETA was designed as an alternative to traditional OSCEs for the reliable assessment of exercise prescription and coaching skills of physiotherapy students within a simulated teleconsultation setting. Standardised patients were involved to enhance the realism of the consultation session where it allows students to practice patient-centred care and professionalism in patient handling. VETA has garnered largely positive experience from both students and SPs. The qualitative responses from the surveys were supportive of the validity, authenticity, and value of VETA; however, important limitations have been highlighted to consider for improvements in the future. This represents a real-world use case of online synchronous assessment that can be implemented to evaluate clinical skills and competencies in medical or allied health education.

B. Assessment Authenticity and Relevance

In this study, VETA provided a unique opportunity for students to conduct and experience a simulated teleconsultation and it has been largely perceived as a valid and authentic assessment. The content validity of VETA can be assessed from the realistic clinical tasks perceived by students, the test content which represents what the curriculum needs to assess (exercise prescription and coaching skills), and the right domains being tested such as communication and patient-care skills and the safe conduct of exercise (American Educational Research Association, 2014). The authenticity and value of VETA were echoed by both the quantitative and qualitative responses in this study where students felt that it was a good way to equip them with skills necessary for telehealth practice. It is paramount to note that the challenge in conducting physical assessments under COVID-19 climate is not uniquely experienced by students but also, by health practitioners (Chen et al., 2020). Telerehabilitation has been advocated and practiced during the pandemic (Turolla et al., 2020; Werneke et al., 2021) to improve accessibility to care despite the movement restrictions.

The current pandemic may bring forth a new era where telehealth becomes more significant and forms a vital service delivery platform for allied health professionals in the future (Negrini et al., 2020). Hence, this supports the relevance of a teleconsultation setting with standardised patients in our virtual assessment. The lack of exercise equipment provided during examination, albeit perceived as a limitation by students, could present a learning opportunity for students to react and cope in low-resource settings which is valuable to their future professional practice. In addition, the ability to assess students’ performance non-obtrusively allows a fair assessment with introducing unnecessary anxiety with the presence of assessor, which might be unavoidable in conventional OSCE stations (Ferreira et al., 2020). Therefore, VETA serves as a viable alternative that allows remote assessment of clinical competency in physiotherapy students.

C. Challenges with Implementation

VETA was conducted synchronously through Zoom platform within campus with students and SPs residing in different locations. Consequently, a reliable IT support structure and network connectivity was crucial to the success of the online assessment (Hopwood et al., 2021). Indeed, the connectivity issue has been reflected in this study where it has led to the loss of precious time for students to perform their teleconsultation. In this scenario, the examiner had to make a precise judgement to either (1) extend the timing and risk delays to the examination process, or (2) determine if there was enough “interaction content” to assess with and proceed with original scheduled time. Therefore, this underscores the need to include buffer time for similar situations when planning for virtual assessment.

Furthermore, the wearing of masks has resulted in the muffling of voices which prevented effective communication between students and SPs on the teleconferencing platform. Facial gestures and expression are known to play an important role in interpersonal communication, comprehension, and the delivery of intended messages and this can be affected by mask-wearing (Mheidly et al., 2020). To ensure that the SP is able to understand the prescription adequately, transparent face-masks could be worn to facilitate communication. Nonetheless, we advocate that allied health students should learn and master non-verbal communication skills as transparent face-masks may not be commonly used in clinical settings.

Time and space allocation have also been perceived to be inadequate. Based on students’ qualitative feedback, the perceived lack of time was pertaining to the interaction with the SP during exercise prescription, and not the duration for reading and planning. Pacing of speech, ensuring clarity and prioritising of information to convey are instrumental in time-effective clinical communication which students need to master (Laidlaw et al., 2014). Therefore, the timing of teleconsultation has to be optimised, not solely based on students’ expectations, but also on the assessment criteria and desired difficulty level. Furthermore, the time allocated should reflect the duration of an actual teleconsultation session where it has been reported in vascular telemedicine setting to be approximately 10 minutes (Baldwin et al., 2003), similar to the VETA format. Secondly, to ensure that SPs can perform exercise freely and safely, future runs of the assessment should cater for 20 to 50 square feet of space in the rooms, as recommended by American Council on Exercise (American Council on Exercise, 2009).

D. Study Limitations

In our study, only 39% of the total student cohort who undertook the VETA completed the survey. Hence, this may inadvertently create responders’ bias in the survey findings (e.g., those who had a positive experience may feel more motivated to participate). In our study, the evaluation survey was disseminated to students only a day after the conduct of VETA. Future studies may explore administering the survey immediately after the completion of the virtual assessment, via accessible QR codes or weblinks, to encourage greater participation rate.

Additionally, the assessment scope of VETA was limited to only a single domain of skill competency (safe exercise coaching and prescription) of the physiotherapy program and may not represent the relevance of such format for evaluating other competencies. As VETA has only been evaluated in one school setting, it remains to be ascertained if a similar format can be successfully adopted by other universities or a different structured health sciences program. Future studies may explore VETA’s implementation in other settings (i.e., evaluating other clinical competencies or conducted in other programs) and identify the potential facilitators and barriers to its adoption.

Despite the use of self-reported questionnaires to evaluate predetermined themes, the exploratory factor analysis has showed that the “effectiveness” component may not be reliably assessed by the items that were designated. To be an effective assessment, it also implies that the assessment has to mimic actual clinical settings and test skills relevant to a physiotherapist. Therefore, the same items have been correlated to the identified constructs such as clinical relevance (directly linked to assessment authenticity) and the value of assessment. Nonetheless, the distilled 13-item subset survey with good internal consistency can be employed to evaluate other novel assessments related to clinical competency.

E. Implications of a Virtual Approach

Virtual OSCE, while shown to be a useful examination format, cannot entirely replace the traditional OSCE in the assessment of physical skills which is required for allied health professional practice. For instance, hands-on skills such as manual therapy involving the massage, manipulation and mobilisation of muscles and joints, are critical to restore the patient’s functional capabilities and promote their self-efficacy (Bronfort et al., 2010). It is challenging to assess such components using virtual assessments. Specific to therapeutic exercises, it is vital to assess physical facilitation (provision of support and tactile cues) during coaching of exercise to frail individuals or patients with mobility limitations. This cannot be properly assessed without allowing physical close contact with the SPs.

Nonetheless, the success of VETA in this study highlights the feasibility of assessing specific clinical skills reliably using an online synchronous approach. When utilised in an appropriate context (e.g., for assessing online exercise prescription skills), the virtual assessment can help students gain literacy and confidence in online care delivery. At the same time, it allows them to appreciate and navigate the challenges in virtual care settings such as the lack of space or limited camera viewing angle identified in this study. With the COVID-19 pandemic, the demonstration of clinical competency over an online platform may prove to be as, if not more, relevant than traditional face-to-face assessments.

F. Looking Ahead: The Application and Value of Virtual Assessments

To understand how virtual assessments can play a bigger role in medical or allied health education, it is first important to identify which clinical skillsets and competencies are applicable or commonly used in telehealth settings. This can help in the selection of appropriate assessment to be used. Digital literacy and proficiency in the use of telehealth technologies should form a key component of undergraduate clinical education. The use of web-based or teleconferencing platforms for care delivery should also be included as part of their formal training as a healthcare professional. This will help equip the students with the relevant skills for the evolving digital world. There is also a need for a paradigm shift to not just rely on traditional OSCEs for clinical assessments, but to incorporate elements of technology and virtual care delivery relevant to telehealth practice wherever applicable.

V. CONCLUSION

While there are still technical difficulties to consider, our current model and examination setup provides an initial framework for others to adopt as an online synchronous method to assess clinical skills, especially during lockdowns or restricted periods. Furthermore, this VETA format may be used for distant learning and remote assessment of clinical competency for healthcare workers residing in rural areas (Palmer et al., 2015) or students on placement in medically underserved areas. As the use of virtual assessments removes geographical barriers, this allows other experienced teachers and faculty from external institutions to join as assessors or observers to calibrate and align assessment outcomes, thereby enhancing the overall quality of medical education across institutions. Taken together, the use of virtual clinical skills assessment is promising and should be carefully considered for integration into the current medical or allied health education system.

Notes on Contributors

TXR contributed to the study design, conceptualised VETA, conducted data collection and analysis, and drafted the manuscript. AG contributed to assessment design and results interpretation. CN devised the study, innovated the VETA format, conducted data collection and contributed to results interpretation. All authors have read and approved the final manuscript.

Ethical Approval

The study was exempted from ethical review with the use of anonymous surveys with no recording of any identifiable information. In line with the Declaration of Helsinki and the institutional IRB exemption criteria, the study presents minimal risk to participants, does not touch on sensitive topics, does not involve vulnerable population, and does not involve deception or withholding of study’s stated aims and objectives from participants.

Data Availability

Datasets generated and/or analysed during the current study are available from the following DOIs: https://doi.org/10.6084/m9.figshare.22641013

https://doi.org/10.6084/m9.figshare.22641115

https://doi.org/10.6084/m9.figshare.22640998

Acknowledgement

We would like to thank all the students and standardised patients who participated in this study.

Funding

The authors received no specific funding for this study.

Declaration of Interest

The authors report no conflicts of interest.

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*Tan Xiang Ren
SIT Dover Campus,
10 Dover Drive,
Singapore 138683
Email: XiangRen.Tan@singaporetech.edu.sg

Submitted: 12 June 2023
Accepted: 24 October 2023
Published online: 2 April, TAPS 2024, 9(2), 81-86
https://doi.org/10.29060/TAPS.2024-9-2/SC3066

Lean Heong Foo¹, Nurul Haziqah Binte Suhaimi², Saudha Binte Sadimin², Marianne Meng Ann Ong¹

¹Department of Restorative Dentistry, National Dental Centre, Singapore; ²Dental Assisting, National Dental Centre, Singapore

Abstract

Introduction: An online survey was conducted on 16 National Institute of Technical Education Certificate (NITEC) Dental Surgery Assistant (DSA) trainees in National Dental Centre Singapore to find out their perceptions and understanding of mental well-being.

Methods: The 43-item survey included (i) Psychological General Well-being Index (PGWB) with 22 items based on 6 domains (anxiety, depression, positive well-being, self-control, general health, and vitality); (ii) 5 items on mental health knowledge; (iii) 4 items on lifestyle; and (iv) 12 items on perceptions of mental well-being and working in the dental clinic. Responses were collated for descriptive analysis and Cronbach’s alpha analysis was done for internal consistency for Likert scale items.

Results: The average PGWB score was 61.5 (range 18-89). Fourteen trainees (75%) indicated they were feeling depressed and 31.2% of trainees felt under stress in the past month. The majority (81.3%) of trainees recognised the role of exercise in maintaining mental health and 75% of trainees were able to differentiate between sadness and depression. However, 56.3% and 87.5% of the trainees incorrectly answered that mental and psychological disorders are not preventable conditions and mental disorders are caused by a wrong way of thinking respectively. The Cronbach’s alpha on PGWB (a = 0.87) and trainees’ perception of working in the clinic (a = 0.76) revealed good internal consistency.

Conclusion: The PGWB scores and survey analysis indicate there is a knowledge gap about mental health and the need to improve mental well-being in this cohort of NITEC DSA trainees.

