Submitted: 29 February 2024
Accepted: 5 February 2025
Published online: 1 July, TAPS 2025, 10(3), 15-25
https://doi.org/10.29060/TAPS.2025-10-3/OA3259

Zaw Phyo¹, Titi Savitri Prihatiningsih², Ye Phyo Aung¹ & Tun Tun Naing¹

¹Department of Medical Education, Defence Services Medical Academy, Yangon, Myanmar; ²Public Health and Nursing Universitas Gadjah Mada, Yogyakarta, Indonesia

Abstract

Introduction: The effective implementation of changes in medical school curricula requires modifications to assessments alongside teaching strategies. The World Federation for Medical Education emphasises the need for assessment policies to align with educational outcomes. In Myanmar, the Defence Services Medical Academy (DSMA) has adopted an outcome-based curriculum since 2017, but the standard setting in assessments remains pending. This study explores concerns and challenges for enhancing assessment practices.

Methods: An explanatory sequential design was used. For a quantitative approach, 36 assessment committee members were surveyed using questionnaires, and pre-and post-test analyses were conducted using SPSS Statistics Version 25. Qualitatively, eight committee members were selected through purposive sampling for in-depth interviews using interpretative methodology with thematic analysis by MAXQDA Software 2022.

Results: It shows that most committee members acknowledge the advantages of standard settings, such as improved teaching and learning defect identification, staff knowledge application, enhanced educational programs, and personal contributions to education quality. Half of the committee members expressed concerns about the increased workload and administrative burden, while another half-supported standard-setting implementation. They all appreciate the integration of standard setting in the outcome-based curriculum, recognising its positive impact on student quality and accreditation standards. Challenges include limited human resources, resistance to change, time-consuming, and an increased workload.

Conclusion: Committee members suggested that targeted interventions are needed to improve awareness, collaboration, and successful implementation. These should consider perspectives, enhance understanding, define roles, and address resources and resistance. This will optimise standard setting, ensure educational quality, and meet accreditation standards.

Keywords:           Assessment, Standard Setting, Integrated Curriculum, Awareness, Perception, Attitude, Lifelong Learning

Practice Highlights

• Members of the committee think that having standards in DSMA’s curriculum is essential for raising the quality of students and the school’s standards.
• Most members know how important it is to set standards, especially for pass/fail exams, and stress how important it is to consider culture and institutional factors.
• Setting standards is thought to help with aligning the curriculum, giving students relevant tests, and meeting accreditation requirements.
• For implementation to go well, all stakeholders must be involved, the process must be in line with real evaluation principles, and teachers must continue to learn and grow.
• Not enough resources, resistance to change, limited time, and more work to do are problems that need solutions based on educational ideas.

I. INTRODUCTION

In the last 30 years, there have been many suggestions for changing the curriculum, but only a few medical schools have made significant changes (Supe & Burdick, 2006). Without altering assessments, modifying curricula or teaching strategies will be ineffective. In the global standards for quality improvement area of the World Federation for Medical Education (WFME), there are clear rules about primary medical education in chapter 3.1 of Assessment Policy and System:

“An assessment policy with a centralised system that guides and supports its implementation will entail using multiple summative and formative methods to acquire the knowledge, clinical skills, and behaviors needed to be a doctor. The policy and the system should be responsive to the school’s mission, specified educational outcomes, available resources, and the context” (World Federation for Medical Education, 2020).

In current Medical Education, with competency-based education becoming more popular, healthcare educational institutions and assessment bodies are being looked at more closely than ever before to make sure they are fair, transparent, and defensible when setting the expected level of performance and rating students’ performance to make decisions about their next steps (Lane et al., 2020). With competency-based assessment, the way the test is done must align with what the student has learned (Crespo et al., 2010).

Regularly setting, keeping, and evaluating assessment standards is essential in medical education. It is not an exact science to set standards. Most educational test validity arguments focus on how well the test matches the curriculum and how valuable the test’s content is (Barman, 2008).

Standards are an expression of values, so the ways to set them are systematic ways to gather people’s opinions on values, make agreements, and show that agreement as a single score on a test (Norcini, 2003). “Standard Setting” is a process used to make precise lines between things like “pass” and “fail” or “honors,” “proficient,” and “needs improvement.” Setting standards is “central to giving meaning to test results and, as such, is at the heart of validity arguments” (Wiliam, 1996).

There are two primary methods in which standards are set: (1) criterion-referenced or absolute methods, in which standards setting is not based on test results, and (2) norm-referenced or relative methods, in which setting standards is based on test results. No golden rule exists (Cohen-Schotanus & Van Der Vleuten, 2010).  In health professions education, it can be challenging to develop credible, defendable, and acceptable passing or cut-off scores for exams (Norcini & Guille, 2002).

In Myanmar, there are currently no private medical schools, although there are five public medical schools and one military medical school (Defence Services Medical Academy). Myanmar medical schools have used traditional lecture-based teaching methods, and many eminent physicians have emerged from teacher-centered educational programs (Myint, 2020).

Defence Services Medical Academy (DSMA), listed in the World Directory of Medical Schools, was founded in Mingalardon, Yangon, on November 19, 1992 (Naing et al., 2022). Since 2017, DSMA has been the first medical school in Myanmar to implement an outcome-based, integrated curriculum. According to the Dundee three circle models, the graduates of DSMA are supposed to be scholars and scientists, as well as practitioners and practitioners professionals (Harden et al., 1999).  The new DSMA curriculum is meant to encourage students to keep learning and give them more responsibility for their learning. It is presently focusing on meeting the criteria of WFME accreditation.

In DSMA, the assessment methods (written, practical, oral, and structured and unstructured observations) include accurate and standardised patients, objective structured clinical examination, patient management problems or simulations, etc. The assessments include continuous assessment, formative assessment, and summative assessment. However, there is no Standard Setting in DSMA, and it will be implemented soon (after training standard setting experts) to set the required basic minimum standards.

Even though accrediting organisations advise medical schools in general what the curriculum should cover and how it should be tested, most medical schools decide how and what to test (Epstein, 2007). There are five ways to figure out how valuable a method of assessment is: reliability (how accurate and repeatable the measurement is), validity (whether the assessment measures what it says it measures), impact on future learning and practice, acceptability to students and teachers, and costs (Van Der Vleuten, 1996). Therefore, the Assessment Committee’s DSMA meetings establish the process and procedures for conducting assessments throughout the undergraduate medical program. The Assessment committee must collect and evaluate feedback regularly, and faculty feedback revealed issues with the assessment process in DSMA.

 For a successful, acceptable, and feasible assessment to implement an outcome-based, integrated curriculum, it is essential to explore how students, faculty, and assessment committee members perceive the implication of the standard setting for the assessment. Therefore, this study investigated what the Assessment Committee members think about setting standards in medical education and the most significant problems.

II. METHODS

A. Research Design

Figure 1 shows explanatory sequential mixed methods design (also called a two-phase model (Creswell & Clark, 2017)): Quantitative followed by qualitative was used to explore the views, opinions, beliefs, and feelings of the assessment committee members (Ivankova & Stick, 2007). For the quantitative, all assessment committee members were asked using questionnaires (Likert scale), and qualitatively, Individual In-depth Interviews (IDI) were asked of the selected assessment committee members.

Figure 1. Explanatory sequential mixed methods design

The main benefit of mixed methods research is that they make a potent mix when quantitative and qualitative data are combined (Miles & Huberman, 1994). In addition, a “complex” image of a social phenomenon might be created, for instance, by evaluating both the quantitative and qualitative aspects of a study’s results (Greene, 2006).

B. Data Collection

For Phase 1 (Quantitative): The survey consists of four parts: (1) Collecting demographic information; (2) Investigating people’s perception of standard-setting procedures; (3) Examining attitudes towards these procedures; and (4) Evaluating these procedures using five-point Likert scale items ranging from 5 (strongly agree) to 1 (strongly disagree).

For Phase 2 (Qualitative): An in-depth interview (IDI) with semi-structured questions was used to collect the data. The researcher made an interview guide, which helped shape the interview and get detailed comments from the assessment committee members. The IDIs lasted 30-45 minutes, and the researcher informed participants that their names and information would be kept private.

The researcher performed all the interviews in the participants’ local language (Myanmar). The IDI explored the themes of the conceptual framework. A video recording was made for continuous recording in a quiet, private section of the medical education department office. The researcher conducted open discussions with the assessment committee members and kept them confidential, especially the students. Each interviewer uses a different set of questions (10–12), and the sessions last between 45 and 60 minutes. The researcher kept doing interviews until it became clear that the stories, themes, and problems had been covered to saturation point. The researchers utilised constructivist reflexivity throughout the entire study procedure, as advised by Alvesson and Sköldberg (2017).

C. Sampling Procedure

In DSMA, there are 38 members of the assessment committee. The assessment committee comprises three groups: Discussant members, voting members, and secretariat.

For Phase 1 (Quantitative): All the assessment committee members of DSMA were recruited. Among the 38 eligible persons who met eligibility, approximately 95% of the population (36 participants) responded to the evaluation survey.

For Phase 2 (Qualitative): By using the purposes sampling methods, individual in-depth interviews (IDIs) with semi-structured questions were given to the selected eight members of the assessment committee who are information-rich persons (two discussant Members, five voting members, and one secretariat) to find out what they thought, what they had done, and how they did it.

D. Data Analysis

The survey data was stored in an Excel file and processed using SPSS software (version 25). Descriptive analysis explored assessment committee members’ perceptions, attitudes, and practices.

The MAXQDA 2022 program extracted themes and sub-themes (Côté & Turgeon, 2005). The recorded interviews were transcribed to do content analysis. First, the data were summarised, proofread, and translated into English. Second, for the data analysis, themes, sub-themes, and clusters were identified (Cresswell, 2012). Finally, conceptualisation and explanation throughout the later stages led to the development of concrete abstracts. Analytic coding was done while reading the transcripts, and emerging issues were thought to be included in the thematic statements.

E. Ethical Considerations

The study was done according to the guidelines published by the Ethical and Research Committee of DSMA. Participation in this study is entirely voluntary.

F. Informed Consent

Before conducting the study, informed verbal consent was obtained for respondents’ autonomy to participate in this study.

III. RESULTS

Quantitatively, thirty-seven questions were asked about each participant’s background, knowledge, perception, attitude, and practices regarding the standard-setting. The survey received responses from 36 participants. The data supporting this study’s findings are openly available in the Figshare repository, https://doi.org/10.6084/m9.figshare.25657875.v1 (Phyo et al., 2024).

A. Demographic Characteristics

According to an analysis of the committee’s demography (see Table 1), two-thirds of the members were older than 25, and males dominated. Faculty members (64%) were primarily doctoral holders on the evaluation committee. More than ten years of teaching experience can be found among half of the assessment committee members.

Table 1. Personal background information of the assessment committee members

B. Awareness of Standard Setting

In Table 2, most assessment committee members believe that DSMA has been implementing a standard setting in the assessment process, but it is still in the process of being fully implemented. However, 75% know the purpose behind establishing standard settings in DSMA. Furthermore, faculty members are debating whether DSMA is a precise standard-setting approach for standardisation and how DSMA intends to implement whatever assessment model.