Keywords:            Mental Well-being, Dental Surgery Assistant Trainee, Psychological General Well-being Index

I. INTRODUCTION

In National Dental Centre Singapore (NDCS), Dental Surgery Assistant (DSA) trainees are required to complete a 1-year National Institute of Technical Education Certificate (NITEC) DSA programme to be qualified as a DSA. Similar to the training of dental students, DSA trainees undergo a significant transition from learning in a classroom setting (4 weeks pre-clinical didactic and observation) to a high-stress dental clinic work environment (clinical) when they start on-the-job training 1 month after commencing their programme. During this transition period, they need to multi-task and adapt to new clinical responsibilities related to infection control, patient management, and assisting clinicians. It has been reported that 80% of 299 Israeli DSAs suffered from a high level of burnout where the most stressful work-related factors were low income, high workload, and work hazards (Uziel et al., 2019). A survey was thus conducted to gain insights into the perceptions of mental well-being and working in the dental clinic among NDCS’s NITEC DSA trainees. This was a needs analysis survey done in June 2022 for a mental wellness module that aimed to provide support to DSA trainees enrolled in the 1-year NITEC DSA programme.

II. METHODS

An online anonymous survey with written consent was disseminated via Form.SG to the 2022 cohort of DSA trainees to complete three months after starting their 1-year programme.  The 43-item survey included (i) Psychological General Well-being Index (PGWB) with 22 items based on 6 domains (anxiety, depressed mood, positive well-being, self-control, general health and vitality) (Dupuy, 1984); (ii) 5 items on knowledge about mental health; (iii) 4 items on lifestyle; and (iv) 2 items on perception of mental well-being (adapted from Puspitasari et al., 2020) and 10 items on working in a dental clinic (crafted based on NDCS context). DSA trainees rated their level of agreement based on a 6-point Likert scale for PGWB (5 -most favourable response to 0 – unfavourable response) and a 5-point Likert scale for the perception of mental health and working in a dental clinic (5 – strongly agree to 1 – strongly disagree). The PGWB score ranges from 0 to 110, effectively representing an individual’s comprehensive subjective well-being. Additionally, the six dimensions of the PGWB index provide valuable insights into the subjective well-being associated with each specific dimension. The survey responses were collated for descriptive analysis and Cronbach’s alpha analysis was done for internal consistency for Likert scale items.

III. RESULTS

The entire cohort of sixteen DSA trainees {all female; age 17-50, mean 28.19 (23.39-32.99)} completed the online survey (100% response rate). The data of this study are openly available in the Figshare repository at http://doi.org/10.6084/m9.figshare.23501136.

Only 25% of trainees (4/16) had more than 1 year of prior working experience in a dental clinic. Their collated responses based on their second-month experience of the 1-year programme are as follows:

A. Psychological General Well-being Index (PGWB)

The average PGWB score for this cohort was 61.5 (range 18-89, 95% CI 52.80 – 70.20), indicating lower than average general well-being in this cohort {normal range 68-83 (Dupuy, 1984)}. No significant correlation was found between age and dental clinic experience on PGWB (r=-0.03; -0.06). The Cronbach’s alpha in PGWB (a = 0.93) indicated good internal reliability with a good individual domain analysis of 0.85 for all the domains (Appendix A: Table 1, Figures 2 and 3).

1) General health: The trainees achieved a mean score of 8.94 (Range 0-15) in general health. The majority (68.75%, 11/16) of trainees agreed they felt healthy enough to function.

2) Positive well-being: The trainees experienced a lower than moderate level of positive emotion and life satisfaction with a mean score of 9.94 (Range 0-20). Only 5 out of 16 trainees (31.25%) were happy with their personal life most of the time.

3) Self-control: The trainees possessed a moderate to higher level of self-control in regulating their behavior and emotions (mean 56, Range 0-15). However, about half of the cohort (56.25%, 9/16) admitted they felt a lack of control over their action in the past month.

4) Vitality: The trainees exhibited a moderate level of energy and vitality (mean 10.31, Range 0-20). However, 7 trainees (43.75%) admitted they felt worn out and exhausted most of the time in the past month.

5) Depressed mood: The trainees, on average, experienced a relatively moderate level of depressive symptoms in the past month (mean:88, Range 0-15). Fourteen trainees (75%) admitted they were feeling depressed and 31.2% of trainees (5/16) had felt under stress in the past month.

6) Anxiety: The trainees exhibited a moderate level of anxiety (mean 12.88, Range 0-25). Majority (81.25%, 13/16) of trainees admitted they felt high-strung quite a good bit of time in the past month.

B. Knowledge about Mental Health

Majority of DSA trainees (81.3%, 13/16) recognised the role of exercise in maintaining mental health and 75% (12/16) of trainees were able to differentiate between sadness and depression. However, 56.3% (9/16) of the trainees incorrectly answered that mental and psychological disorders are not preventable conditions, and a majority (87.5%, 14/16) incorrectly answered that mental disorders are caused by a wrong way of thinking (Appendix B).

C. Lifestyle

Half of the cohort exercised at least once a week. Only 50% of the cohort had self-care activities for themselves. Majority of the trainees (15/16) did not meditate and 50% of the trainees sought help from their friends and family when necessary (Appendix B).

D. Perception of Mental Well-being and Working in a Dental Clinic

Majority of the trainees also gave a neutral response (75%, 12/16) to the statement related to stress from working in the dental clinic. Majority agreed that mental health is important for their general health (87.5%, 14/16). Only half of the cohort indicated they were comfortable to work in the dental clinic (56.3%, 9/16) (Figure 1). About ¾ of the cohort believed they could complete the training programme and were confident to perform the on-the-job training (75%, 12/16). Majority (81.3%, 13/16) were willing to seek help if they encountered problems working in the dental clinic (Figure 1). The Cronbach’s alpha of trainees’ perceptions of working in the clinic (a = 0.76) revealed good internal consistency.

Figure 1. Perceptions of DSA trainees of mental well-being and working in the dental clinic in the second month of their 1-year programme

IV. DISCUSSION

Mental well-being is associated with one’s ability to cope with normal stresses of life and work productivity. This is particularly important in health professionals, including DSAs, to ensure the quality of patient care and professional satisfaction. To our knowledge, this is the first local survey to investigate DSA trainees’ perceptions of mental well-being and working in the dental clinic. The PGWB analysis revealed this cohort of DSA trainees had a lower-than-normal score that was even lower than a group of 320 Japanese dental students (61.5 versus 68.63) (Sugiura et al., 2005). Additionally, the trainees also demonstrated moderate levels of depression and anxiety, with a detailed analysis indicating a significant number experiencing stress.  This observation highlighted the transition from pre-clinical to clinical training phase can be challenging and stressful with increased workload and responsibility, as evident among DSAs who demonstrated a moderate level of professional burnout (Uziel et al., 2019). A similar trend was observed in this transition phase for dental students, where stress was associated with increased responsibility and demands associated with caring for real patients (de Souza Ferreira et al., 2023). Despite the difference in curriculum and a larger student cohort, the Japanese dental students (Sugiura et al., 2005) appeared to cope with their training better as their PGWB revealed they were more relaxed (Anxiety 16.43 versus 12.88) and cheerful (Depression 11.24 versus 9.88) compared with our DSA trainees. This finding reflects the need for providing mental well-being support for our DSA trainees in their programme.

The misconceptions about mental health and infrequent self-care practices among trainees suggest a lack of awareness of mental wellness.  Implementing a mental wellness module focusing on positive psychology, coping techniques like breathing exercises and meditation, and resource awareness can help address these issues. The Trainees’ willingness to seek help and recognise exercise’s role in mental health shows openness to support and intervention. Our pilot data is constrained by a small sample size and the absence of a control group for comparison, making it insufficient for general population inferences. The limitation of PGWBI includes only 6 dimensions and the potential of bias due to self-reported data.  Future recommendations involve re-evaluating the impact of the mental wellness module at the end of the 1-year program, inclusion of qualitative data, and establishing a supportive work environment with accessible mental health resources and mentorship to enhance the well-being and job satisfaction of DSAs.

V. CONCLUSION

In conclusion, the survey findings from this small cohort of DSA trainees underscore the importance of addressing mental health and well-being in this group of learners. The high prevalence of depressive symptoms and reported stress among the trainees highlights the need for targeted interventions and support systems to promote mental well-being. Hence, a mental wellness module will be introduced to this cohort of DSA trainees and this survey will be repeated 3 months after the module completion to assess any changes in this cohort’s perception of mental well-being and working in the dental clinic. 

Notes on Contributors

FLH reviewed the literature, contributed to the study conception, data acquisition, and data analysis, drafted, and critically revised the manuscript.

NHS contributed to the data acquisition, data analysis, and critically revised the manuscript.

SS contributed to the data acquisition, data analysis, and critically revised the manuscript.

MO contributed to the study conception, data acquisition and critically revised the manuscript. All authors gave their final approval and agreed to be accountable for all aspects of the work.

Ethical Approval

This study was exempted from the formal Centralised Institutional Review Broad review by SingHealth Institutional Review Board (CIRB Ref: 2022/2122).

Data Availability 

The data that support the findings of this study are openly available in the Figshare repository http://doi.org/10.6084/m9.figshare.23501136.

Acknowledgement

We would like to thank Ms Liu Yanting for her help in data preparation and collection.

Funding

There was no funding involved in the preparation of the manuscript.

Declaration of Interest

The authors declare no conflict of interest.

References

de Souza Ferreira, F., Barros, I., da Costa Neves, T., Pazos, J. M., & Garcia, P. P. N. S. (2023). Stress amongst dental students in the transition from preclinical training to clinical training: A qualitative study. European Journal of Dental Education. 27(3), 568-574.

Dupuy, H. J. (1984). The Psychological General Well-Being (PGWB) index. In: Wenger NK, Mattson ME, Furberg CF, & Elinson J (Eds). Assessment of quality of life in clinical trials of cardiovascular therapies. 170-183. Le Jacq.

Puspitasari, I. M., Garnisa, I. T., Sinuraya, R. K., & Witriani, W. (2020). Perceptions, knowledge, and attitude toward mental health disorders and their treatment among students in an Indonesian university. Psychology Research and Behaviour Management, 27(13), 845-854. 

Sugiura, G., Shinada, K., & Kawaguchi, Y. (2005). Psychological well-being and perceptions of stress amongst Japanese dental students. European Journal of Dental Education. 9(1),17-25. 

Uziel, N., Meyerson, J., Birenzweig, Y., & Eli, I. (2019). Professional burnout and work stress among Israeli dental assistants. Psychology, Health & Medicine, 24(1), 59-67.

*Foo Lean Heong
National Dental Centre Singapore
5, Second Hospital Avenue
168938 Singapore
Email: foo.lean.heong@singhealth.com.sg

Submitted: 30 May 2023
Accepted: 24 October 2023
Published online: 2 April, TAPS 2024, 9(2), 60-69
https://doi.org/10.29060/TAPS.2024-9-2/OA3062

Mary XiaoRong Chen¹ & Dora Howes²

¹Health and Social Sciences, Singapore Institute of Technology, Singapore; ²Nursing & Health Care School, School of Medicine, Dentistry & Nursing^, University of Glasgow, United Kingdom

Abstract

Introduction: Nurses’ professional identity is important for their career orientation and clinical practice. This study explored Singaporean nurses’ perceptions of professional identity. The results provide an understanding of how guided learning and reflection could help nurses in their professional identity formation and development.