No	Question	Answers	Total (n=36)
			Frequency	Percentage
1	Does DSMA have a standard Setting in the MBBS Programme?	Yes	23	63.9
		No	11	30.6
		Uncertain	2	5.6
2	Who Is the most Responsible person in the Implementation standard setting within DSMA?	Rector	9	25.0
		Assessment Committee	6	16.7
		All Staff	20	55.6
		Uncertain	1	2.8
3	Why did DSMA introduce a Standard setting?	Rector’s foresight and planning	8	22.2
		Requirement of MMCAC guideline	27	75.0
		Uncertain	1	2.8
4	How many types of standard settings?	One	6	16.7
		Two	22	61.1
		Three	8	22.2
5	The assessment system of the DSMA is designed by applying a ready-made model like programmatic assessment.	Yes	12	33.3
		No	12	33.3
		Uncertain	12	33.3
6	Does DSMA have an exact standard-setting method to standardise the assessment system?	Yes	17	47.2
		No	10	27.8
		Uncertain	9	25.0

Table 2. Awareness of standard setting

Table 3. Perception, attitude, and practice towards standard setting

The attitudes section indicates lower ratings (2.0–3.0) with worries about increasing workload (59% agreement) and administrative burden (56% agreement), revealing resistance or uncertainty among some staff members towards the practical implications of standard setting. They also feel that implementing standards creates an uncomfortable academic environment, but 81% think the standard-setting process is successful (4.0 ± 0.7).

The high mean scores (4.0–4.4) and agreement percentages (up to 88%) in sections on perceptions and practices indicate strong support for standard setting among respondents. This suggests a recognition of its value in improving educational quality.

The data suggests that standard settings are supported, but there’s a need for more engagement and clear communication about its processes. Apprehension about workload and administrative tasks may stem from a lack of understanding or poor implementation strategies. Institutions could benefit from transparent, inclusive, and efficient management of standard-setting processes, including regular updates, training sessions, and support systems. A balanced approach is needed to address apprehensions and ensure positive outcomes for educational quality and student success.

D. Thematic Analysis Outcomes

The participants were Assessment Committee Members (n=8) from the Assessment Committee of the DSMA who were involved in developing the Standard setting for the Assessment.  The data collected from IDIs were organised into five themes and 19 sub-themes in Figure 2.

Figure 2. Showing the main themes and sub-themes

1) Perceptions of the assessment committee members: The assessment committee members expressed appreciation for the incorporation of standard setting in the Outcome-based Integrated curriculum at our university. Most committee members showed enthusiasm for using this method, which they believed was fitting for assessing students in this program. Additionally, the committee aimed to enhance the assessment techniques used in the Outcome-based Integrated curriculum. They were convinced that implementing standard settings would improve student and DSMA quality.

“An outcome-based integrated curriculum has replaced DSMA’s old curriculum. The product of an outcome-based curriculum is not produced. So, we must prepare for that product to be assessed using the standard setting. It is a transitional period for our DSMA from the old curriculum to the outcome-based curriculum. So, the state holders and teachers from DSMA must understand the standard setting. We must set the standard for the assessment of DSMA, but slowly and steadily.”

(Participant 1)

“If the integrated curriculum is changed and outcomes are improved, the quality of the university will improve. Local or international qualifications will be enhanced, not only by students but also by the quality of the DSMA.” 

(Participant 3)

2) Understanding of standard settings: It was evident that members emphasised the importance of standard setting, particularly in the context of Pass/Fail exams for students. Furthermore, committee members demonstrated knowledge regarding various types of standard setting. They were able to identify the most suitable method for DSMA, taking into consideration factors such as cultural context and institutional requirements.

“The standard setting is a method designed to determine a student’s pass or fail scores, and it is also a technique for determining whether students will pass or fail a test.”

(Participant 4)

“DSMA has to set standards for the assessment according to our culture, values, and conditions. We have taken the standard setting of another prestigious university as a reference. It is not suitable to apply the ready-made model.”

(Participant 1)

3) Benefits of implementing standard settings: The assessment committee members recognised Standard Settings are essential for effective curriculum alignment, meaningful student assessment, and accreditation. DSMA can demonstrate its commitment to delivering high-quality education and meeting accreditation standards by aligning the curriculum, teaching practices, and assessments through Standard Settings. The committee members believe Standard Settings play a crucial role in enhancing the quality of education DSMA provides.

“It is beneficial for constructive alignment. So, we adopted and prepared the standard setting for assessing DSMA for accreditation. It is also essential for the teaching and learning process and method. We can check the teaching and learning process, and if errors occur, we can fix them and circle again for the following year.”

(Participant 1)

“I think the outcomes that come out improve not only the student’s quality but also the DSMA’s quality. If the integrated curriculum is changed and outcomes are improved, the quality of the university will improve. Local or international qualifications will be enhanced, not only by students but also by the quality of the DSMA.”

(Participant 3)

4) Roles and responsibilities while implementing standard setting in DSMA: The Assessment Committee members recognised the critical roles and responsibilities of implementing standard setting. They emphasised the need for an inclusive approach involving all stakeholders. Furthermore, they highlighted the importance of aligning standard setting with authentic assessment principles and providing continuous professional development for faculty members. By considering these factors, the committee members aimed to enhance the quality of assessment and promote meaningful learning outcomes for students.

“The standard setting must be built with support; all teachers at DSMA are responsible for it because only the medical education department knows about the standard setting, which is ineffective. Teachers in all departments, including professors, must know about the standard setting. That’s why all the teachers at the university need to understand when setting standards.”

(Participant 2)

“The assessment committee is in charge of the standard setting in DSMA, including the medical education committee, the curriculum committee, the quality assurance committee, the assessment committee, etc. The assessment committee can emphasise its role and responsibility, including implementing the standard setting. Thus, it is more reasonable and practical.”

(Participant 6)

5) Challenges and weaknesses of implementing the standard-setting: The Assessment committee members identified several challenges in implementing standard setting. These challenges include limited human resources, resistance to change, time-consuming processes, and increased workload. Understanding these challenges through the lens of educational theories can guide the development of strategies to address them effectively and ensure the successful implementation of standard-setting practices.

“Human resources are our main weakness. There are very few human resources in DSMA to apply the standard setting. Time-consuming is another area for improvement.”

(Participant 1)

“Most importantly, students don’t know what a “standard” setting is, and some teachers don’t know either. They need to know what a “standard” setting is.”

(Participant 7)

IV. DISCUSSION

The outcomes from the study at the Defence Service Medical Academy (DSMA) assessment committee shed light on essential aspects of standard-setting in medical education. In institutions like DSMA, which implement the outcome-based integrated curriculum, medical students must remember what they learned in their preclinical training to make sound clinical decisions based on reliable scientific principles (Lazić et al., 2006). In medical education, it is crucial to establish, maintain, and frequently review assessment criteria (Senanayake & Mettananda, 2005).

The study revealed a predominantly male composition within the assessment committee, highlighting the need for diversity and expertise among committee members. While increasing the diversity of academic medical leadership to address the underrepresentation of minorities and women in medicine has been proposed, there has been limited investigation into this topic (Meadows et al., 2023).  Encouraging diversity can contribute to robust discussions and decision-making processes related to standard-setting. While committee members demonstrate a solid grasp of standard-setting, the results indicate a requirement for continual education to translate this knowledge into practical application (Norcini & McKinley, 2007). Therefore, targeted interventions and professional development programs must enhance their knowledge and awareness.

Committee members show favorable attitudes towards standard-setting, but there is a discrepancy between their perceptions and actual practices. Implementing open communication strategies consistent with Downing’s (2005) emphasis on the value of clarity in assessment practices could close this gap. Moreover, the lack of active participation in the implementation process may indicate a more significant engagement problem within academic committees (Van der Vleuten et al., 2010).

The study highlights issues that align with existing literature on medical education reform, citing resource limitations and reluctance to change as typical obstacles to adopting innovative instructional approaches (Swing, 2007). The committee’s alignment with constructivist and cognitive theories advocates for a transition to more interactive and participatory learning methods, which a parallel change in evaluation methods should accompany (Harden & Crosby, 2000). Committee members emphasised the need for an inclusive approach involving all stakeholders and aligning standard-setting with authentic assessment principles, resonating with sociocultural theories emphasising social interaction and collaboration in the learning process.

The findings offer crucial insights into the committee’s perceptions and experiences with standard-setting in the integrated outcome-based curriculum. Aligned with educational theories, these insights underscore the importance of lifelong learning and can guide future research and targeted interventions to continuously enhance standard-setting practices.

V. CONCLUSION

In conclusion, the findings from both the quantitative and qualitative research provide valuable insights into the assessment committee’s knowledge, perceptions, attitudes, and practices regarding standard-setting in medical education at the Defence Service Medical Academy (DSMA). While there is a positive attitude towards the potential benefits of standard-setting, there are also concerns and doubts among some committee members.

The study emphasises the importance of targeted interventions in medical education to improve awareness, address concerns, foster collaboration, and support the successful implementation of standard-setting. The Assessment Committee Members appreciate the incorporation of standard setting in the outcome-based integrated curriculum and recognise its importance during the transitional period. They demonstrate a strong understanding of standard settings, particularly in Pass/Fail exams, and emphasise the need to consider cultural and institutional requirements. Standard settings can enhance curriculum alignment, meaningful student assessment, and accreditation purposes.

The committee members emphasise the roles and responsibilities associated with implementing standard setting, including an inclusive approach, continuous professional development for faculty members, and addressing challenges such as limited human resources, resistance to change, time-consuming processes, and increased workload. Strategies informed by educational theories are needed to improve human resource capacity, provide training on standard setting, and create awareness among students and teachers.

These findings underscore the importance of supporting the assessment committee in their understanding, implementation, and continuous improvement of standard-setting practices. By addressing concerns, providing necessary resources, and promoting collaboration, DSMA can optimise the benefits of standard-setting in medical education and ensure the quality of its educational programs. Incorporating lifelong learning fosters continuous professional development, keeping DSMA at the forefront of educational excellence and adaptability.

Notes on Contributors

Dr. Zaw Phyo contributed significantly to the manuscript development process, including reviewing existing literature, identifying research gaps, and addressing questions and goals. He helped draft and revise the manuscript, emphasising its importance for medical education.

Titi Savitri Prihatiningsih contributed to shaping the research question and framework, ensuring a systematic approach. She applied her expertise in evaluation to refine the research tools and meticulously reviewed the thesis and manuscript for accuracy.

Dr. Ye Phyo Aung engaged in the study’s methodology phase, endorsing the chosen research design, sampling strategies, and data collection techniques, adding valuable insights to the research execution.

Dr. Tun Tun Naing assisted in the meticulous proofreading of the article, ensuring clarity, coherence, and compliance with academic standards.

Ethical Approval

The Ethical Review Committee of the Defence Services Medical Academy,  Yangon, Myanmar, granted ethical approval. (2 / Ethics/ 2021).

Data Availability

The data supporting this study’s findings are openly available in the Figshare repository, https://doi.org/10.6084/m9.figshare.25657875.v1 (Phyo et al., 2024).