Methods: Using an exploratory descriptive qualitative research study and purposive sampling by researchers teaching in the programme, 64 Registered Nurses with a diploma qualification pursuing a Bachelor of Science degree with Honours in Nursing programme in Singapore were invited to participate. They responded to open ended survey questions online, which were analysed using a thematic analysis. Ethical approval was obtained.

Results: All 64 first year students were invited to participate at the start of the module and upon the completion. The response rates were 94% and 81% respectively. Two overarching themes – “nurses as professionals with knowledge and moral character” and “the construction of professional identity” – emerged from the data.

Conclusion: The nurses perceived their professional nursing identity as a construct comprised of knowledge and moral characteristics, which is consistent with international literature. A professional nursing identity, relationships with other healthcare professionals, patients and confidence in practice were all interrelated. Guided reflection and discussion on clinical experiences and social interactions helped students become aware of their professional identity and responsibilities. Such purposive educational effort needs to be started early and supported through the students’ educational journey into clinical practice.  

Keywords:           Professional Identity of Nursing, Singapore Nurses, Image of Nursing, Social Perception of Nursing in Singapore, Nurse Education

Practice Highlights

• Professional nursing identity can be facilitated by guided reflection.
• Purposive educational effort needs to be started early and continued in clinical practice.
• Awareness of professional identity relates to practice, relationship and professional development.

III. RESULTS

All 64 students agreed to participate and signed the consent form. The response rate at each collection point was 94% and 81% respectively. While the reason for the drop is not clear, it is possible that the demands from competing modules at the time of the second survey were influential.

Two overarching themes emerged (Table 4). The first, “Nursing profession is perceived as a profession with knowledge and moral character” stood out clearly from the responses given. It encompassed the subthemes of knowledge and moral character. The second theme – “The construction of professional identity” – elicited codes that made up the subthemes of social factors, identity challenges and nurses’ role in the construction of their professional identity.

Theme 1. Professionals with Knowledge and Moral Character

Students perceived a professional nurse as someone with a “good character, and capable of knowing” and “doing what was needed with self-control and discipline”. The theme was supported with two subthemes – ‘knowledge’ and ‘moral character’. 

1) Knowledge: The students believed a professional nurse needed to engage in learning throughout their professional lifetime. A knowledgeable nurse was described as “knowing the job well” and “having special knowledge and being able to perform well”. The knowledgeable nurse could create new knowledge through study as exemplified in the quote below.

“…Professionalism is the outcome of a work that can have both the elements of arts and science …. been thoroughly sorted out to create knowledge that could be of relevance to the present study or development for future studies.”

(S37)

2) Moral character: The moral character of a professional nurse encompasses the moral agency demonstrated in his/her daily practice. A nurse needed to be “someone with good virtues and moral values” and uphold “ethical conduct and practice contentiously beyond any selfish thoughts”. The quotes below indicate some of these moral characteristics:

“Nursing is a job that is not meant for anyone, it takes dedication, strength and passion to be one.”

(S44)

“Because we work together as a team, it is important to trust each other based on the individual training that we had gone through and are able to carry out our duties well. It also serves as a form of accountability to people in our team and people receiving care from us”

 (S08)

Students were clearly aware of the ethical code expected of them, which was reassuring in terms of the pre-registration education received.

Theme 2. The Construction of Professional Identity

This theme illuminated how the students viewed the construction of their professional identity. Three subthemes including ‘a social perception’, ‘identity challenges’ and ‘realising their role in the construction of professional identity’ were elicited.

1) A social perception: The students’ perception of their professional identity was influenced by the images and values directed towards nursing by society in comparison to other professions. The students perceived doctors, lawyers, and teachers as well-respected professionals. Doctors were “in a white coat with a stethoscope around their neck with confidence” while lawyers and teachers had “nice and neat suits” and were deemed to be “a sage or Master Yoda”, or “a confident global speaker”, “the force is within them”, or “have an aura of superiority, authority and power”. In contrast, the students viewed themselves as engaging in a “low skill/dirty job and of lower social status” due to the nature of the essential care they delivered daily. Such socially perceived images of being a professional were internalised resulting in the projection of a poor perception of their care work and image, as indicated here.

“When the word professionalism…the image of a doctor comes to my mind…portrayed as a superior figure as compared to a nurse… they (patients) will usually turn for help from [the] doctors as they perceive that doctor[s] have all the information and knowledge…parents also encourage or advise their children to become doctors…

(S17)

2) Identity challenges: Closely linked to social perception, the students encountered identity challenges from their interactions with people around them. They noted the development of special relationships with patients while remaining deferential to doctors. Some students also felt the process of professionalisation was akin to a sorting method, which differentiated professionals into higher or lower social status. Such relationships caused confusion and challenged their professional identity as the following quotations exemplify.

“I think that by having professional identity…only favours the doctors… Even if nurses make the right decision and doctors are wrong in the case, patients will still think that doctors are always right.”

(S17)

“The effect of professional identity in our practice is that the people around us may or may not get [us] respected. For example, in front of the doctors, we would portray like a maid who just do as what they say. However, in front of patients, we are their healthcare advocates which they listened to. Thus, it is a mixture of set of identity…”

(S28)

3) Realising their role in the construction of professional identity: The guided reflection created a safe space and provided methods for students to learn from their own and others’ experiences. As the module progressed, students came to realise their roles and their relationship with other professionals, as well as their responsibility in constructing their professional identity and how this identity was then portrayed to others. The quotes below offer some examples:

“The effects of the professional identity are how you portray the occupation to the world. People tend to judge the occupation by the way we portray ourselves.”

(S63)

“I value my role as a nurse as I feel that nurses can play a lot of roles…versatile, as nurses have greater knowledge than patients think. Also, nurses have judgment and good assessment skills so that we can identify what is not right with patients right away.”

(S17)

At a wider level, the students portrayed an optimistic outlook on their professional status with reference to the approved prescription rights to APNs in Singapore (Liew, 2018). The students felt their devotion towards patients led to them gaining wider trust and respect, as shown here:

“I valued the fact that my role gave me a sense of responsibility to advocate to the best of my patient’s interest. And the fact that more people are approaching nurses for advice makes me feel that we have slowly gained public trust on nurses.”

(S64)

The students believed that mutual respect was essential for quality patient care, positive relationships, and the affirmation of their professional identity. Student S54 provided an example.

“As a nurse, I feel that mutual respect is vital for nursing. As the nurse respects the patient as an individual to provide the best quality care, the value for respect towards nurses should also be established as professionals.”

(S54)

IV. DISCUSSION

The study demonstrated that students perceived nursing as a professional with knowledge and moral character, which is consistent with the professional requirement by the SNB (2011). However, students perceived a lack of awareness of nurses’ roles and some confusion about nursing identity by the public and other healthcare professionals, which does not reflect the intended development of nursing practice.

The repeated comments of nurses being perceived as inferior to doctors by the public indicated that to them, nursing is still viewed negatively and of lower social status in Singapore, similar to the study done by Tay et al. (2012) ten years ago where nurses felt devalued and disrespected. Internationally, a division in the treatment towards doctors and nurses persists, as people tend to give doctors credit and recognition and view nurses as having a complementary role (de Araujo Sartorio & Pavone Zoboli, 2010; de Meis et al., 2007; Johnson, 2018; Kemmer & Paes da Silva, 2007). The biased perception and treatment contribute to the devaluation of nursing, resulting in a focus solely on nursing functions and categories, rather than profiling nursing’s professional identity.

Despite more nurses pursuing higher education and leading comprehensive patient care roles such as APNs in Singapore, patients still have a poor perception of their roles and lack awareness of the preparation needed (Woo et al., 2020). A study set in a primary care setting found that doctors viewed APNs as competent clinical partners, but their roles were not well understood (Soh et al., 2021). This role confusion is possibly due to the breadth of nurses’ roles and a failure to communicate their professional roles effectively to the public. Pimenta and Souza (2017) reviewed 55 newspapers concerning the professional identity of nursing from 1983 to 2012 and found that nursing was treated as a unified entity. There was no differentiation between “nursing practiced by nurses” from the “nursing practiced by the other workers making up the team” (Pimenta & Souza, 2017, p4) indicating there is still much work to be done to make the roles of nurses more comprehendible and visible.

This study showed how intentional education can help nurses to reflect on their clinical experiences and form a positive professional identity. The finding is consistent with that of a recent study by Fitzgerald and Clukey (2022, p1349) who found that reflection helped students to “think about thinking”, connecting the dots together to know what nursing really is and internalise their professional identity. The educational effort highlighted in both studies can be extended to interprofessional education, to create opportunities for different professional groups to learn together and understand one another’s abilities and roles better. In Singapore, studies on interprofessional learning revealed improved communication, mutual respect, trust and changing the stereotypes and attitudes towards the nurse–physician relationship (Liaw et al., 2014; Liaw et al., 2023). Another study demonstrated how interprofessional virtual rounds helped students from six healthcare courses, including nursing, to gain insights into one another’s professional role and build mutual trust (Liaw et al., 2020). However, these studies were all based in schools with a short duration of learning. Intentional education and long-term studies on professional identity and interprofessional relationships should be continued in clinical settings.

A Singaporean ethnographic study by Chen et al. (2021) exposed the complexity of nurses’ daily work and how nurses navigated their participation and relationships with other healthcare workers. The deliberation of nurses’ professional identity is not a single professional affair, but that of all healthcare professionals. Nevertheless, more action is needed from nurses, nurse educators, and nursing leaders to define, develop, and portray their professional identity. Ben Natan and Becker (2010) urged nurses to let the public know what their work entailed by giving speeches and presenting their work through social media. With the Healthier SG movement (MOH, 2023), it is foreseeable that nurses will play more important roles in preventive and community health. Nurses should seek opportunities to communicate their roles and articulate their abilities to the public.

This study collected data from only one group of nurses undergoing a top-up degree study. Many nurses did not explain their ideas in detail. Future studies can consider using interviews and focus group discussions to explore these ideas in further depth. Nurses from various nursing schools and clinical settings could also be included and views from the public and other healthcare professionals would be welcomed.

V. CONCLUSION

Nursing identity is influenced by multiple factors, which can cause role confusion. The educational effort is vital to nurture nurses’ abilities to reflect, deliberate and communicate their professional identity. Nursing schools in Singapore and further afield need to include such intentional reflective approaches to help nursing students deliberate their professional identity and to nurture their ability to do so throughout their professional careers. Nurses and nursing leaders need to be more proactive in communicating their professional values and roles. More longer-term research is needed in both education and clinical practice settings to understand the sustained effect of education on nurses’ ongoing negotiation of their professional identity.

Notes on Contributors

Dr Mary XiaoRong Chen reviewed the literature, designed the study, conducted the data collection, data analysis and wrote the transcript.

Dr Dora Howes reviewed the data analysis, contributed to the manuscript and gave critical feedback on the final version.

Both authors read and approved the final manuscript.

Ethical Approval

The study was approved by the Singapore Insitute of Technology Ethics Committee (Project 2018007).

Data Availability

The data that support the findings of this study are available in the repository at: https://doi.org/10.25447/sit.23515425

Acknowledgement

We thank all student nurses who participated in the research.

Funding

This research did not receive any specific grant from funding agencies in the public, commercial, or not-for-profit sectors.