Acknowledgment

I would also like to thank the FAIMER Regional Institute of Indonesia for Educational Development and Leadership (FRIENDSHIP) for helping me finish this research project at the Faculty of Medicine, Public Health, and Nursing at Universitas Gadjah Mada (Indonesia).

I would also like to thank my supervisor, the head of the medical education department (DSMA), and my colleagues. Without their help, I would not have been able to survey my research. I am grateful to all the assessment committee members from DSMA, Myanmar, who helped me complete my survey by giving me their valuable opinions and experiences.

Funding

The research was carried out during the study period at the FRIENDSHIP-FAIMER Regional Institute of Indonesia for Educational Development and Leadership. No financing is associated with this publication.

Declaration of Interest

There is no conflict of interest in the current research.

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*Zaw Phyo
No.94, Pyay Road, Mingaladon Township,
Postal code – 1102
Yangon, Myanmar
Phone: 95 92032754
Email: dr.zawphyoo@gmail.com

Submitted: 27 November 2024
Accepted: 28 April 2025
Published online: 1 July, TAPS 2025, 10(3), 10-14
https://doi.org/10.29060/TAPS.2025-10-3/GP3589

Thilanka Seneviratne, Wathsala Edirisingha & Wathsala Palpola

Department of Pharmacology, Faculty of Medicine, University of Peradeniya, Sri Lanka

Abstract

Introduction: Pharmacology, though challenging, is fundamental in medical practice, necessitating effective knowledge acquisition and retention for future application. This study aims to analyse student perceptions of the newly introduced teaching method, peer assessment, to enhance pharmacology teaching.

Method: Eighty-six third-year medical students of the Faculty of Medicine, University of Peradeniya participated in the peer assessment. They were divided into two groups of 40-45 and a case scenario in pharmacology was given to answer. Three volunteers from each group presented the answers. Peers evaluated the answers using provided criteria and gave feedback. The teacher then facilitated discussions, highlighting key points. Assessors and assesses perceptions on the teaching learning method was assessed using questionnaire and focus group discussions (FGD).

Results: The majority of students (n=64) (74.41%) enjoyed the task of assessing their peers. 80.23% (n=69) acknowledged the value of peer assessment for student engagement. However, 34.88% (n=30) mentioned that they did not feel they had the skills and knowledge to assess their peers. 17.43% (n=15) mentioned that they were reluctant to be critical of their peers. In the FGD students mentioned that in this student-centered learning method all students actively participated than the usual small group discussion sessions. They could compare peers’ knowledge with their own knowledge and preferred the teacher grading to be combined with peer grading.

Conclusion: Peer assessment for enhancing pharmacology teaching was well received by the students. Also, students emphasise the importance of lecturer guidance and advocate for a combined assessment approach to improve engagement and learning outcomes.

Practice Highlights

• Peer assessment keeps the students more focused during teaching learning process.
• Peer assessment enhances critical thinking and allows student centered learning.
• Combined assessment approach improves engagement and learning outcomes.
• Peer assessment for enhancing pharmacology teaching is well received by the students.

I. INTRODUCTION

The focus in higher education has shifted from conventional teaching methods to a more learner-centric approach, moving away from teacher-centered management toward fostering student self-direction (Arnold et al., 2005). This transition has sparked a growing interest in the educational benefits associated with students evaluating both their own work (self-assessment) and that of their peers (peer assessment).

Peer assessment is defined as assessment by and of individuals who have attained the same general level of training or expertise, exercise no formal authority over each other, and share the same hierarchic status in an institution (Arnold et al., 2005).

Peer assessment can be summative or formative. This focuses on the formative side, helping students plan learning, identify strengths and weaknesses, improve, and build metacognitive and professional skills. Traditional teacher-centered assessments often limit such growth. Educators valuing dialogue and collaboration should actively involve students in assessments.

Evidence is scarce regarding the utilisation of peer assessment methods for undergraduate formative assessments of a particular subject.

Pharmacology is often perceived as challenging to remember and thus, less engaging for students. Consequently, there’s reduced enthusiasm for participation in lectures. However, pharmacology serves as a fundamental aspect of medical practice, necessitating students to acquire and retain knowledge effectively for future application. Interactive teaching offer distinct advantages over traditional, teacher-centered methods by facilitating long-term retention, contextual learning, and the development of essential skills and attitudes. Thus, we introduced this teaching and learning method related to the peer assessment that integrates student centered learning within the classroom setting.

II. METHODS

A. Study Setting

The study was conducted at the Faculty of Medicine, University of Peradeniya, Sri Lanka.

B. Informed Consent

Informed written consent was obtained from the students who volunteered to the study.

C. Participants

The study involved third-year medical students from the Faculty of Medicine, University of Peradeniya, Sri Lanka. These students participated in small group discussions, each consisting of 40-45 members.

D. Peer Assessment Process

Each group was assigned short essay questions on pharmacology and students encouraged to draft written answers. Three volunteers from each group presented their answers to the class, and peers assessed them gave feedback based on criteria set by the lecturer. The teacher then facilitated discussions, highlighting key points.

E. Gathering Student Perceptions

1) Using Questionnaires: All students, except the three who presented, were provided with a self-administered Likert scale questionnaire to capture their perspectives as “assessors,” drawing from McGarr and Clifford (2013). The students who presented their answers completed a different Likert scale questionnaire, designed to capture their viewpoints as “assesses,” referencing Tahir (2012).

2) Focus Group Discussions: Nineteen students volunteered. They were divided into 3 groups. Focus group discussions, using a structured interview guide led by one investigator, lasted 30 to 40 minutes each, continued until data saturation was reached. The discussions were recorded for transcription. Participants were assured of confidentiality, and their views were anonymised. During transcription, all identifying features were removed.

F. Analysis

Quantitative data from the questionnaires were analysed using percentages. Qualitative data from the focus group discussions were analysed separately by identifying common themes in the responses.

Transcribed data were analysed using inductive content analysis. The researchers first read the transcripts to familiarise themselves with the data. Then, each transcript was coded into broad content categories. The transcripts were reread sentence by sentence and further coded into categories and subcategories.

G. Ethical Considerations

Ethical clearance was obtained from the ethics review committee of the Faculty of Medicine, University of Peradeniya. (2024/EC/25).

III. RESULTS

Eighty-six students participated as assessors. Six students participated as assesses. The results from students who assessed their peers showed mixed perceptions. A significant portion (74.41%) enjoyed the task. 44.17% agreed they were nervous about the peer assessment at the start of the module, while 29.07% were neutral (Table 1).

The comments from students assessed by their peers were generally positive. 66.67% felt they received sufficient comments, while the rest remained neutral. All participants noted that peer assessment offered more opportunities for discussion and practice. Peer assessment is recognised as a valuable exercise for students shown in Table 2.

Table 1. Assessors’ perception regarding the peer assessment method

Table 2. Perception of the students who got assessed by peers

Several key themes were identified by the focus group discussion.

A. Benefits of the Peer Assessment

1) Less stressful: Students mentioned that being assessed by their peers was less stressful than being assessed by a lecturer. They also noted that this method encouraged active participation in the assessment process due to its more convenient and relaxed nature.

“No nervousness at all. Because I just assesses my colleagues”

2) Kept students focused: Students commented that peer assessment is fairer than the traditional method as it kept them focused on work more than usual.

“When students have to assess their peers, they have to focus on the presenting answer. So, all students fully focus on the process.  The lecturer will discuss the given scenario again. So, I think we do not miss any subject content, we can learn effectively.”

3) Peers are more accessible than lecturers: They accepted this method as a good alternative to traditional assessment methods as lecturers are not always available for the assessment.

“It’s unable to assess students by lecturers all the time, so peer assessment is a good approach to assess students.”

4) Improved understanding: Being able to know how their peers answer a question was found as a good way of comparing their knowledge and improving themselves.

“Can compare our knowledge with peers”

5) Confidence building: Another advantage they pointed out was an improvement in the level of confidence in facing an assessment as they felt more comfortable when they are assessed by peers.

“Improved confidence”

B. Challenges of Peer Assessment

1) Peers are not knowledgeable enough: Some students identified being assessed by the lecturers is better than the peer assessment as lecturers are more knowledgeable than the peers.

“Lecturers are more knowledgeable than students, so being assessed by them is essential.”

“We didn’t have deep, fine knowledge to assess peers, but we had superficial knowledge to assess them.”

C. Suggestions

A larger proportion of participants expressed appreciation for both traditional assessment methods and peer assessment, stating that using both simultaneously would be ideal.

“I think the lecturer grading is the best because we are not very experienced. However, with the time limitation, it is hard to assess students by lecturer frequently. In that case, peer assessment will be beneficial if it is combined with lecturer grading.”

Many participants expressed preference for using this in other courses.

IV. DISCUSSION

While superior assessment has been the traditional and more prevalent approach, it faces challenges due to increasing student numbers, limited lecturer availability, and time constraints. This study aims to explore students’ perceptions of peer assessment as a complementary evaluation method, addressing some of the limitations of superior assessment. The findings reveal several advantages and challenges of peer assessment.

A. Less Stressful, More Focused Learning Environment

One of the key advantages of peer assessment is its ability to create a less stressful and more focused learning environment. The results indicate that students feel more comfortable being evaluated by their peers, which allows them to engage more deeply in the learning process.

Presenters and assessors both noted that the peer assessment structure promoted active engagement, as assessors remained attentive throughout the session to provide meaningful feedback, and those not presenting felt more relaxed and focused compared to traditional SGD formats. This shows that peer assessment method enhances student focus in learning environment.

B. Increased Availability and Accessibility

Given the time constraints and growing student populations, continuous evaluation by lecturers is challenging. However, well-prepared peer groups can effectively bridge this gap, providing timely feedback and support. This aspect of peer assessment enhances students’ opportunities for formative feedback, which is critical for their learning process.

C. Improves the Assessor’s Understanding of the Subject/Confidence Building

Students gain valuable insights and deepen their understanding by evaluating and providing feedback on their peers’ written work, as this process enhances their critical thinking and analytical skills (Topping, 2009). This fact was noted by the participants of our study also. They appreciated the chance to analyse their peers’ answers.

The supportive environment of peer assessment enabled students to share and compare their knowledge openly, which in turn helped them refine their answers and learn better organisational techniques, which improve their confidence.

D. Addressing Knowledge Gaps

One challenge identified in peer assessment is the limited expertise of peers in accurately assessing their classmates. However, this challenge can be mitigated with proper preparation and guidance from lecturers. Topping (2009) has highlighted that training students to provide constructive feedback is a challenging process. However, the benefits it yields outweigh the burden of training peer assessors.

Literature also gives evidence regarding the doubt about the validity level of peer assessment among teachers and students (Holroyd, 2000). This attitude has been identified as a major barrier to the use of peer assessment as a standard method of evaluating students.

Fry (1990) highlighted that, when it is implemented in the right way, peer evaluation demonstrates results, which are comparable with lecturer evaluation.

E. Overcoming Personal Bias

A drawback noted by students was the difficulty of remaining objective when assessing their peers. Many students found it challenging to give low marks or critically evaluate their friends’ work as a lecturer might. This concern highlights the need for students to be properly trained as an assessor.

Several published studies shows that peer evaluation can be affected by negative social factors like peer pressure, favoritism, or fear of criticism, especially when done face-to-face. To address these issues, it’s important to use methods that ensure anonymity in peer reviews.

F. Recommendations for Future Application

Overall, students in this study expressed a positive view of peer assessment and suggested its use in other courses. They acknowledged that combining peer assessment with superior assessment could enhance learning outcomes. To ensure the effectiveness of peer assessment, students recommended conducting it under the supervision and guidance of lecturers. This combined approach would offer the benefits of peer-to-peer engagement while maintaining the academic rigor provided by expert feedback.

V. CONCLUSION

While peer assessment presents certain challenges, it offers substantial advantages in creating a more accessible, engaging, and confidence-building learning environment. With proper training and lecturer involvement, peer assessment can serve as a valuable complement to traditional assessment methods in higher education.

Notes on Contributors

Thilanka Seneviratne led the study’s conception, design, and implementation, contributed to data analysis and interpretation, drafted and critically revised the manuscript. Wathsala Edirisingha was involved in the implementation of the study and contributed to data acquisition and analysis. Himali Palpola contributed to the study’s implementation, data analysis, and manuscript drafting. All the authors have read and approved the final manuscript.

Ethical Approval

Ethical clearance was obtained from the ethics review committee of the Faculty of Medicine, University of Peradeniya, (2024/EC/25).

Acknowledgement

We acknowledge the staff of the department of Pharmacology, Faculty of Medicine, University of Peradeniya for their valuable contribution in material and organisational support.

Funding

No funding sources are associated with this paper.

Declaration of Interest

All authors declare no conflict of interest.

References

Arnold, L., Shue, C. K., Kritt, B., Ginsburg, S., & Stern, D. T. (2005). Medical students’ views on peer assessment of professionalism. Journal of General Internal Medicine, 20(9), 819–824. https://doi.org/10.1111/j.1525-1497.2005.0162.x

Fry, S. A. (1990). Implementation and evaluation of peer marking in higher education. Assessment & Evaluation in Higher Education, 15(3), 177–189. https://doi.org/10.1080/0260293900150301

Holroyd, C. (2000). Are assessors professional? Student assessment and the professionalism of academics. Active Learning in Higher Education, 1(1), 28–44. https://doi.org/10.1177/1469787400001001003

McGarr, O., & Clifford, A. M. (2013). ‘Just enough to make you take it seriously’: exploring students’ attitudes towards peer assessment. Higher education, 65, 677-693. https://doi.org/10.1007/s10734-012-9570-z

Tahir, I. H. (2012). A study on peer evaluation and its influence on college ESL students. Procedia-Social and Behavioral Sciences, 68, 192-201. https://doi.org/10.1016/j.sbspro.2012.12.219

Topping, K. J. (2009). Peer assessment. Theory Into Practice, 48(1), 20–27. https://doi.org/10.1080/00405840802577569

*Thilanka Seneviratne
Faculty of Medicine,
University of Peradeniya, Sri Lanka, 20400
Email: thilanka.medi@gmail.com

Submitted: 26 September 2024
Accepted: 25 March 2025
Published online: 1 July, TAPS 2025, 10(3), 5-9
https://doi.org/10.29060/TAPS.2025-10-3/GP3504

Shihoko Yamakawa¹, Olga Razvina², Fumiko Okazaki², Hiroshi Hibino³, Toshiyuki Someya⁴ & Tatsuo Ushiki⁴

¹Niigata University Institute of Global Affairs, Japan; ²Niigata University Medical Education Centre, Niigata University Graduate School of Medical and Dental Sciences, Japan; ³Department of Pharmacology, Osaka University Graduate School of Medicine, Japan; ⁴Niigata University, Japan

Abstract

Introduction: Niigata University School of Medicine and Niigata University Graduate School of Medical and Dental Sciences have been engaging in medical exchanges with Russian medical universities for over 30 years. In 2015, a double-degree program with Russian medical universities was initiated, leading to a multi-layered education project that included short-term undergraduate student exchange programs and graduate-level double-degree programs, resulting in the circulation of human resources.

Methods: The program was conducted in English, and a maximum of 15 credits could be transferred based on the universities’ regulations. Degree examinations were conducted independently, and successful candidates were awarded degrees from both Niigata University and their home university in Russia. The project was overseen by the G-MedEx Centre at Niigata University, which included staff with international experience.

Results: The difference in standard study duration between Japan and Russia was eliminated by using a four-year system in the graduate school doctoral programs. Three study models were proposed by Russian universities, considering each university’s regulations and various circumstances. The curriculum was determined based on the rules of the universities in Russia and the circumstances of the students. Agreements were made with each university in supplementary documents.

Conclusion: Despite the differences in educational standards and the lack of a common educational framework between Japan and Russia, the difficulties can be overcome, and educational compatibility can be increased.

Practice Highlights

• Thanks to a long history of interaction with Russia, we were able to organise a large educational project, which included multi-layered programs, one of which was a double degree program.
• As part of the project, we established a coordination centre (G-MedEx Centre) that effectively engaged with students, teachers, and university administration to address challenges and tasks as they arose.
• We successfully navigated the differences in educational standards between Russia and Japan and developed effective mechanisms for collaboration.
• Despite the challenges of the double degree program, we have two successful examples of students who completed their double degrees.
• We were able to train doctors and scientists who gained unique international experience and will be able to make significant contributions on the world stage in the future.

Figure 1. Credits and study hours (Niigata University and Russian Partner Universities)

Figure 2. Basic course curriculum and number of credits, Russian Graduate School doctoral program

We developed a group of courses for specialised classes to streamline the collation process. A unified evaluation standard based on Japan and Russia’s systems was adopted, significantly speeding up credit transfers.

C. Eliminating Differences in the Standard Study Period and Creating a Study Model

We have worked on eliminating the difference in standard study duration between Japan and Russia, which is a structural problem. Although undergraduate education in the medical field is six years both in Japan and Russia, the duration of graduate school doctoral programs differs. In Japan, it is four years, and in Russia, it is usually three years. Although DDP allows credits to be transferred, it is quite difficult to complete study programs at both universities and write two dissertations in three years. Therefore, we decided to use a four-year system.

The extra one-year study period in Russia has been an ongoing academic issue. After discussions between Japan and Russia, Russian universities proposed three study models based on regulations and circumstances. It was suggested that students spend the first two years in Russia and the remaining two at their home university. They also noted that compulsory subjects are concentrated in the first year, making it appropriate for students to start research and gain basic skills in their native language.

The three study models proposed were as follows:

– Model 1: After completing two years, the student takes a one-year leave at a Russian university. Then the student returns to school for the fourth year and completes the Japanese and Russian programs at the same time.

– Model 2: Establishing a new four-year doctoral course program at Russian universities. This is a special curriculum in which the 180 credits that should be earned over three years are distributed evenly over four years, resulting in 45 credits earned in one year.

– Model 3: At the end of the third year, all completion requirements except for thesis defense should be completed, and graduation is suspended. After it is confirmed that the students are expected to graduate from the university in their fourth year, they will proceed to the examination and officially complete their studies in Japan and Russia at the same time.

In the case of models 2 and 3, students have to pay tuition fees for four years in Russia based on the length of study. Additionally, in the case of model 3, upon completion of the third year, students are required to return to Japan temporarily for up to one month for graduation exams and related procedures. The curriculum was determined based on the rules of the universities in Russia and the circumstances of the students. The agreements were made with each university in supplementary documents.

Figure 3. DDP Models

D. Thesis Defense

Russia and Japan have different systems for evaluating theses. In Russia, dissertations are typically 100 to 150 pages long and are written in Russian. They are reviewed by the Higher Accreditation Commission. In contrast, in Japan, dissertations must be written in English and be published in an international journal. Because of these regulatory differences, a single-thesis evaluation approach was not feasible, resulting in separate reviews for each thesis. While foreign examiners can attend public hearings for dissertations in Russia, they are not allowed to serve on examination committees due to government restrictions.

E. Building a Network with a Dedicated Project Team

Since the G-MedEx Centre’s establishment, its international network has expanded across Russia, with exchange agreements established with nine universities. Appointing liaison professors at Russian universities significantly motivated local faculties and had an unexpected positive impact. Regular information exchange enabled the swift identification and resolution of issues, contributing to the project’s success and improvements in the study environment and safety management for international students.

IV. DISCUSSION

This paper highlights the challenges faced in implementing the Double Degree Program (DDP) and the measures taken to address them. Six students were enrolled in the program, and two of them have already obtained their degrees. While most of the academic and curricular challenges have been resolved, some issues still need to be addressed. Although credit transfer can reduce some duplication of study content, fulfilling the graduation requirements of two universities within the standard study period is challenging. After gathering feedback from students participating in the program, we learned that many found it very challenging, particularly those conducting research that required wet experiments. In contrast, students focused on statistical research did not express similar concerns.

Another factor contributing to the program’s complexity was that the research topics at the two universities often had no connection, forcing students to manage two entirely unrelated projects. This increased their workload and sometimes hindered their ability to complete the program successfully.

Consequently, we concluded that for future programs, it is essential to choose departments that can coordinate their projects, ensuring they engage in collaborative research. This approach would make it easier for students to complete both projects on time. Regarding the credit system, a transfer method based on the “competency-based” approach is being considered, where students are evaluated based on the acquired results of comprehensive and specialised abilities and skills required for the subject, rather than assigning academic training per credit by the time spent in it. To speed up the process, we have limited credit transfer to specialised subjects at our university. However, as the number of students increases and the scale of projects grows, it will be essential to systemise credit transfer and simplify administrative procedures further. Therefore, we need to build a system that guarantees a higher level of educational quality between the two countries while referring to the framework provided by ECTS and the Erasmus Project (European Community Action Scheme for the Mobility of University Students), which are the standard in Russia. From the viewpoint of human resource circulation, some graduates have become post-doctoral fellows or faculty members at Niigata University, while others have returned to their home countries to work as doctors.

V. CONCLUSION

Witnessing young medical scientists grow and start playing active roles in both countries is the greatest joy of international collaboration in education. Russia recently withdrew from the Bologna Process. As a result, the country may develop its own education system that does not depend on the European framework. Russian students may face challenges in integrating into the European education system and accessing European educational grants.

However, interactions with countries not part of the Bologna process—such as Japan, India, and China—will remain unaffected, since these countries operate according to their own independent systems. The key will be finding common ground and promoting academic mobility, though this won’t be straightforward based on our past experiences.

Thus, cooperation with these countries will require careful attention. It is essential to focus on the future effects on education and ensure the educational environment’s protection for students, drawing on the knowledge and experience gained so far.

Notes on Contributors

SY, the first author, contributed significantly to the design, wrote and edited the paper, and reviewed the literature. OR was responsible for data collection, resource verification, reviewing and editing the manuscript. FO conducted resource verification, reviewed and edited the manuscript. HH provided critical feedback during the writing process, analysed the data, implemented and supervised the project. TS led the project, interpreted the data, and provided guidance. TU, the lead conceptualiser, designed the study, was responsible for  conceptualisationand obtaining funding.