Declaration of Interest

The authors do not have any conflicts of interest. Participation in the research was voluntary and anonymous. Student nurses were assured that their participation or nonparticipation would not affect their learning or academic standing.

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*Mary Chen Xiaorong
10 Dover Drive,
Singapore 138680
Email: Mary.chen@singaporetech.edu.sg / xiaorong8@gmail.com

Submitted: 2 July 2023
Accepted: 17 November 2023
Published online: 2 April, TAPS 2024, 9(2), 51-59
https://doi.org/10.29060/TAPS.2024-9-2/OA3078

Soi Moi Chye¹, Rhun Yian Koh¹ & Pathiyil Ravi Shankar²

¹Department of Applied Biomedical Science and Biotechnology, School of Health Science, International Medical University, Kuala Lumpur, Malaysia; ²IMU Centre for Education, International Medical University, Kuala Lumpur, Malaysia

Abstract

Introduction: People skills play a crucial role in the professional development of Biomedical Scientists. A laboratory management and professional practice module was offered as part of the people skills development for Biomedical Science first-year students.  This study aims to describe the use of role-play to teach stress and anger management skills to Biomedical Science students and reports on students’ opinions of role-play as a teaching-learning method.

Methods: Students were divided into groups with 10 or 11 students per group. Each group of students presented a role-play for 15 to 20 min. This was followed by reflections by the group, feedback from other groups, and the facilitators. At the end of the session, student feedback was taken by a questionnaire using both closed (using a 5‑point Likert scale) and open‑ended questions. Statistical evaluation of the collected data was carried out using SPSS version 28 for Windows.

Results: A total of 96 students from the 2021 and 2022 cohorts participated in the role-plays. The survey was completed by 48 students from the 2021 intake and 33 students from the 2022 intake. The overall response rate was 84.37%. Respondents perceived role-play to be enjoyable, useful, and helpful for developing stress and anger management skills. They wanted role-play to be used as a teaching-learning method in the future.

Conclusions: Role-play can be effective to teach stress and anger management skills to undergraduate Biomedical Science first-year students.

Keywords:           Role-Plays, Stress and Anger Management Skills, Biomedical Science, Professional, Questionnaire, Feedback; Undergraduate

Practice Highlights

• Respondents perceived role-play to be enjoyable, useful, and helpful for developing stress and anger management skills.
• Role-play can be effective to teach stress and anger management skills to undergraduate Biomedical Science first-year students.
• Role-play was recommended to be used as a teaching-learning method in the future.

I. INTRODUCTION

People skills are the ability to communicate effectively with others, build relationships, and work collaboratively. People skills include active listening, empathy, conflict resolution, and teamwork. Anger and stress can impact people skills, especially interpersonal communication (Strumska-Cylwik, 2014). It is important to note that people who are easily angered and stressed often come from families that are disruptive, chaotic, and not skilled at emotional communication. Uncontrolled anger and stress can negatively affect physical health and emotional well-being and can lead to problems at work, in personal relationships, and in the overall quality of life (Armstrong, 2012). There is an important link between anger, stress, interpersonal skills, and emotional intelligence (Schutte et al., 2001). Bennett et al. (2016) reported that soft skills (people skills) are more critical for future employment than technical skills, and their enhancement has a lifelong impact. These skills are particularly important for health professionals due to the close relationship between them and their patients.

Health professionals are required to possess a technical background, which includes reasoning and critical judgment, as well as competency in communications, conflict resolution, negotiation, and decision-making (Morrell et al., 2020). A study among undergraduate medical students found a decline in students’ people skills, and a more technical approach replaced a more spontaneous and humane approach (Wahlqvist et al., 2005). Ahmad et al. (2014) concluded that most engineering students possess technical skills but lack people skills. One of the reasons is that teachers lack comprehensive knowledge and experience in teaching soft (people) skills to students (Ahmad et al., 2014). Ministry of Higher Education Malaysia (2005) states that the development of soft (people) skills requires a student-centred approach. Similarly, Mohd-Amin and Mohd-Nor (2010) and Morris (2009) suggest that teachers should be more creative when devising teaching and learning strategies so that students’ people skills can be more effectively organised and developed. Curriculum quality and teachers have an impact on students’ listening, responding, questioning, and formulating abilities (Morris, 2009). These skills acquired by an individual assist them in optimising their performance and include communication skills, teamwork, leadership skills, problem-solving skills, critical thinking skills, time management, and emotional intelligence (Siu et al., 2021). Teachers are therefore vital to implementing people skills relevant to the courses they teach. At our university student evaluations of laboratory management and professional practice module indicated they were not satisfied with the teaching of these skills through lectures. Students indicated that the lectures were boring, not effective, and the content was already known. Thus, we used a different method of role-play to teach stress and anger management skills. 

Role-play is defined as an approach to learning in which learners act out roles in case scenarios to provide targeted practice and feedback for the development of skill and competency (Nair, 2019). As a result, they gain a first-hand experience of human interactions and a better understanding of appropriate behavioural approaches to situations like those in real life. This approach emphasizes the learner’s need to know, self-direction, and varied experiences, contributing to the adoption of a problem-centred approach (Shankar et al., 2012). According to Harries and Raban (2012), role-play is a useful technique for engaging students in the learning process and environment. Through role-play, students can communicate and experience different situations and contexts, which can be used by teachers to develop students’ problem-solving, critical thinking, and creative skills. Furthermore, role-play allows students to experience a variety of different domains: cognitive, emotional, physical, and literacy domain (Beard et al., 1995). Additionally, role-play has been proven to be an effective method of developing skills such as active listening, problem-solving, empathy, teamwork, knowledge acquisition, and effective communication in various fields of training (Beard et al., 1995; Harden & Gleeson, 1975; Kim, 2018). Apart from this, role-play is an effective teaching strategy for health science students and is used by medical students to practice communication skills effectively and promote empathy and a more patient-centred approach to care (Ong et al., 2022). Based on the findings of Rønning and Bjørkly (2019), role-play in health sciences education enhances students’ therapeutic and communicative skills and facilitates personal and professional growth as it increases students’ ability to learn what it is like to be in others’ shoes and, through that experience, develop empathy and reflection. Role-play can be an effective tool for developing stress and anger management skills. It allows individuals to practice new behaviours and techniques in a safe and supportive environment, which can help to build confidence and improve overall well-being (Snowden & Rebar, 2018; Sutton, 2022).

The International Medical University (IMU), Bachelor of Science (Hons) in Biomedical Science programme is designed to produce work-ready graduates who are well-equipped with knowledge and are competent in practical, as well as people skills. The curriculum of the programme includes research-based teaching and problem-based learning, and students learn from experienced faculty. In addition to didactic large group teaching sessions (plenaries), the programme is also delivered through small group teaching sessions, such as problem-based learning, workshops, computer-aided learning, tutorials, seminars, presentations, etc. The learning outcomes of stress and anger management sessions are the definition of anger and stress; anger and stress management skills; contributing factors to stress and anger; and approaches to managing stress and anger engagement. The present study was conducted to explore the participants’ perception of the usefulness, understanding, enjoyment, and feedback of using role-play as a teaching-learning method for developing stress and anger management skills.

II. METHODS

Stress and anger management skills are a component of the laboratory management and professional practice module. This module is compulsory for first-year Biomedical Science students. Role-play was chosen to deliver stress and anger management skills because previous students were not satisfied with lectures as the teaching-learning method. Role play serves as a method of experiential learning in which learners assume various roles and engage in interactive experiences in diverse learning environments. The theory of experiential learning underscores the significance of acquiring knowledge through hands-on experience and subsequent reflection, constituting fundamental components of contemporary approaches to adult education (Nestel & Tierney, 2007).

A total of 96 students from the 2021 and 2022 cohorts participated in the role-plays. The sample size calculation is shown below.

The calculator.net (www.calculator.net) sample size calculator was used. The confidence level was 95%, and the margin of error was set at 5%, assuming a population % of 50% and a population size of 96. The recommended sample size using these parameters was 77.

The questionnaire used to obtain student feedback is based on that used by Shankar et al. (2012) with some modifications as shown in Appendix I. In that study, original role-play questionnaires were used by students from the third, fifth, and sixth semesters of the Medical Humanities module. Thus, some of the questions, such as “Have you been exposed to the use of role-plays for educational objectives before?” “Are you aware of the use of role-plays in medical education elsewhere?” were removed. The rest of the questions are similar. Feedback was obtained from the Biomedical Sciences programme first-year students. The questionnaires contained both close-ended (using a 5-point Likert scale) and open questions. The survey was conducted after the students completed the role-play from 18 to 22 October 2022. Participants were informed about the study’s objectives before participating, and they were required to provide written informed consent.

Data were analysed using MS Excel and SPSS version 28. The distribution of the scores for enjoyment, understanding, and usefulness were compared using the one-sample Kolmogorov-Smirnov test (p<0.05). The distributions were not normal and hence median and interquartile range were used as measures of central tendency and variation. The median (interquartile range) scores among the two cohorts and among males and females were compared using the independent samples median test (p<0.05). Each open comment was analysed systematically in an iterative manner by creating a thematic coding structure. As new themes emerged, the coding structure was revised, and the previous comments were reread for consistency. Moreover, the comparison of the difference between cohorts and gender for the perception of enjoyment, understanding, and usefulness was conducted because role-plays for cohort 2021 were conducted online due to Malaysia’s movement control order during the COVID-19 pandemic. However, the cohort 2022 role-plays were conducted physically. Studying gender differences in the perception of different educational interventions may be important because behaviours, styles of social interaction, academic motivations, and choices may be different across genders, and it helps identify disparities and promote equity and inclusivity in the classroom. It allows educators to address any biases or barriers that may hinder students’ educational opportunities and success (Myaskovsky et al., 2005).

III. RESULTS

A total of 96 students from 2021 (56) and 2022 cohorts (40) participated in the role-plays. A total of 81 students (overall response rate of 84.1%) participated in the survey. Our results show forty-eight students were from the 2021 cohort and the cohort response rate was 85.7%, Thirty-three students were from the 2022 cohort and the cohort response rate was 82.5%. The percentage of males was 22.22% and females were 77.78%.  According to Figure 1, 65% of students prefer role-play to teach stress and anger management skills, followed by small group discussions (15%), case-based learning (13.3%), and lectures (6.7%). This is based on question 8 of the questionnaire. Figure 2 illustrates the skills students learned during role-play. Communication skills were mentioned by 62.3% of the respondents, followed by teamwork (16.9%), stress and anger management (12.9%), and problem-solving skills (7.8%). This is based on question 4 of the questionnaire. The data that supports the study is available at https://doi.org/10.6084/m9.figshare.23607033.v1.

Figure 1. Instructional methods preferred by students to learn stress and anger management skills

Figure 2. Skills students learned through role-plays

Sixty-six students (90.4%) mentioned role-plays can be used for future topics/modules while 7 students (9.6%) were not in favor (based on question 9 of the questionnaire).

The perceptions of students about the use of role-play in anger and stress management were measured on a scale of 1 to 5 with 1 being the least and 5 being the highest. Table 2 shows the median and interquartile range of the scores for enjoyment, understanding, and usefulness among the two cohorts and among male and female students. There was no statistically significant difference in the scores between the two cohorts and between male and female students.