Acknowledgement

We would like to express our sincere gratitude to professors of Krasnoyarsk State Medical University, Far Eastern State Medical University, and Pacific State Medical University for their cooperation in conducting this study.  

Funding

This research was supported by JSPS Grant-in-Aid for Scientific Research 20K02936.

Declaration of Interest

The authors declare that they have no conflict of interest.

References

Jargin, S. (2024). Medical education and postgraduate training in Russia: An update. Journal of Integrative Medicine & Therapy, 7(1), 1. https://doi.org/10.13188/2378-1343.1000019 

Obst, D., & Kuder, M. (2012). International joint- and double-degree programs. International Higher Education, 66, 5-7. https://doi.org/10.6017/ihe.2012.66.8585

Sitnikov, V., & Bizunkov, A. (2016). The higher education at the post-Soviet territories: The long echo of the Bologna process. Vestnik Otorinolaringologii, 81(4), 72-77. https://doi.org/10.17116/otorino201681472-77

Teplyashina E., Petrova M., Salmina A., & Razvina O. (2017) The experience of networking postgraduate training programmes. The Education and Science Journal, 19, 4. https://doi.org/10.17853/1994-5639-2017-4-118-129

Yamakawa, S., Razvina, O., Ito, M., Hibino, H., Someya, T., & Ushiki, T. (2018) Medical exchange project for students and young doctors between Japan and Russia. Medical University, 1, 32-39. https://doi.org/10.2478/medu-2018-0005

*Shihoko Yamakawa
1-757, Asahimacho-dori, Chuo-ku,
Niigata, Japan 951-8510
-81 (025) -227-2063
Email: yamakawa@med.niigata-u.ac.jp

Submitted: 29 July 2024
Accepted: 24 February 2025
Published online: 1 July, TAPS 2025, 10(3), 1-4
https://doi.org/10.29060/TAPS.2025-10-3/GP3478

Tayzar Hein¹, Ye Phyo Aung¹, Khin Aung Htun¹ & Tin Tun²

¹Department of Medical Education, Defence Services Medical Academy, Myanmar; ²Department of Human Resources for Health, Ministry of Health, Myanmar

Abstract

Introduction: The medical education system of Myanmar has evolved through a dynamic history influenced by colonial legacies, national development efforts, and global collaborations. This article explores the progression of medical education in Myanmar, focusing on its historical milestones, challenges, and advancements in response to societal and healthcare needs.

Method: This study is based on a comprehensive review of historical records, policy documents, and academic literature, with “A Concise History of Medical Education in Myanmar” by Aung Than Batu as a primary reference. Key milestones, collaborations, and innovations were analysed to trace the evolution of medical education from the colonial period (1907) to the present day. Quantitative data, including the number of medical universities, training durations, and infrastructure developments, were included for a clearer perspective.

Results: The analysis highlights transformative milestones, including the establishment of the first medical school in 1907 and Rangoon Medical College in 1927. Over time, Myanmar has adapted to challenges such as resource constraints and political instability by fostering international collaborations and leveraging technology. Teaching methods have evolved significantly, integrating modern technologies alongside traditional pedagogies.

Conclusion: Myanmar’s medical education exemplifies resilience and adaptability. By aligning its system with global standards, fostering research, and leveraging international expertise, the nation continues to contribute to global medical education and healthcare. This narrative serves as an inspiration for countries navigating similar challenges in medical education.

Practice Highlights

• Myanmar’s medical education journey began in 1907, blending indigenous practices with Western methodologies, and expanded post-independence with the establishment of multiple medical universities.
• Myanmar overcame challenges like resource limitations and political instability by fostering global collaborations and integrating modern technologies into medical education.
• The MBBS program combines robust theoretical knowledge with clinical training, while postgraduate education emphasises research, making Myanmar a contributor to global medical advancements.

I. INTRODUCTION

Myanmar, a nation of profound cultural richness and historical depth, unfolds a narrative that intricately intertwines with the evolution of its medical education system. This comprehensive overview embarks on a journey through the diverse facets of Myanmar’s medical education landscape (Batu, 2015). Beyond a mere chronological exploration of historical administrative periods, it endeavors to unravel the intricate threads woven into policy development, the establishment of medical universities, and the ceaseless pursuit of addressing challenges and seizing opportunities within the nation’s healthcare and educational sectors. The journey begins in 1927, with the establishment of the Rangoon (Yangon) Medical College, a milestone in introducing formal medical education during the British colonial era (Batu, 2015). This marked the fusion of indigenous healing traditions with Western medicine, laying the foundation for a unique and dynamic approach to healthcare education (Coderey, 2021). After independence in 1948, the nation’s commitment to advancing medical education became evident with the expansion of medical facilities and the development of policies aimed at addressing the healthcare needs of its population. By the 1960s, the establishment of additional institutions, such as the Institute of Medicine (I), reflected Myanmar’s growing emphasis on training a competent cadre of healthcare professionals. In 1970, the establishment of the University of Medicine 2 in Yangon further demonstrated this dedication to expanding medical education access (Batu, 2015). Infrastructure development and facility expansions in subsequent decades signaled foresight that extended beyond immediate requirements, highlighting a long-term vision for excellence and capacity-building in medical education (Batu, 2015).

Amidst challenges such as resource limitations and periods of political instability during the 1980s and 1990s, the story Myanmar of took a resilient turn, transforming obstacles into opportunities. International collaborations, such as partnerships initiated in the 2000s, and the adoption of technological advancements emerged as beacons of progress, underscoring the adaptability and determination of Myanmar to elevate the standards of its medical education (Saw et al., 2019). As Myanmar enters the 21st century, it not only continues to address its domestic healthcare needs but also contributes to the global context. Its influence reverberates through research contributions, milestones in undergraduate and postgraduate medical education, and a commitment to integrating public health perspectives (Saw et al., 2019). Myanmar emerges not just as a nation shaping its healthcare narrative but also as a participant in the broader discourse on global health, contributing to the collective effort to address worldwide health challenges (Proserpio, 2022).

II. ADMINISTRATIVE PERIODS IN MYANMAR

Colonial Era (1824–1948): Under the shadow of British rule, the colonial period of Myanmar bore witness to the initial introduction of Western medicine. The 1860s marked the beginnings of formal medical education when the British established training programs for healthcare workers to address the needs of colonial administration and military personnel. In 1927, the foundation of the Rangoon (Yangon) Medical College became a pivotal moment in the integration of Western methodologies into Myanmar’s medical education system. This era marked the confluence of indigenous healing practices with the methodologies imported during colonial occupation (Coderey, 2021).

Post-Independence Era (1948 onwards): The post-independence period signaled a fervent drive by Myanmar to shape its own destiny. The establishment of the Institute of Medicine (I) in the 1960s marked a significant step toward creating specialised medical education institutions to cater to the nation’s healthcare needs. This commitment was further exemplified by the opening of the University of Medicine 2 in Yangon in 1970, ensuring broader access to medical education. In 1992, the Defence Services Medical Academy (DSMA) was established as the nation’s sole military medical university, dedicated to training medical professionals for the armed forces. With six medical universities in total five civil institutions and one military. The country has demonstrated a sustained effort to expand medical education. This era also saw the formulation of policies aimed at strengthening public health systems and addressing resource limitations, particularly during the politically turbulent 1980s and 1990s. These efforts laid a strong foundation for Myanmar’s aspiration to build a healthcare system reflective of its cultural identity and societal requirements (Coderey, 2021).

III. MEDICAL EDUCATION POLICY IN MYANMAR AND DEVELOPMENT OF MEDICAL UNIVERSITIES

The evolution of medical education policies in Myanmar from 1950 onwards has been a dynamic and adaptive process. Over the years, these policies have responded to societal needs, embraced technological advancements, and aligned with global standards in medical education. A key focus has been the alignment with international benchmarks, ensuring that the education imparted equips Myanmar’s medical graduates to meet and exceed global standards in healthcare delivery. Myanmar’s journey in medical education began in 1907, with the establishment of the Government Medical School in Yangon, which laid the groundwork for structured medical training. The pivotal moment came in 1927, with the establishment of the Rangoon (Yangon) Medical College, formalising Western medical education. Following independence in 1948, the nation prioritised medical education policy development, leading to the creation of the Institute of Medicine (I) in the 1960s and the University of Medicine 2 in 1970 (Batu, 2015). The subsequent decades witnessed the growth of additional medical universities, including the University of Medicine, Mandalay, and the University of Medicine, Magway, which were established to decentralise medical education and improve access. Infrastructure development and the expansion of facilities became pivotal strategies, particularly during the 1980s and 1990s, to accommodate the surging demand for medical education and enhance the overall quality of healthcare provision. These initiatives reflect the commitment of Myanmar to fostering a robust and sustainable healthcare system (Batu, 2015).

IV. CHALLENGES, OPPORTUNTIES AND MEDICAL EDUCATION RESEARCH

Throughout its history, the medical education system of Myanmar has faced formidable challenges, ranging from resource limitations to periods of political instability, such as during the politically turbulent 1980s and 1990s (Saw et al., 2019). Despite these adversities, these challenges have served as crucibles for transformation, providing opportunities for resilience and innovation. By the 2000s, Myanmar actively embraced international collaborations, partnering with global institutions to strengthen its medical education framework. These collaborations have acted as catalysts for overcoming structural and educational challenges, fostering knowledge exchange, and enhancing training methodologies (Proserpio, 2022). In recent decades, technological advancements have presented unprecedented opportunities to bridge gaps in medical education delivery. For instance, the integration of e-learning platforms and simulation-based training since the 2010s has improved both accessibility and quality, enabling students across Myanmar to benefit from innovative educational tools (Saw et al., 2019). This dual narrative of challenges and opportunities paints a dynamic picture of Myanmar’s medical education landscape one that is continuously evolving and adapting to the shifting sands of the global healthcare arena.

Myanmar’s indelible mark on medical education research is a testament to its commitment to academic excellence. The country has emerged as a significant contributor to the global knowledge base in medical education, particularly since the early 2000s, fostering an environment where researchers explore innovative methodologies and address critical questions within the field in 1990s (Saw et al., 2019). Myanmar’s researchers, often collaborating across borders, have played a pivotal role in advancing educational practices worldwide. The research landscape in Myanmar is characterised by a diverse array of studies, including pedagogical approaches, curriculum development, and assessments of educational outcomes. Researchers have delved into the effectiveness of various teaching methods, the impact of cultural nuances on medical education, and the integration of technology into learning strategies (Coderey, 2021). These endeavors not only enhance the quality of medical education within Myanmar but also contribute valuable insights to the broader international community. the commitment of Myanmar to medical education research extends beyond national boundaries, with researchers actively engaging in cross-cultural studies and collaborative projects. Examples include partnerships with institutions in Southeast Asia and beyond, leading to impactful studies on public health education and global health challenges (Proserpio, 2022). This collaborative spirit enriches the local research landscape and fosters a global exchange of ideas, ultimately elevating the standards of medical education on an international scale.

V. UNDERGRADUATE MEDICAL EDUCATION AND POSTGRADUATE MEDICAL EDUCATION

Undergraduate Medical Education in Myanmar: The structure of undergraduate medical education in Myanmar has undergone a transformative journey, evolving into a robust system that imparts a comprehensive understanding of medical science. The curriculum, meticulously developed over the decades, strikes a balance between theoretical knowledge and practical application, ensuring that graduates are well-equipped to navigate the complexities of healthcare. Milestones in curriculum development have played a pivotal role in shaping an adaptable and rigorous educational framework. Since the establishment of the Government Medical School in 1907 and the introduction of formal undergraduate medical training at Rangoon Medical College in 1927, Myanmar has continually refined its approach to align with global standards while addressing local healthcare needs (Batu, 2015). The integration of foundational medical sciences with clinical training, particularly from the 1960s onward, has created a holistic educational experience.

Clinical Training: Clinical training is a cornerstone of undergraduate medical education, offering students invaluable exposure to patient care, medical decision-making, and collaborative healthcare practices. From the 1970s, rotations in diverse medical specialties were formalised, enabling students to gain insights into the multifaceted nature of healthcare delivery. This hands-on approach fosters the development of critical thinking, diagnostic acumen, and a patient-centered mindset. Despite challenges such as resource constraints and political instability during the 1980s and 1990s, the resilience of Myanmar has been evident. By the 2000s, international collaborations and advancements in technology allowed for significant improvements in medical education delivery (Batu, 2015). Initiatives such as e-learning platforms and virtual simulations have enhanced accessibility and quality, ensuring a dynamic learning environment.

Outcomes and Global Impact: Graduates of Myanmar undergraduate programs emerge with a blend of strong theoretical knowledge, practical skills, ethical grounding, and communication proficiency. Many contribute to the global medical community, bringing cultural understanding and internationally recognised expertise to diverse healthcare settings.

Postgraduate Medical Education in Myanmar: Myanmar postgraduate medical education system has witnessed substantial transformation, adapting to the increasing demand for specialised expertise in healthcare (Saw et al., 2019). The diversification of postgraduate programs since the 1980s reflects a commitment to align with global standards while addressing the unique challenges of the nation’s healthcare system.

Specialised Training and Research: Postgraduate training emphasises advanced clinical skills and specialisation across medical disciplines. From the 1990s, research became an integral part of postgraduate education, fostering innovation and addressing critical healthcare gaps. Myanmar postgraduate students actively contribute to cutting-edge research, positioning the nation as a hub for medical advancements (Batu, 2015). This dual focus on research and clinical expertise ensures the preparation of professionals capable of tackling evolving healthcare challenges.

Collaborative Endeavors: International collaborations have played a pivotal role in enhancing postgraduate medical education. Partnerships with regional and global institutions have facilitated the exchange of expertise and best practices, enriching both training programs and research initiatives (Proserpio, 2022). These efforts underscore Myanmar’s commitment to participating in and contributing to the global medical community.

Outcomes and Ethical Practice: Myanmar postgraduate medical education is characterised by a dynamic interplay of specialised training, collaborative research, and a steadfast commitment to ethical medical practice (Rosenbaum et al., 2021). This multifaceted approach elevates the capabilities of healthcare professionals and enhances the overall standard of healthcare delivery, both nationally and internationally.

VI. CONCLUSION

Myanmar’s history of medical education is a dynamic narrative marked by resilience, adaptability, and the ability to turn challenges into opportunities. From its early adoption of Western medical practices during the colonial era to the establishment of a robust and evolving educational framework, Myanmar has consistently demonstrated a commitment to excellence. This global perspective highlights Myanmar’s efforts to align its medical education system with international benchmarks, contribute substantively to medical research, and actively engage in global public health initiatives. As Myanmar continues to shape its medical education landscape, it stands poised to make lasting contributions to global healthcare. Myanmar’s unwavering dedication to excellence not only enhances its own healthcare system but also enriches the global discourse on medical education and public health, positioning the nation as a vital contributor to the collective effort of improving global health outcomes.

 Notes on Contributors

Tayzar Hein contributed to this manuscript’s first draft version , and revised its subsequent draft. Ye Phyo Aung, Khin Aung Htun, and Tin Tun contributed to the manuscript and critically revised the first draft. All the authors discussed and contributed to the final manuscript.

Funding

The activity is undertaken for the sake of personal and professional growth, and does not require any financial support.

Declaration of Interest

There is no conflict of interest in the current research. 

References

Batu, A. T. (2015). The history of medical education in Myanmar (1886 to 2010). Myanmar Academy of Medical Science.

Coderey, C. (2021). Myanmar Traditional Medicine: The making of a national heritage. Modern Asian Studies, 55(2), 514-551. https://doi.org/10.1017/S0026749X19000283     

Proserpio, L. (2022). Myanmar higher education in transition: the interplay between state authority, student politics and international actors.

Rosenbaum, S. A., Tushaus, D., Hubbard, B., & Sharp-Bauer, K. (2021). The Myanmar Shwe: Empowering law students, teachers, and the community through clinical education and the rule of law. Indiana Journal of Global Legal Studies, 28(1), 153-230.

Saw, Y. M., Than, T. M., Thaung, Y., Aung, S., Shiao, L. W.-S., Win, E. M., Khaing, M., Tun, N. A., Iriyama, S., & Win, H. H. (2019). Myanmar’s human resources for health: Current situation and its challenges. Heliyon, 5(3), e1390. https://doi.org/10.1016/j.heliyon.2019.e01390

*Tayzar Hein
No.94, D-1, Pyay Road, Mingaladon Township,
Yangon, Myanmar Postal code – 11021
+95 95188093
Email: dr.tayzarhein@gmail.com

Submitted: 13 March 2025
Accepted: 18 March 2025
Published online: 1 April, TAPS 2025, 10(2), 1-3
https://doi.org/10.29060/TAPS.2025-10-2/GP3694

Shuh Shing Lee, Jillian Han Ting Yeo & Dujeepa D Samarasekera

Centre for Medical Education, Yong Loo Lin School of Medicine, National University of Singapore, Singapore

Abstract

Introduction: The Asia Pacific Medical Education Conference (APMEC) 2025 focused on evolving medical education amidst global transformations. The theme, “Developing a Holistic Healthcare Practitioner for a Sustainable Future,” emphasised integrating sustainability, inclusivity, and advanced technologies like AI into healthcare education.

Methods: APMEC 2025 featured a comprehensive program including 29 workshops, 1 special course, 2 keynote speeches, 6 plenary sessions, 19 symposia, and 3 panel discussions, with 84 free communications and 107 short communications presented. The conference facilitated dialogues on innovative curriculum design, sustainability in healthcare education, AI integration, and interprofessional education.

Results: Key discussions emphasised incorporating “Possibility Thinking” and student-centered learning, embedding planetary health in curricula, and integrating AI while preserving essential human skills like empathy. The NUS Common Curriculum for Healthcare Professional Education demonstrated significant improvements in empathy and teamwork. The conference highlighted the importance of faculty development and inclusivity, particularly concerning disability in medical education.

Conclusion: APMEC 2025 demonstrated a commitment to transforming medical education through collaboration and innovation. By aligning educational practices with global trends and regional needs, APMEC serves as a catalyst for comprehensive curriculum reforms. Ongoing efforts are needed to translate these insights into actionable strategies, ensuring future healthcare professionals are well-prepared to address dynamic global challenges.

Practice Highlights

• Student involvement in curriculum planning is essential to enhance student-centered learning and competency-based education.
• AI’s role in augmenting healthcare education while ensuring the retention of essential human skills.
• Incorporating planetary health concepts into medical curricula to prepare healthcare professionals for environmentally responsible practice.
• Implementing structured models like NUS’s Common Curriculum to improve empathy and teamwork in healthcare training.
• Enhancing teaching quality and leadership through structured faculty training programs, crucial for sustained educational improvements.

I. INTRODUCTION

The APMEC conference was held this year from January 13th (Monday) to 18th (Saturday) at Yong Loo Lin School of Medicine, National University of Singapore.  Medical education is in the midst of a global transformation, influenced by technological advancements, new pedagogical techniques, and a focus on sustainability and inclusivity. The Asia Pacific Medical Education Conference (APMEC) serves as a crucial platform for medical educators, researchers, and policymakers to discuss and shape the future of healthcare education. This year’s theme, “Developing a Holistic Healthcare Practitioner for a Sustainable Future – Trends ● Issues ● Priorities ● Strategies,” highlights the alignment of medical education with sustainable practices, innovative learning, and inclusive policies. The conference featured 29 workshops, 1 special course, 2 keynotes, 6 plenary sessions, 19 symposia, 3 panel discussions, 84 free communications, and 107 short communications, providing a comprehensive platform for exchange and learning.

II. LEARNINGS FROM VARIOUS SESSIONS

The concept of “Possibility Thinking” advocating for a shift beyond disease-focused approaches toward holistic healthcare strategies was shared in Plenary 1 by Professor Ronald Harden. Prof Harden emphasised the need for student engagement in curriculum planning, fostering a more integrated and participatory learning experience. This aligns with global calls for student-centered learning, competency-based education, and the co-creation of curricula with learners. In line with this year’s theme, symposiums explored how to embed sustainability in medical education. Climate change is affecting global health, making sustainability a key focus in health professions education worldwide.

In the opening keynote, Prof Yang Faridah shared practical approaches for resource-poor countries. She gave examples from Malaysia, showing how medical schools are integrating planetary health into their curricula. This prepares future healthcare professionals for environmentally responsible practice. The use of artificial intelligence (AI) is reshaping health professions education. It enhances decision-making, improves efficiency, and boosts diagnostic accuracy. However, panellists stressed the irreplaceable value of human skills like empathy, communication, and ethical judgment. The discussion highlighted a global shift towards integrating AI in healthcare education while ensuring technology complements, not replaces, the human touch. Another key aspect discussed at the conference was how best to restore engagement and joy in learning by revitalising medical. Several sessions focused on applying practical strategies to boost engagement and create supportive learning environments. Key discussions covered creative learning approaches that use playfulness to improve concept retention. Panellists highlighted the importance of teamwork in reducing loneliness and enhancing performance. They also stressed the need for inclusive, psychologically safe spaces that nurture enthusiasm for medical education. The speakers also emphasised mentorship and peer support as critical factors in reducing burnout and increasing overall satisfaction. Participants explored strategies to encourage work-life balance, recognising the importance of self-care and having hobbies outside medicine. Addressing burnout triggers and implementing sustainable changes within medical education institutions were highlighted as necessary steps to prioritise joy and well-being alongside academic excellence.

Interprofessional education (IPE) is gaining global recognition as a key strategy to break down professional silos and prepare healthcare graduates for integrated, patient-centred care. In the opening ceremony speech, the Dean of the Yong Loo Lin School of Medicine, National University of Singapore, Prof Chong Yap Seng, introduced NUS’s Common Curriculum for Healthcare Professional Education, launched in 2023. This structured approach to IPE aims to enhance collaboration. Early evaluations of the program show improvements in empathy, teamwork, and collaborative practice.