Submitted: 1 July 2023
Accepted: 24 October 2023
Published online: 2 April, TAPS 2024, 9(2), 39-50
https://doi.org/10.29060/TAPS.2024-9-2/OA3074

Muhammad Irfan Kamaruddin^1,2, Andi Alfian Zainuddin^1,3, Berti Nelwan^1,4, Sri Asriyani^1,5, Firdaus Hamid^1,6, Tenri Esa^1,7 & Irawan Yusuf^1,8

¹Department of Medical Education, Faculty of Medicine, Hasanuddin University, Indonesia; ²Department of Ophthalmology, Faculty of Medicine, Hasanuddin University, Indonesia; ³Department of Public Health, Faculty of Medicine, Hasanuddin University, Indonesia; ⁴Department of Pathology Anatomy, Faculty of Medicine, Hasanuddin University, Indonesia; ⁵Department of Radiology, Faculty of Medicine, Hasanuddin University, Indonesia; ⁶Department of Microbiology, Faculty of Medicine, Hasanuddin University, Indonesia; ⁷Department of Clinical Pathology, Faculty of Medicine, Hasanuddin University, Indonesia; ⁸Department of Physiology, Faculty of Medicine, Hasanuddin University, Indonesia

Abstract

Introduction: A good learning environment (LE) will affect the quality and standard of the learning process, student performance, and the outcome of the curriculum as well as predictor of the quality of health services. Our study aims to assess residents’ perception of the LE in Ophthalmology training programs for future improvement.

Methods: Mixed method with an explanatory sequential design was implemented in this study using the Post-graduate Hospital Educational Environment Measure (PHEEM) as a quantitative approach and open-ended questions collaborated with focus group discussion (FGD) as a qualitative measurement. A comparison of the quantitative data was made using parametric and non-parametric analyses. Thematic analyses were performed for qualitative data. Integration of quantitative and qualitative data was done by connecting both data.

Results: Fifty-three residents participated in this survey. The mean age was 30.96±2.18 years old, 64.15% were female and 77.36% are at the internship stage. The mean score of overall PHEEM was 123.40 ±12.35, indicated an excellent LE, while the mean score of perceptions of role autonomy, perceptions of teaching, and perceptions of social support were 42.57±4.62, 47.75±4.84 and 33.08±4.15, respectively. There is no significant difference between gender and study period with the perception of LE. Thematic analysis from qualitative data reveals six positive and five negative perception themes. All discovered themes confirmed concordance with the result of LE perception.

Conclusion: Learning environment perception in the ophthalmology residency program was excellent and essential for the student’s skills and performance quality. Some specific areas still need improvement strategies for institutional development.

Keywords:           Learning Environment, PHEEM, Ophthalmology, Residency, Mixed Method

Practice Highlights

• Ophthalmology resident has an excellent learning environment.
• Good teacher, learning system and social life will give positive perception on learning environment.
• Lack of learning opportunity, less mentoring time, and suboptimum facilities influence students negative perception of learning environment.

I. INTRODUCTION

A good learning environment (LE) will affect the learning process and student behavior and determine the outcome of the curriculum (Al-Shiekh et al., 2014; Bari et al., 2018; Binsaleh et al., 2015; Ong et al., 2019; Ong et al., 2020). Learners who experience an excellent LE will actively participate in the learning process (Clapham et al., 2007). With an ideal LE, learners can achieve better academic success than learners who perceive the LE negatively (Ong et al., 2019; Ong et al., 2020).

The clinical LE is an essential factor influencing the quality of medical education in residency programs (Sandhu et al., 2018). The resident LE, which mostly took place at the hospital, differs from that of medical students. This environment has many destructive factors that impact residents’ performance and mentality and can result in residents experiencing symptoms of burnout (Prins et al., 2010; Ripp et al., 2017). Suboptimal clinical LE have been associated with poor patient care and learning outcomes (General Medical Council, 2016). Therefore, efforts to improve the quality of the LE not only positively impact the environment in which learners learn and participate in patient care but also affect the practice of graduate doctors in the future.

This study aims to determine the residents’ perception of LE in the ophthalmology training program. Based on current data, there is still no study about ophthalmology residents’ perception of LE and its associated factors. This study is a pioneer and pilot study of LE in Ophthalmology training programs, especially in Indonesia.

II. METHODS

A. Study Design and Subjects

This mixed methods study was conducted with explanatory sequential design with both quantitative and qualitative measurements that were performed from January to May 2023 at two main teaching hospitals for the ophthalmology specialist program (OSP) Faculty of Medicine, Hasanuddin University in Makassar, Indonesia.

The study consists of two phases; the first is an offline survey comprising The PHEEM questionnaire and open questions data collection. The second phase of the study was focus group discussion (FGD).

Total sampling was used to determine the sample for the study’s first phase. Our inclusion criteria for the first phase were ophthalmology residents who have experience training in both main teaching hospitals and have attended a minimum of 6 months of ophthalmology residency training. Sixty residents met the inclusion criterion, and seven were excluded because they could not participate in the offline survey due to personal reasons. Fifty-three residents were included in the first phase of the study.

On the other hand, purposive sampling was employed to decide on phase two study participants. The PHEEM score, open-ended questions responses, and representation for each year of residency training were used to ensure heterogeneity of participants for different perspectives. Residents with high and low PHEEM scores and with exciting and evoking responses to open-ended questions were selected as respondents while considering resident representation for each year of training. Twenty residents were included in phase 2 of the study. The residents were divided into two groups consisting of 10 residents to attend FGD.

B. Study Instruments and Procedure

A cross-sectional survey that included a paper based PHEEM questionnaire, open-ended questions, and sociodemographic data, including age, gender, and year of residency, was distributed to all study subjects. The survey was conducted by single-trained data collector which was not part of the study program. Before administration, the study background, including its purposes and potential impacts, was explained to the residents and the written consent of each resident was obtained. Resident confidentiality and anonymity were also guaranteed.

The PHEEM consists of 40 items regarding LE subdivided into three subscales, each assessing perception of role of autonomy, perceptions of teaching, and perceptions of social support. It is scored on a 5-point Likert scale ranging from “strongly disagree” (0) to “strongly agree” (4), with a maximum score of 160. The findings were interpreted according to the original study shown in Supplement Table 1 (Roff et al., 2005). Four negative questions (questions 7, 8, 11, 13) were scored in reverse. PHEEM has been validated to assess the post-graduate clinical learning environment after the original study, including after translation to different languages, including the Bahasa Indonesia version (Raharjanti & Ramadianto, 2016; Roff et al., 2005). Multiple subsequent studies have shown good internal reliability (Bari et al., 2018; Clapham et al., 2007; Ong et al., 2019). The Bahasa Indonesia version of the PHEEM questionnaire was used to suit the local context. Bahasa Indonesia version of the PHEEM Questionnaire shows good validity and reliability (Raharjanti & Ramadianto, 2016). Eight open questions were added to the questionnaire. The questions were related to 3 subscales on the PHEEM questionnaire. Validation of the open-ended questions was done by expert judgment from two experts.

A semi-structured focus group session was conducted among the selected group of residents to supplement the PHEEM results. Two FGD session was done with a group size of ten. The FGD questions focused on exploring supporting and barrier factors that influence a good LE. The session lasted 60-90 minutes and was guided by a single-trained facilitator experienced in qualitative research methodology. FGD was conducted until new insights were no longer attained, reaching saturation.

Both quantitative and qualitative demographic data were coded by the trained data collector for maintaining the anonymity of the data. The response from both anonymous data were stored securely by the author for further analyses.

C. Statistical Analyses

Quantitative data were analysed using IBM Statistical Package for Social Sciences (SPSS) version 25. Descriptive statistics were presented using percentages, means, and standard deviation (SD). Internal reliability was assessed using Cronbach’s alpha coefficient. Comparison of quantitative data was made using Independent T-Test, Mann–Whitney U-Test, One-way ANOVA, and Kruskal–Wallis H-test. A p-value <0.05 was considered statistically significant.

For qualitative analyses, transcriptions of the open-ended questions answers and the audio and video recording of FGD were made by an independent data collector, and its accuracy was confirmed by the first author and the FGD facilitator. For open-ended questions, participants were coded with “P(Participant Code)-OEQ” (e.g. participant 1:P1-OEQ) while for FGD participants were coded with “P(Participant Code)-FGD(Group)” (e.g. participant 1 in FGD 2: P1-FGD2). The transcripts were coded into common themes independently by two investigators and discussed using thematic analysis using QDA Miner Version 5.0 for open questions and MAXQDA Analytics Pro 2020 for FGD.

III. RESULTS

A. Quantitative Data

Fifty-three ophthalmology residents were included in this mixed-method study, with the majority being female (64.15%). The mean age of residents was 30.96±2.18 years old. The largest age group is aged 30-34 (67.93%). 77.36% of respondents are at the internship stage or in the year 1 to 3 period of study, where respondents in year 3 have the most significant number of residents (32.08%).

Internal reliability of the PHEEM score was good, with Cronbach’s alpha coefficient of 0.872. No significant change with the removal of any of the 40 questions, proving its good internal reliability. Data in the perception of the role of autonomy was not normally distributed (P<0.05), but in the perception of teaching (P=0.200), perception of social support (P=0.200), also overall PHEEM score (P=0.200), the data were distributed normally.

As shown in Table 1, the mean score (SD) of the overall PHEEM score was 123.40±12.35, which is categorised as an excellent learning environment (LE) (>120). The mean perceptions for each subscale were 42.57±4.62 for perceptions of the role of autonomy classified as “more positive than negative”; 47.75±4.84 for perceptions of teaching classified as “model teachers”; 33.08±4.15 for perceptions of social support classified as “more pros than cons.”

No	PHEEM Subscales	Mean (SD)	Interpretation	Maximum Score
1	Perceptions of role of autonomy	42.57±4.62	more positive than negative	56
2	Perceptions of teaching	47.75±4.84	model teachers	60
3	Perceptions of social support	33.08±4.15	more pros than cons	44
4	Overall PHEEM	123.40±12.35	Excellent	160

Table 1. The PHEEM scores

Abbreviation: PHEEM, Postgraduate Hospital Environment Measure; SD, Standard Deviation.

From the overall PHEEM item, there are 28 items with an average score >3, nine items in the perception of the role of autonomy, twelve items in teaching perception, and seven items in the perception of social support (Table 2). Only one item has a score >3.5 or is classified as real positive points; that is item number 3 (I have protected educational time in this post) for the perception of teaching. The highest score for the perception of the role of autonomy was item 34 (The training in this post makes me feel ready to be a consultant) and item 24 (I feel physically safe within the hospital environment) in the perception of social support.

C. Quantitative and Qualitative Data Integration

The integration of quantitative and qualitative data can be shown in Figure 1 and Supplement Table 2. Overall, the mean total PHEEM scores (123.40±12.35), which indicated an excellent LE environment, were confirmed by more positive perception themes compared with negative perception found in qualitative data analyses (Figure 1). Besides, we could also see that in each subscale, the composition of the themes connecting to each subscale could confirm the results of the quantitative data, whether the trend of the graphs is primarily high, average, or low. For example, in the perception of teaching, we could see mostly positive perception themes were connected to the subscale rather than negative perception; from this, we could say that the quantitative data of the perception of teaching in which mostly classified as model’s teacher was confirmed by its connection towards the final themes.

Figure 1. Integration of overall quantitative data classification with qualitative data

Quantitative data represent by graph and qualitative data (positive and negative perceptions) represent by box. Perceptions in the circle area means that it was connected to the area. Overlapping box in the circle means that perception was connected to more than one area.