Inclusivity, particularly support for students with disabilities in medical and health professions education, was a key focus at APMEC this year. The updated Canadian technical standards were shared by Professor Cheryl Holmes from University of British Columbia defining core competencies based on functional abilities. These standards were developed through collaboration with a diverse group, including learners and physicians with disabilities. This initiative sets a precedent for regional collaboration. It encourages other countries to update educational standards to promote equity, support students with physical challenges, and improve the quality and accessibility of medical education.

Amid these evolving trends, faculty development remains a cornerstone of advancing medical education. Stories shared during the faculty development session illustrated how structured programs empower educators to drive change at institutional, national, and regional levels. Investments in faculty training are critical in ensuring sustained improvements in teaching quality and leadership in health professions education. By exposing participants to global best practices, it encourages the adoption of innovative teaching strategies. These approaches are tailored to address specific regional challenges and opportunities, enhancing the overall quality of medical and health professions education.

III. GLOBAL TRENDS AND IMPACT IN THE ASIA PACIFIC REGION AND BEYOND

The themes discussed at APMEC align with several global trends shaping the future of medical education. One key shift is the growing adoption of competency-based medical education (CBME), which is gradually replacing traditional time-based models. CBME prioritises the acquisition of practical skills and the application of knowledge in real-world settings, ensuring that graduates are better prepared for clinical practice.

Technological advancements are also playing a transformative role. Artificial intelligence (AI), virtual reality (VR), and simulation-based training are becoming more accessible, revolutionising the way medical students learn. These innovations enhance diagnostic accuracy, refine clinical decision-making, and provide immersive, hands-on learning experiences in a risk-free environment.

At the same time, sustainability in healthcare education is gaining momentum. With increasing awareness of environmental challenges, medical schools are integrating planetary health concepts into their curricula. This ensures that future healthcare professionals are equipped to adopt sustainable practices and address the impact of climate change on global health.

These evolving trends reflect a broader movement towards a more adaptive, technology-driven, and socially responsible approach to training the next generation of healthcare practitioners. Another key area of discussion was student and faculty well-being. There is a growing focus on addressing mental health challenges and reducing burnout in medical training. Faculty well-being is especially crucial, as educators play a vital role in shaping future healthcare professionals. Supporting their mental and emotional health ensures they can provide high-quality education while maintaining their own resilience and job satisfaction.

IV. CONCLUSION

APMEC continues to align global trends with regional needs, acting as a hub for advancing medical education. It drives transformation by offering a platform for knowledge exchange, enabling collaboration among educators and policymakers. The conference strengthens connections between institutions across the Asia-Pacific region, promoting shared learning and research. As participants return to their institutions, the focus must shift to translating insights into concrete actions that improve medical and health professions education. Through collaboration, innovation, and inclusivity, APMEC ensures that future healthcare professionals are prepared to tackle the evolving challenges of a dynamic world.

Notes on Contributors

LSS  contributes to the conception of the work. LSS, JHTY and DDS drafts the work and revising it, approves the final version to be published, and agrees to be accountable for all aspects of the work.

Acknowledgement

We extend our gratitude to all participants, speakers, and organisers of APMEC for their invaluable contributions to advancing medical education.

Funding

There is no funding for this paper.

Declaration of Interest

The author declared no conflict of interests.

*Lee Shuh Shing
10 Medical Drive,
Singapore 117597
66013452
Email: medlss@nus.edu.sg

Submitted: 18 May 2024
Accepted: 25 November 2024
Published online: 1 April, TAPS 2025, 10(2), 4-7
https://doi.org/10.29060/TAPS.2025-10-2/GP3347

Juliet Mathew¹, Hazlina Binti Abu Bakar² & Shilpa Murthy²

¹Clinical Skills & Simulation Centre and School of Medicine, IMU University, Malaysia; ²Department of Clinical Skills and School of Medicine, IMU University, Malaysia

Abstract

Introduction: Medical students are known to have a higher prevalence of psychological distress although they begin medical school with better mental health than their peers. Depression and burnout rates are high among them and many of these students do not seek help due to the associated stigma linked with mental health concerns. At present, there are several known resilience-enhancing modules incorporated within the curriculum to improve students coping skills, however, there are no known modules yet that introduce this concept within the early medical curriculum, especially within the pre-clinical years.

Methods: IMU University introduces a Resilience Workshop within early pre-clinical years to appropriately engage students to recognise and address common challenges. This can be tackled by understanding the various coping mechanisms that can be adopted. This workshop describes four main areas: introduction to resilience, interactive activities, discussions, and reflection platforms. This initiative aligns with the university’s curriculum focus on person-centred care, emphasising personalised care as a priority.

Results: Preliminary results suggest that the Resilience Workshop can aid in developing suggested and self-regulated interventions to manage adversities faced by medical students. Attention to individual students’ coping reservoirs can help promote well-being and minimise burnout. Formal and informal offerings within medical schools can help fill the reservoir.

Conclusion: This article provides a perspective on fostering resilience building within the early medical curriculum to cultivate core strengths among medical students for managing adversities.

Practice Highlights

• Psychological distress is prevalent among medical students.
• Challenges occur in medical students seeking help.
• Resilience strength is vital to medical students to recognise and address common challenges.
• A gap exists in the curriculum to improve medical students’ coping skills in the early years.
• Fostering resilience in early medical curricula can cultivate core strengths among medical students for managing adversities.

I. INTRODUCTION

IMU University’s Resilience Workshop was designed and implemented within the medical curriculum in pre-clinical years to develop students’ core inner strengths to their possible highest growth. This is so that they are fully equipped and ready to meet the challenges of competent care delivery to patients. In line with IMU University’s revised medical curriculum’s direction which focuses on the philosophy of person-centred care with humanistic values, this workshop emphasises self-care as a priority before embarking on to selfless care of patients.

In this revised curriculum, much emphasis is placed on the development of skills, behaviours, and attitudes within the delivery of care to patients, encompassing the basic concepts of human interaction, patient safety, quality improvement, and systems thinking; while enhancing the skills of teamwork, effective communication, leadership, negotiation, and cooperation.

The aim has been to best prepare our graduates to practice within the needs of the health profession in the 21st century. This includes equipping them in communication, clinical, cultural, interpersonal, research, and system thinking competencies. These prepare our students to be ready for any advanced clinical training within local or international institutions.

The curriculum’s goal is also to produce graduates who are person-centred and with humanistic values, with professional attributes of being empathetic, compassionate, responsive, and adaptive besides being a transformative leader, lifelong learner, and professionally competent.

Thus, the new curriculum emphasises graduates’ wellness, person-focus services, effective communication, personalised care, multi-disciplinary collaboration & approach, coordinated, continuous & seamless care delivery manner; & application of system thinking and value-based care.

In aligning with this direction and ensuring that our graduates are fit to practice as global doctors with opportunities to practice internationally, the Resilience Workshop engages and guides students in building their own core coping mechanisms while reviewing the principles of determinants of resilience. It is designed to inspire and empower students to be resilient. The postulation is that the students would have retained a substantial knowledge base which constitutes an increasing resource for coping with the diverse challenges they will be exposed to in their medical journey, and for building core resilience strength.

II. METHODS

A. Structured Workshop Flow

The lesson outcomes from this workshop aim at achieving student’s understanding of the importance of adapting well in the face of adversity, threats, or even significant sources of stress, as well as engaging in resilience throughout medical school. With inspiring themes such as “Bend, But Do Not Break” in semester two and “Be Managing Adversities Delightfully (Be MAD)” in semester four, pre-clinical medical students are exposed to challenging scenarios that they may encounter. These scenarios extend beyond their roles as students, to include their relationships with friends, roommates, peers, and more.

The workshop is designed to engage students in four main areas:

Session 1: Introduction to Resilience

Session 2: Activity on Resilience

Session 3: Discussions on Resilience

Session 4: Reflection on Resilience

At the beginning of the workshop, students are provided with The Brief Resilience Scale adapted from Ohio University. It consists of simple and focused scoring scales. It is concise and has good psychometric properties including strong validity and reliability, capturing resilience effectively. Students can score and gauge their resilience levels with easy-to-follow instructions. This allows them to understand their coping strengths, identify their ability to recover from adversities, focus on areas for improvement, and guide them toward improved performances within medical training.

Subsequently, students are introduced to the concept of resilience. They are then led into small group discussions to engage, brainstorm scenarios presented, and grasp levels of coping and managing difficult scenarios that are commonly encountered. They are also given opportunities to share their experiences and discuss possible solutions to the scenarios and their insights. Debriefing includes discussions based on structured questions that could engage students in their thought processes and emotional experiences. It also focuses on their possible courses of action, ideas, or solutions in managing difficult situations within the scenario presented.

B. Reflection Analysis

Students are encouraged to reflect on their experiences and take-home messages from the workshop. They are required to submit a 500-word essay via e-mail, documenting the challenges and strengths that surfaced for them during the session. This must be submitted within a stipulated time frame after the workshop, via e-mail to facilitators for assessment. These reflection essays are reviewed and students with potential mental health concerns are identified. They are then followed personally or referred to their mentors for appropriate support.

III. RESULTS

The scenarios used exposed students to common issues encountered during their early medical training. It encompassed adjustments to the new environment on campus and hostels, adjustments to a new culture of peers, understanding new subjects, meeting professionalism requirements, and addressing unique and individualised adversities.

These scenarios stimulated discussions in the breakout sessions, where standard questions were posed to ignite the development of possible solutions to the simulated adversities faced: (A) How would you handle this situation? (B) What would you do? (C) How would you feel? (D) Explain.

Students were encouraged to narrate their experiences and explore their thoughts and emotions. This helped students realise that there are common issues that are endured by many. Most students reported that the workshop helped them to understand the various coping mechanisms that can be adopted to solve issues that may arise within their journey and progress in medical school. Verbal responses received include:

“I didn’t realise how important managing stress was until I was hit by a personal issue. It affected my studies. This workshop showed me how I can handle stress better…”

“I didn’t want to attend this workshop at first.  But the scenarios discussed were mostly what I had endured. I wish I knew these coping strategies earlier…”

IV. DISCUSSION

Students can establish strong foundations in coping strategies, emotional intelligence, and stress management by introducing resilience throughout the preclinical years. The hurdles are mostly theoretical and academic, making it a less demanding environment to begin honing these talents. Students can study the fundamentals of resilience, through such workshops. The basic ideas from the preclinical years could be modified and built upon to deal with the interpersonal, ethical, and emotional difficulties that may arise in their academic obligations and their clinical practice.

The challenges encountered can be described within the following phases:

A. Pre-workshop Challenges

The lack of facilitators with adequate skills in resilience science and mental health advocacy was the main challenge. As mental health issues require more in-depth management, the deliverance of such workshops had to be done by facilitators who are skilled in strong communication skills, empathy, patience, and compassion. The initial perspective was that all faculty would be well-equipped with these skills, however, it became clear post-workshop, that this was not the case. The selection of such facilitators to deliver the context of this workshop in a non-lecturing but inspiring way posed a challenge. The solution is to include training for faculty before the workshop.