In each subscale, the high and low items’ scores were confirmed with the final themes, both for positive and negative perception (Supplement Table 2). All positive perceptions confirmed quantitative results by related with a minimum of one item from 3 subscales with mostly high mean scores (>3). Only three negative perceptions related to a minimum of one item from 3 subscales with low scores (<3) confirm these themes’ relation to quantitative results. One negative perception (Inadequate learning opportunities among residents/discrimination issue) is connected to an item with high scores, showing that this theme did not confirm the quantitative finding. Two themes appear contradictory in positive and negative perceptions (well-established facilities and suboptimum facilities). Both themes were related to the same item in which the scores were not high or low, which could confirm the possibility from both perspectives.

IV. DISCUSSION

Our finding shows an excellent perception of LE of ophthalmology residents. Based on previously published articles, this study has the highest score for overall scores and for each subscale among peer-reviewed publications of PHEEM studies worldwide. The highest score from a previous peer-reviewed publication was a study by Ong et al. (2020), which reported a more positive than negative internal medicine residents’ perceptions of their LE in Singapore. On the contrary, Fisseha et al. (2021) and Liaqat et al. (2019) reported a plenty of problems LE from the perception of internal medicine residents in Ethiopia and pediatric surgery residents’ perception in Iran, respectively. Many factors, such as differences in discipline and sites of training, could cause the differences. There is no previous study yet about ophthalmic residents’ perception of LE using PHEEM. However, it is previously proved that some studies evaluated several different training programs reported that there is a difference in overall and subscale PHEEM scores among various training programs (Chan et al., 2016). In line with discipline, studies that evaluated different sites of training mainly reported that there is a different score between sites of training (Chan et al., 2016). Another reason for the difference could be a result of the differences in curriculum and teaching methods. Some studies reported increasing perception of LE after implementing modern curriculum and student-centred learning (Brown et al., 2011; Shankar et al., 2014). The themes found from our qualitative study also supported this excellent perception of residents toward their LE. Most of our themes were positive and related to all aspects of the PHEEM questionnaire. Gruppen et al. (2019) reported a conceptual framework of LE in which all components of the framework, i.e., personal, social, physical, and organisational, supported and covered by our positive perception themes finding, confirming the excellent perception of LE from the residents.

We did not find any different perceptions of LE between gender and year of study. Our findings were similar to some studies that reported no gender differences (Al-Shiekh et al., 2014; Ong et al., 2020; Sandhu et al., 2018). Other studies have different results; some studies reported that males have a better perception than females (Fisseha et al., 2021; Gough et al., 2010); on the contrary, Liaqat et al. (2019) reported a better perception of females than males. Similar to Risberg et al. (2003) that reported, gender issues were more significant and essential during clinical consultation than tutoring. Our qualitative data did not confirm our quantitative results. There is one negative perception theme in which some of our students feel that there is a discrimination issue related to learning opportunities; one of them is gender discrimination. Although our quantitative data show no differences between gender, the negative perception theme regarding discrimination issues must be taken into account by the stakeholder.

Concerning the year of training, we also found no significant difference in perception. The finding regarding different perceptions for different years of training was varied. Our result was the same with some studies (Ong et al., 2019; Sandhu et al., 2018), but other studies also reported higher PHEEM scores for senior to junior (Gough et al., 2010; Khoja, 2015; Liaqat et al., 2019; Pinnock et al., 2009), and some studies also reported that junior has better score than senior (Fisseha et al., 2021; Mahendran et al., 2013). The differences in perception of junior and senior residents could be explained by some reason, such as available access to educational opportunities (Mahendran et al., 2013), greater responsibility with increased seniority (Pinnock et al., 2009), and different training locations for trainees of different seniority (Khoja, 2015).

All subscales show promising results; residents’ perception of teaching was the highest among other subscales. Our qualitative data also support this finding; most of our positive theme was related to the perception of teaching, one of them being a good clinical teacher. Despite good perceptions on teaching, residents also experienced less mentoring time with clinical teachers. Fisseha et al. (2021) also reported the same issue. Inadequate supervision was proved to be a barrier in post-graduate medical education, as reported by Talib et al. (2019). Ong et al. (2019) also reported that focus group data suggested that inadequate supervisor contact and feedback resulted in negative perceptions of the LE. This finding informs us that residents need appropriate supervision, and clinical teachers should be understanding and prepared for their roles in residency training programs (Ramani & Leinster, 2008). Increasing learning time without any addition to supervisor-resident contact time still results in a low perception of LE (Silkens et al., 2018), proving the importance of the supervisor-resident relationship. Besides, good supervisory strategies proved to be contributed to a good LE (Boor, 2009). A good teaching environment influences the standard of the learning process (Al-Shiekh et al., 2014; Bari et al., 2018), satisfaction with education, and determines the outcome of the curriculum (Bari et al., 2018; Binsaleh et al., 2015). Faculty should focus on developing adequate supervision and teaching skills programs for clinical teachers.

Perception of social support has the lowest score among other; it is affirmed by our qualitative finding in which three negative perception was connected to this subscale. Similar results were also reported from studies in intensive care and pediatric training program (Al-Shiekh et al., 2014; Clapham et al., 2007). Related to social support, catering facilities is problem area of this study, other studies also identified this issue as a problem (Al-Shiekh et al., 2014; Binsaleh et al., 2015; Fisseha et al., 2021; Ong et al., 2020). This finding was not specifically appeared on FGD, but the strategy to solve the problem should be considered. Another interesting result related to social support is about facilities. The topic has both perspectives, positive and negative. Quantitative item related to this finding was not had very high or very low scores, supporting that some facilities were good, but there is still area for improvement, especially for diagnostic tools and surgical training facilities, as stated in FGD. Other studies also reported that suboptimal facilities related to hospital diagnostic tools were also a barrier to achieving good LE (Fisseha et al., 2021; Talib et al., 2019). Schönrock-Adema et al. (2012) have highlighted that interaction and collaboration with others were significant in determining the LE. Faculty should pay attention to social support as it has a vital role in a residency program, as it could alleviate the effects of stress, depression, and burnout (Vieira, 2008). Strategy to escalate this area should be considered, especially in providing good facilities for the learning process.

Residents’ perception of the role of autonomy is also satisfying, most of the positive themes confirmed this subscale. Good autonomy can improve decision-making skills, self-confidence, and responsibility, which further influence the readiness of residents to be independent (Allen et al., 2019). It also improves work satisfaction and can reduce burnout (Allen et al., 2019). Although overall autonomy perception was good, there are some areas for improvement. Our finding shows that residents were imposed with inappropriate tasks, such as administrative tasks. Some activities not related to education are also obligated to the residents at a certain level of training. This condition could lead to an excessive, inappropriate workload and interfere with protected educational time. Therefore, the faculty should set precise regulations regarding job descriptions and accountability.

Our study was done in the main teaching hospital which was part of a university-based study program, the results could be benefit for other hospital with same basis. It shows that university-based program has a good teaching area especially for the curriculum and teaching resources including human resources and facilities. University-based teaching hospital could enhance their program by maximising their teaching area also paying attention to some factors that could be a barrier in university-based program such as learning opportunity and inappropriate task.

A mixed method with explanatory sequential design is fundamental in our study as it provides a comprehensive perception of residents. Qualitative data make our finding more solid, show us some weaknesses, and emphasise our areas for improvement which are not easily identified from quantitative analyses. This is also a pioneer study for ophthalmology residents’ perception of LE, making our finding also crucial in adding insight to understanding residency LE from multiple perspectives. On the other hand, several limitations were also identified. First, our study was only done in one centre and discipline, which may limit data generalisability. Second, the study time constraint was cross-sectional, so the causative relation between factors could not be established. Third, differences perceptions in each different training year cannot be ascertained because there can be information bias related to the perceptions of second-year students and so on towards their experiences in previous years. Fourth, the researcher is a clinical lecturer from the program who conducted the study, which could be the subject of bias. However, a single trained data collector was used to collect open-ended questions data and facilitate FGD to reduce the possible bias effect.

V. CONCLUSION

In conclusion, our finding shows that our resident has an excellent perception of their ophthalmology residency training. The program has strong areas such as a good clinical teacher, a well-organised learning system, and a good social environment. Several areas should pay attention to, especially equal learning opportunities, mentoring time, and facilities. Faculty should organise strategies for preserving current LE and to further improve the LE along with monitoring and evaluation. Our finding could be benefit for other university-based teaching hospital especially in Asia regions to enhance their program. Further study involving multiple centres and disciplines should be done to give a more general perspective of LE in residency training.

Notes on Contributors

Muhammad Irfan Kamaruddin involved in conception or design of the work, data collection, data analysis and interpretation, drafting the article, critical revision of the article, and final approval of the version to be published.

Andi Alfian Zainuddin involved in conception or design of the work, data analysis and interpretation, critical revision of the article, and final approval of the version to be published.

Berti Julian Nelwan involved in conception or design of the work, critical revision of the article, and final approval of the version to be published.

Sri Asriyani involved in conception or design of the work, critical revision of the article, and final approval of the version to be published.

Firdaus Hamid involved in conception or design of the work, critical revision of the article, and final approval of the version to be published.

Tenri Esa involved in conception or design of the work, critical revision of the article, and final approval of the version to be published.

Irawan Yusuf involved in conception or design of the work, critical revision of the article, and final approval of the version to be published.

Ethical Approval

Before conducting the research, permission was obtained from Faculty of Medicine, Hasanuddin University Institutional Review Board  (Reference number 36/UN4.6.4.5.31/PP36/2023). Participants were informed of the objectives and purpose of the study. They were invited to sign an informed consent if they agreed to be part of the study. Every participant was given a chance to deliberate on their rights to participate, refuse, or withdraw at any time they wished to do so.

Data Availability

The authors confirm that the data supporting the findings of this study are available within the article and its quantitative data along with supplemental tables are openly available in Figshare repository https://doi.org/10.6084/m9.figshare.23606157. Representative qualitative data translated into English are shown in the Result section (Kamaruddin et al., 2023). All qualitative data, open questions, and the FGD protocol which all written in Bahasa, are available from the corresponding author on reasonable request.

Acknowledgement

The authors would like to express our sincere gratitude to Ichlas Nanang Affandi from the Psychology study program, Faculty of Medicine, Hasanuddin University, for his valuable support throughout the research process. His expertise in qualitative study helps us to overcome challenges. In particular, we would like to thank Natalia Widiasih Raharjanti, MD, from the Department of Psychiatry, Faculty of Medicine University of Indonesia, and Assistant Professor Henok Fisseha, MD, from the Department of Internal Medicine, St. Paul’s Hospital Millennium Medical College, Addis Ababa, Ethiopia for their support in allowing us to use their research instrument and study protocol as one of our references in our research. Thank you also to Rusdina Bte Ladju, MD, Ph.D., for her valuable input to our manuscript. We are also grateful to the Department of Medical Education, Faculty of Medicine, Hasanuddin University, and Department of Ophthalmology, Faculty of Medicine, Hasanuddin University, for providing us with the resources and support needed to complete this study.

Funding

None of the authors receive any financial support for this study.

Declaration of Interest

The authors did not have a conflict of interest to be declared in this study.

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*Muhammad Irfan Kamaruddin
Department of Medical Education,
Faculty of Medicine, Hasanuddin University,
Jalan Perintis Kemerdekaan KM 10
Makassar 90245
Email: iphenk_tampo@yahoo.com

Submitted: 6 October 2023
Accepted: 6 December 2023
Published online: 2 April, TAPS 2024, 9(2), 28-38
https://doi.org/10.29060/TAPS.2024-9-2/OA3151

Sinead Kado¹, Simon Clarke² & Sandra Carr¹

¹Division of Health Professions Education, School of Allied Health, University of Western Australia, Australia; ²Graduate School of Education, University of Western Australia, Australia

Abstract

Introduction: Health Professions Education (HPE) leadership development is advocated for success at the individual, team, and institutional levels. Many leadership theories exist informed mainly by Western perspectives, however, Pacific HPE leadership has not been investigated. Therefore, this research aimed to understand Pacific HPE leaders’ perspectives to develop substantive theory to guide faculty development in this setting and add nuanced perspectives to the international HPE leadership discourse.

Methods: Using an interpretivist case-study methodology, seven HPE leaders were purposefully recruited. Data collection tools included Rich Pictures, Talanoa Zoom interviews, and reflective journals. Participants drew a picture on ‘Being an HPE leader’, subsequently explaining their depiction, and then reflected on leadership events in their journals over six months. Codes and themes were identified using Miles, Huberman and Saldaña’s approach.

Results: Metaphors were assigned to three HPE leadership styles identified: The ‘Bridge’- helping students from novice to competent; the ‘Coconut Tree’- multiple roles and sturdy in the storm; and the ‘Boat’ – navigating towards the vision.

Conclusions: Rich Pictures, interviews and reflective journals allowed HPE leaders to reflect on ‘Being an HPE Leader’ and revealed tacit perspectives. This study suggests there are different styles of leadership, pertinent to the Pacific context, depending on the aims, strategies, and attributes of different HPE leaders. Although grounded in the Pacific, certain aspects may resonate in similar contexts. Notwithstanding that many facets of leadership identified align with current leadership models, intrapersonal emotional intelligence and cultural aspects of HPE leadership should be considered when designing contextually embedded faculty development.

Keywords:           Medical Education, Health Professions Education, Leadership, Qualitative Research, Case Study, Pacific

Practice Highlights

• Rich Pictures assist revealing tacit perspectives by facilitating reflection on leadership.
• Many aspects of contemporary leadership are practiced in HPE leadership in the Pacific.
• Development of intrapersonal emotional intelligence is required to thrive in this challenging context.
• A better understanding of HPE Leadership in the Global South is required to inform a Global HPE leadership framework.

I. INTRODUCTION

Effective leadership is advocated to foster growth in the ever-evolving Health Professions Education (HPE) landscape and ensure success at the individual, team, and institutional levels (Lieff & Yammarino, 2016; McKimm & Swanwick, 2013; Sandhu, 2019; Steinert et al., 2012). However, Health Professions Education (HPE) leadership is a complex social phenomenon encompassing relationships, cultural and personal influences (Steinert et al., 2012; van Diggele et al., 2020), making it difficult to define, and then guide development. Whilst many leadership development initiatives exist purporting to enhance leadership capabilities, multiple systematic reviews investigating leadership development at the undergraduate (Evans et al., 2023; Lyons et al., 2018; Rodríguez-Feria et al., 2023), graduate (Lyons et al., 2021; Onyura et al., 2019; Sadowski et al., 2018; Sultan et al., 2019) and faculty (Steinert et al., 2012) level found that leadership development is rarely grounded in theoretical frameworks and that evaluation of interventions remains superficial. Similar issues occur in other HPE disciplines including pharmacy (Reed et al., 2019) and interprofessional (Brewer et al., 2016) education. These systematic reviews recommend that leadership development needs grounding in theoretical frameworks and capabilities assessed over a longitudinal period.

Additionally, across the reviews there was a dearth of studies from the global south informing their conclusions; most studies originated from the United States followed by the UK, Canada, Europe and Australia. Although established frameworks exist for physician leadership, including CanMEDS, NHS medical leadership competency framework, and ACGME, (Onyura et al., 2019) there is only one recently proposed for health professions educators (McKimm et al., 2022), based on the authors’ expertise and contemporary leadership theories, but not on empirical literature around HPE leadership. However, recommendations are that to develop tomorrow’s HPE leaders an empirically informed, culturally sensitive, leadership framework for health professions educators is required (Ramani et al., 2020; Sandhu, 2019).

Empirical research around HPE leadership has mainly been deductively analysed, using Western leadership frameworks, including Yukl’s power model (Sundberg et al., 2015), Bolman and Deal’s four frames model of leadership (Lieff, 2010), Goleman’s six leadership styles (Saxena et al., 2017), and character-based leadership (Torti et al., 2022). This deductive analysis potentially misses important aspects of leadership, indeed one example of subsequent inductive analysis identified different themes including reflection and feedback not included in the original deductive analysis (Lieff & Albert, 2012; Lieff, 2010). Additionally, most empirical research has relied on semi-structured interviews alone (Lieff et al., 2013; Lieff, 2010; Saxena et al., 2017; Sundberg et al., 2015; Torti et al., 2022), which may not have encapsulated all aspects of leadership, and have been conducted in Western contexts. Spoken language may not convey all the cultural contexts and meanings (Amazonas et al., 2019; Brocklesby & Beall, 2018; Lyon, 2020) and therefore it is recommended considering complementary data collection tools to further our understanding of HPE leadership (Lieff & Albert, 2012; Varpio et al., 2017). Furthermore, there are consistent calls to investigate HPE leadership in different cultural contexts to inform a faculty development framework (Dujeepa et al., 2019; Steinert et al., 2012; Varpio et al., 2017).

From a Pacific perspective, HPE leadership development is required (Kado et al., 2022; Sweet et al., 2018), however, HPE leadership from the cultural perspective of contemporary leaders in the Pacific is not currently described. Thus, this research reported here embarked on understanding the perspectives of current HPE leaders from this Pacific global south context to provide empirical evidence towards a framework for HPE leadership in this setting to guide faculty development. Furthermore, it contributes a diverse perspective to the current HPE leadership literature to assist building a more nuanced global HPE leadership theory.

This article describes the empirical research conducted at a major Pacific University utilizing an interpretivist case study approach. It then outlines three styles of leadership identified and discusses how these relate to competencies purported to be needed at different levels of leadership and the current theoretical and empirical discourse around HPE leadership. Implications from this discussion will provide recommendations for Pacific faculty development. Through rich, deep description it is hoped that others in similar settings will resonate with the findings, drawing on insights to apply in their own contexts.

II. METHODS

To understand Pacific perspectives around HPE leadership an interpretivist case study was undertaken at a major Pacific University (Denzin & Lincoln, 2000; Silverman, 1997). A qualitative methodology facilitated participants’ perspectives to be fully explored, and using several innovative data sets through a case study approach enabled tacit perspectives to be revealed and triangulated (Merriam, 1988; Merriam & Tisdell, 2016). The case was bound by health professionals who had completed a health education degree and had an active University HPE leadership role. Seven of ten eligible HPE leaders volunteered following purposeful recruitment and ethics approval. Written consent was provided and then data were collected through Rich Pictures, Talanoa interviews, and reflective journals over a one-year period (April 2021 to April 2022), with each participant assigned a pseudonym to maintain anonymity. Each data collection method was chosen to provide rich data to complement and build the interpretation of Pacific HPE leadership guided by the central research question ‘What are the perspectives of Pacific GCME graduates on being an HPE leader?’

First, Rich Pictures (Cristancho & Helmich, 2019; Gisby et al., 2023; Kado et al., 2023a) were used to reveal tacit perspectives on being an HPE leader. Participants drew a picture depicting ‘Being an HPE leader’ and then a subsequent Talanoa interview (Hindley et al., 2020; Tunufa’i, 2016) explored the deeper meanings of the picture and how they enacted leadership. Talanoa is a Pacific way of communicating where people are free to ‘tala’- talk ‘noa’- around the subject (Hindley et al., 2020). Thus, similar to semi-structured interviews, a set of guiding questions was used such as ‘Tell me about your picture’ and ‘How do you see yourself as an educational leader in this picture’, nevertheless the participants were allowed to ‘talanoa’ or talk around these questions in a culturally comfortable manner. These Talanoa interviews were held via Zoom (Gray et al., 2020) as the research was conducted in the midst of the Covid-19 pandemic. Next, following an orientation session on reflection (Schön, 1987), participants were requested to use a reflective journal with guiding questions and reflective prompts over six months. The reflective journals (Filep et al., 2018; Milligan & Bartlett, 2018) provided an avenue for the HPE leaders to reflect on doing leadership contemporaneously and with minimal influence from the researcher (Alaszewski, 2006). Finally, the second Talanoa interview was conducted, as planned after initial data analysis, exploring aspects of motivation and the influence of culture more deeply, with questions such as: ‘What motivates you to continue in your role as an HPE leader?’ and ‘How do you think the culture has shaped your leadership journey?’

A. Data Analysis

Data analysis was guided by Bell et al.’s (2019) framework for the Rich Pictures and Miles, Huberman and Saldaña’s (2014) approach for the textual data. Bell et al.’s (2019) framework comprises seven steps including:

1. Locating the style – context of the Rich Picture
2. Descriptive features – colour, shapes, and drawings
3. Primary features – which aspects are bold or central
4. Value features – linkages between images
5. Low-level interpretation – overall picture
6. High-level interpretation – interpretation from the artist
7. Critical judgement – has the participant reflected and engaged with the drawing?

 

For this research, we relied primarily on the high-level interpretation and other aspects were asked in the Talanoa interview as the research was based on the participants’ perspectives.

Data analysis began immediately after the interviews with the primary researcher (SK) noting initial impressions in her research journal and then transcribing the interviews verbatim. Data were anonymised and entered into NVivo for further analysis, copies of the transcripts were also stored in the University’s data management system. The data were further analysed using Miles, Huberman and Saldaña’s (2014) approach which consists of three linked stages:

1) Data Condensation:

Data condensation involves ensuring relevant data to answer the research question is captured and synthesised through coding, memoing and developing concepts.

2) Data Display:

Data is displayed using data summaries and pictorial illustrations to convey the main ideas.

3) Drawing and Verifying Conclusions:

Conclusions illustrate the themes and propositions abstracted from the data display.

This article focuses on the results of the second stage of data analysis, data display, which illustrated three styles of leadership identified through data interpretation. Initial coding was done by the primary researcher (SK) and discussed with the principal supervisor (SC) to refine. Concepts were developed together and the data summaries were compiled by SK and then revised through discussion (SK, SC & SC). The process was iterative where new codes and concepts were discussed and transcripts re-read to ensure alignment. Finally, composite narratives were produced for each leadership style, consisting of the participants’ voices combined to maintain anonymity, (Willis, 2018) and a synopsis of each style of leadership was interpreted by the primary researcher, providing rich data summaries for the leadership styles identified. These can be accessed through Figshare: https://doi.org/10.6084/m9.figshare.24241195.v1 (Kado et al., 2023b)

B. Researcher Positionality

The primary researcher is a white, Anglo-Saxon, medical educator who had completed medical training in the UK and then subsequently lived and worked in a Pacific culture for over 20 years. She completed the health education degree with the research participants and was known to them. At the time of the research, she was not employed at the Pacific University and had no authority over them. Whilst having a deep understanding of the culture and context in which the research was conducted, there is the possibility that her Western upbringing will have influenced the interpretation. This was minimised by taking steps to ensure trustworthiness.

C. Trustworthiness

Trustworthiness was maintained through several avenues. First, the primary researcher practised reflexivity by maintaining a diary throughout the research process to note ideas and meanings from the data. Second, triangulation of the results occurred through data analysis discussions with the research team and differences agreed to. Third, member checking was utilised at each step of the analysis whereby research participants were asked to confirm the transcripts, composite narratives and summaries, and the leadership styles.

D. Ethics Approval

Ethics approval was granted by the University of Western Australia (UWA – 2019/RA/4/20/6529) and the Fijian Ministry of Health (Fiji – FNHRERC 31/2020). Furthermore, the University ethics department was consulted and they gained access to the participants ensuring they felt under no obligation to participate in the research.

III. RESULTS

Seven HPE leaders participated, their academic positions, ethnicities, specialities, years of service and age range are depicted in Figure 1. One participant had originated from a Global South country outside the Pacific but had resided in the Pacific for over 25 years.

Figure 1. Demographics of Pacific HPE Leaders

Figure 2. Being a Bridge

Figure 3. Being a Coconut Tree

The ‘coconut trees’ of HPE leadership had multiple roles and a passion for developing and helping others. Their multiple fronds as HPE leaders included primarily being a clinician and educator, alongside a researcher, administrator, committee lead, and organisation member. They are aiming to ensure excellence and achieve this by valuing both feedback and evaluation to improve themselves, others and the curriculum.

‘I am basically multitasking, I can wear different hats and can achieve a lot of things with the different activities. So, we are teaching, teaching, but we are also at the same time we are learning ourselves, and not just because of a one way delivery, it’s two ways, we get the feedback from the students’

-Judith (1st Interview)

 

They are rooted in the foundations of faculty development (GCME – Graduate Certificate of Medical Education) and have grown strong, sturdy and resilient, and yet adaptable to the constant changes and challenges they face. Their experiences have enabled them to grow in confidence but also to nurture others to develop their own leadership style. Jane and Judith understand the importance of working together towards a common goal and ensuring the team is committed and feels valued, providing the support that is required.

 

‘And I think the way GCME was structured and taught I think that really helped us. If you look at who’s holding these leadership roles, it’s those who did GCME’.

-Judith (2nd Interview)

‘We have a group of young faculty staff who wants to make a difference as medical educators and I believe my leadership style is more of a coach.’

-Judith (Reflective Journal)

Although they are juggling many roles and at times feel overwhelmed they are committed to improving health education in the Pacific. They enlist the assistance of experts in this quest.

‘I have liaised with my network to ask for supplementary teaching for our Postgraduate trainees.’

-Jane (Reflective Journal)

Overall, they know they need to ‘walk the talk’ to develop the next generation of HPE leaders, as they endeavour to promote excellence in HPE.

C. Being a Boat

Being a Boat was illustrated by Julie and James who were striving to sail to a vision on the horizon to improve HPE at the individual and organisational level. James describes this as a journey with his Rich Picture and interview excerpt (Figure 4).

 

Figure 4. Being a Boat

James and Julie visualised themselves on a leadership journey in a boat heading towards a vision of excellence in health professions education. They are both intrinsically motivated to do their best by building a strong leadership team, utilising the strengths of the group and collaborating with external stakeholders.

Identify the strengths in people that we can nurture and play to the people’s strengths. If we play to the strength of people and all the strengths complement each other it’s really good.

-James (1st Interview)

Although they are both consultants in their clinical domain, their identity is now more embedded in their leadership role in health professions education. Their focus is on ensuring good curriculum, development for faculty and leaders, and improving University processes.

What we need is some more basic foundational learning…health professions education for the whole college and so that would be something I would totally pursue to allow and to think of something that would be doable.

-Julie (1st Interview) 

Their journey is fraught with navigating University obstacles and the storms of change, especially the COVID-19 pandemic. These frustrations have left them exhausted and overwhelmed, on the verge of burnout, and in need of respite and support.

I had been frustrated with the processes and felt so much more could be done to support staff and students.

-Julie (Reflective Journal)

Stress in an already uncertain environment in the midst of a Pandemic.

-James (Reflective Journal)

The boat’s overall aim is to grow the next generation of HPE leaders across the whole college through curriculum development and support from the University.

 

IV. DISCUSSION

In our Pacific setting, all the HPE leaders were aiming to develop excellent healthcare workers to make a difference to the health of the Pacific, however, they did this in different ways. Three styles of leadership were identified across the HPE leaders, which were given visual metaphors of ‘The Bridge, Coconut Tree and Boat’. ‘The Bridges’ focused on developing competent and caring students, ‘The Coconut Trees’ had multiple roles and nurtured their successors as well as the students, and ‘The Boats’ focused on the system level to provide the necessary supports for HPE leaders and the students.

These three styles of leadership could be conceptualised as levels, similar to Maxwell’s (2011) five levels of leadership which classifies leadership as a process through position – a leadership title, permission – developing relationships, production – getting things done, people development – empowering others, and pinnacle – growing the organisation, however, McKimm et al. (2022) argue that all HPEs can be leaders, they do not need to be in a position of leadership. Although our participants were primarily in positions of leadership, they did not specifically identify that their position assisted or deterred their leadership journey, therefore, it is difficult to say if this positional status impacted their leadership style. From their interviews and journals, the HPE leaders were more focused on relationship building, the second level: permission. Each style of leadership focused on different aspects of building relationships: ‘The Bridges’ nurturing their students, ‘The Coconut Trees’ developing both students and faculty and ‘The Boats’ collaborating with faculty and external stakeholders to support the college. Relationship building or the interpersonal aspects of leadership were key in all styles of leadership. This is well supported across the theoretical (McKimm et al., 2022; Pinder & Shabbits, 2018; Sandhu, 2019) and empirical research (Lieff & Albert, 2012; Varpio et al., 2017) around HPE leadership.

Focusing on the next level, production, that is getting results from others through influence and credibility, all styles of HPE leaders were respected consultants in their field and were able to influence students, faculty, and the institution. Indeed, evidence suggests that to be a respected HPE leader it is necessary to first have a reputation as an excellent clinician or researcher as being a good educator is often perceived as less esteemed (Maile et al., 2019; Sundberg et al., 2015). Did this hamper their progression to the fourth level, reproduction? All styles of leadership encouraged empowering others, whether that be at the student or faculty level, although they utilised different strategies. ‘The Bridge’ acted as a role model to develop novice students into competent health professionals, ‘The Coconut Tree’ utilised a coaching style to nurture the next generation of HPEs and ‘The Boats’ focused on developing structures and courses within the University to ensure succession planning. The HPE leaders displayed an authentic approach to developing others by often ‘walking the talk’ and being open to feedback, especially the coconut trees (Lieff & Yammarino, 2016; McKimm et al., 2022). Finally, the impact the leaders had on the organisation varied and this is perhaps where the styles of leadership differed most in comparison to the final level of pinnacle, developing future HPE leaders and growing the university. This was an ideal envisioned by ‘The Bridges’ but was actualised by ‘The Coconut Trees’ at a local departmental level and by ‘The Boats’ at the wider college level. Here a more adaptive style of leadership was portrayed by engaging with the challenges of a low-resource setting and the pandemic and seeking innovative solutions to address them (McKimm et al., 2022).

We would argue that rather than moving through levels of leadership that all these factors, bar level one, position, are evident in the different styles of leadership portrayed in this setting, albeit expressed in different ways. Additionally, although adaptive leadership has been advocated for HPE leaders during these challenging times (McKimm et al., 2022) some aspects were not evident in our HPE leaders. While they acknowledged being stressed and frustrated there was little evidence of them identifying ways to build resilience and perseverance and other intrapersonal aspects of emotional intelligence (Goleman, 2001). To build HPE leaders’ emotional intelligence capacities we would advocate utilising faculty development strategies that enhance reflection, such as Rich Pictures, and cultural ‘Talanoa’ discussions to assist future HPE leaders in reflecting on their experiences and developing strategies to overcome their obstacles (Cammock et al., 2021; Kado et al., 2023a). We also concur with Lyons et al. (2021) that ‘bespoke’ faculty development is recommended to encompass different styles of leadership encountered in the Pacific cultural setting, rather than using frameworks from an entirely Western perspective.

A. Strengths and Limitations of the Research

This study is the first to our knowledge, investigating HPE leadership in a Pacific setting and it followed leaders over a prolonged period to obtain rich, deep data, using novel data collection methods such as Rich Pictures and Talanoa interviews enabling unique perspectives to be captured.

Nevertheless, there are several limitations including, a small sample size of seven participants at only one institution. This study was also conducted during the Covid-19 pandemic limiting face-to-face interactions which may have affected the findings attributable to Zoom interviews and the unprecedented experiences of the HPE leaders. Additionally, although several measures were taken to increase the trustworthiness of the research there is the real possibility that the findings have been affected by the unconscious biases of the primary researcher (SK).

V. CONCLUSION

Pacific HPE leaders displayed three styles of leadership that were conceptualised as ‘Being a Bridge’ – focusing on being an effective educator and clinician; ‘Being a Coconut Tree’ – aiming to develop faculty whilst also maintaining their clinical and educator identities; and ‘Being a Boat’ who were mostly aiming for organisational change. They accomplished these styles through similar strategies based on developing relationships, being credible and empowering others that are advocated in the different levels of leadership, and which mirrored aspects of authentic and adaptable leadership. However, although the Pacific HPE leaders identified themselves as resilient and adaptable they also expressed significant challenges in relation to the University and the Covid-19 pandemic in this low-resource global south setting. Intrapersonal aspects of emotional intelligence could strengthen HPE leaders’ resilience in this cultural setting through faculty development that encourages reflection, such as Rich Pictures and Talanoa.

Notes on Contributors

Dr Sinead Kado is a doctor, medical educator and PhD candidate who reviewed the literature, designed the study, and then collected and analysed the research data, before drafting the original manuscript.

Professor Simon Clarke is a senior honorary research fellow at the University of Western Australia who reviewed and revised the study design, reviewed the data analysis and critically revised the manuscript.

Professor Sandra Carr is the Head of Health Professions Education at the University of Western Australia who revised the study design, analysed the data and then critically revised the manuscript.

All authors have read and approved the final manuscript.

Ethical Approval

Ethics approval was granted by the University of Western Australia (UWA – 2019/RA/4/20/6529) and the Fijian Ministry of Health (Fiji – FNHRERC 31/2020).

Data Availability

Supplementary data in the form of composite narratives – the combined narratives of several participants, and the data summaries interpreted by the researchers are available in Figshare at https://doi.org/10.6084/m9.figshare.24241195.v1. Original full transcripts are not available due to anonymity and confidentiality issues.

Acknowledgement

The authors would like to acknowledge the research participants for their commitment and engagement with the research.

Funding

The primary researcher (SK) was in receipt of an Australian Government Research Training Program (RTP) scholarship for this research.

Declaration of Interest

The researchers declare that they have no known conflicts of interest, including financial, consultant, institutional and other relationships that might lead to bias.

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*Sinead Kado
Division of Health Professions Education,
University of Western Australia
Perth, 6009, Australia
Email: sinead.kado@research.uwa.edu.au