B. Workshop Challenges

During the Malaysian Movement Control Order (M.C.O.) when this workshop was first introduced to help students cope, it was delivered online.  Hence, the active involvement of students was limited as being on camera had its challenges. Further, many students considered such a workshop to be non-mainstream and non-exam oriented, thus, needing much encouragement to participate fully. The solution is to introduce face-to-face workshops to better engage students.

C. Post-workshop Challenges

Most students who attended the workshop completed and e-mailed the reflection exercises. However, a certain percentage of them failed to do so. This presents a challenge in identifying any student who may have a serious underlying issue with managing adversities resiliently. The solution is to track attendance when delivering assignments.        

A possible way to capture all reflections would be to make attendance marked only upon receiving the assignment. As these are medical students in their early years, this approach may not be effective and can lead to non-genuine or robotic responses. While addressing and reinforcing professionalism may be another goal for obtaining reflective essays, it may seem forced. More self-regulating and motivating strategies should hence be developed and applied.

This two-hour workshop is a brief intervention within the time-limited curriculum within semesters two and four. Moving forward, a half-day workshop with more time for interaction with peers and educators could better engage students. A survey could be conducted post-workshop to assess students’ feedback. Providing progression reports of students’ resilience levels could be a more accurate measure of the workshop’s impact. Also, the BRS could be re-used in semester four, to review recovery or the ability to regain equilibrium after adversity.

The students’ submissions of their reflective essays constitute a dataset that can be analysed for further studies in this field, to address and create various aspects of positive interventions within mental health access and stress-relief resources. The aim is, to create better impacts on students’ learning and experience in medical school.

V. CONCLUSION

Above all, we need to understand that resilience is a lifelong ability that cannot be acquired in a single workshop. It needs to be constantly supported through different educational stages, within challenging and stressful circumstances.

Attention to individual students’ coping reservoirs can help promote well-being and minimise burnout. Formal and informal offerings within medical schools can contribute to this effort. Helping students cultivate the skills to sustain their well-being throughout their careers has important payoffs for the overall medical education enterprise.

IMU University’s Resilience Workshop can aid in the development of suggested as well as self-regulated interventions to manage adversities faced by medical students. A formal study is ongoing to substantiate this. Further to this, the development of a student-led multifaceted approach that promotes not only care-taking behaviours but also focuses on institutional and cultural change to empower students to participate in these resiliency strategies can be considered.

This and other models of coping should be empirically validated, for students to not stumble through medical school, but soar.

Notes on Contributors

Dr Juliet Mathew is the first author who designed and wrote this article. Director of the Clinical Skills & Simulation Centre at IMU University, she teaches simulation concepts to pre-clinical students. She confirms sole responsibility for this article’s conception, design, analysis, interpretation of results of context, and manuscript preparation.

Dr Hazlina Binti Abu Bakar supervised the conception of this project and contributed to the critical review of the manuscript. She is a lecturer teaching clinical skills and simulation concepts at the School of Medicine University, IMU University. She also holds a master’s degree in healthcare and medical simulation.

Dr Shilpa Murthy contributed to the continuous review of the important intellectual content and final version of the manuscript. She also contributed to the conception of this project. She is a senior lecturer teaching clinical skills and simulation concepts to pre-clinical medical students at the School of Medicine, IMU University.

Acknowledgements

The authors would like to express our sincere appreciation to Dr Cheah Xian-Yang for his invaluable assistance in proofreading this article. We also extend our gratitude to Associate Professor Dr Sow Chew Fei for her guidance.

Funding

There is no funding for this paper.

Declaration of Interest

The authors of this paper have no conflicts of interest to declare.

References

Bird, A., Tomescu, O., Oyola, S., Houpy, J., Anderson, I., & Pincavage, A. (2020). A curriculum to teach resilience skills to medical students during clinical training. MedEdPORTAL, 16, Article 10975. https://doi.org/10.15766/mep_2374-8265.10975

Cook, M. C., & Stewart, R. (2023). Resilience and sub-optimal social determinants of health: Fostering organizational resilience in the medical profession. Primary Care: Clinics in Office Practice, 50(4), 689-698. https://doi.org/10.1016/j.pop.2023.04.013

Omari, O. A., Yahyaei, A. A., Wynaden, D., Damra, J., Aljezawi, M., Qaderi, M. A., Ruqaishi, H. A., Shahrour, L. A., & AlBashtawy, M. (2023). Correlates of resilience among university students in Oman: A cross-sectional study. BMC Psychology, 11, Article 2. https://doi.org/10.1186/s40359-022-01035-9

Rotenstein, L. S., Ramos, M. A., Hom, J., & Gardner, A. (2016). Prevalence of depression, depressive symptoms, and suicidal ideation among medical students: A systematic review and meta-analysis. JAMA, 316(21), 2214-2236.https://doi.org/10.1001/jama.2016.17324

Thompson, G., McBride, R. B., Hosford, C. C., & Halaas, G. (2016). Resilience among medical students: The role of coping style and social support. Teaching and Learning in Medicine, 28(2), 174-182. https://doi.org/10.1080/10401334.2016.1146611

*Dr Juliet Mathew
IMU University, 126, Jalan Jalil Perkasa 19,
Bukit Jalil, 57000 Kuala Lumpur
Federal Territory of Kuala Lumpur
+6012 – 574 1723
Email: julietmathew@imu.edu.my

Submitted: 15 June 2024
Accepted: 12 September 2024
Published online: 1 April, TAPS 2025, 10(2), 8-12
https://doi.org/10.29060/TAPS.2025-10-2/GP3440

Galvin Sim Siang Lin¹, Tong Wah Lim² & Mariana Minatel Braga³

¹Department of Restorative Dentistry, Kulliyyah of Dentistry, International Islamic University Malaysia, Malaysia; ²Division of Restorative Dental Sciences, Faculty of Dentistry, The University of Hong Kong, Hong Kong S.A.R.; ³Department of Orthodontics and Pediatric Dentistry, School of Dentistry, University of São Paulo, Brazil

Abstract

Introduction: Dental education is undergoing a major transformation due to evolving healthcare needs, technological advancements, and the demand for dental practitioners to meet the diverse needs of a global patient community. Competency-based education (CBE) is at the forefront of this change, focusing on what students are competent in upon graduation. Unlike traditional models, CBE emphasises practical skills, critical thinking, and problem-solving.

Methods: This article explo res the shift towards CBE in dental education, examining frameworks that support CBE like Miller’s Pyramid and guidelines from organisations such as the Accreditation Council for Graduate Medical Education (ACGME) and the American Dental Education Association (ADEA). It also involves a detailed analysis of these frameworks and their application in designing competency-based curricula.

Results: The findings reveal that CBE facilitates a student-centric approach, enhancing critical thinking, problem-solving, and autonomous self-assessment. These frameworks guide the design of curricula including identifying core competencies, defining competency levels, mapping competencies to learning outcomes, selecting effective teaching methods and utilising various assessment strategies. However, implementing CBE faces challenges, including measuring soft skills and resistance from educators and students.

Conclusion: CBE represents a paradigm shift in dental education, ensuring graduates are not only knowledgeable but proficient in practical skills. Future recommendations include incorporating technology-enhanced learning, global health competencies, and sustainability practices into the curriculum. Continuous professional development for educators and robust feedback mechanisms are needed to maintain the curriculum’s relevance and effectiveness, ensuring dental graduates are well-equipped to meet the demands of modern dental practice.

Practice Highlights

• Dental education is evolving to meet global healthcare needs and technological advancements.
• CBE focuses on practical skills, critical thinking, and problem-solving
• CBE ensures dental graduates are competent and ready for modern practice challenges.
• Several frameworks can be used to guide CBE in developing clinical
• Designing CBE curricula involves defining core competencies and using diverse assessment methods.

I. INTRODUCTION

Dental education is at a pivotal moment, facing a profound transformation influenced by the dynamic intersection of changing healthcare needs, technological advancements, and the urgent call for dental practitioners to cater to the diverse requirements of a globalised patient community. Amid this swiftly evolving landscape, traditional approaches to dental education are undergoing a fundamental reimagination. The aim is to nurture a generation of dental professionals not only well-versed in theoretical knowledge but, crucially, equipped with the competencies vital for thriving in modern dental practice. Competency-based education (CBE) emerges as a key player in this educational revolution. This approach to curriculum design and teaching revolves around a central question: What should students be able to do or achieve at the culmination of their course or program? In the realm of dental education, CBE moves beyond the traditional focus on accumulating knowledge and places a spotlight on the practical skills students need to excel in their future roles. It is not just about what students know; it is about what they can proficiently do. Why adopt competency-based education in dentistry? The answer lies in its power to enhance student learning by emphasising hands-on skills, critical thinking, and problem-solving abilities. CBE ensures that graduates are not merely well-informed in dental theory but are also competent practitioners capable of meeting the ever-changing demands of contemporary dental care.

II. THE SHIFT TOWARDS COMPETENCY-BASED DENTAL EDUCATION

In recent years, the field of dental education has undergone a transformative shift, pivoting away from the traditional education models to embrace the principles of competency-based dental education. This evolution is rooted in a fundamental recognition that the mastery of dental skills and knowledge is a dynamic process, necessitating an educational paradigm that transcends mere adherence to a predetermined timeframe (Chuenjitwongsa et al., 2018). While various definitions of competency-based education exist, there is a consensus that it revolves around outcome-based learning, ensuring the production of graduates with the requisite knowledge, skills, and attitudes to serve society effectively, meeting the standards of national qualifications frameworks, stakeholders, and the labour market.

Traditional-based dental education has faced criticisms for its potential to produce graduates who may lack practical proficiency or struggle to adapt to emerging trends in dentistry. It emphasises time spent in the classroom, irrespective of individual mastery. Furthermore, traditional models may sometimes struggle to keep pace with the rapid advancements in dental technology and shifting paradigms in patient care, underscoring the need for a more adaptive and outcomes-focused approach. On the other hand, CBE signifies a departure from traditional education, characterised by its teacher-centred, examination-focused, time-constrained, and discipline-oriented approach. It transitions towards a student-centric educational model using an outcome-based approach that enhances students’ capabilities in critical thinking, problem-solving, and autonomous self-assessment.

Moreover, in CBE, the focus shifts from completing a predefined course of study to ensuring that learners attain proficiency in specific competencies, enabling them to navigate the complexities of dental practice effectively. In a competency-based framework, success is measured by demonstrating specific skills, ensuring that graduates are not merely knowledgeable but possess the practical expertise required for clinical practice. Besides, future professionals tend to be able to make decisions even when ideal/learned circumstances are changed. This paradigm shift promotes a deeper understanding of concepts and fosters a culture of continuous improvement. In CBE, novice dental students commence their training in simulation laboratories, preparing them to progressively attain beginner and competent levels in clinical settings.

III. FRAMEWORK FOR COMPETENCY-BASED DENTAL EDUCATION

A. Miller’s Pyramid

The Miller Pyramid of Competence, introduced by psychologist George Miller in 1990 (Miller, 1990), stands as a foundational framework for evaluating clinical proficiency in healthcare education. This pyramid encapsulates a four-tiered hierarchy, delineating the progressive stages of competence acquisition. At its base, the pyramid begins with “knowledge”, representing the foundational cognitive understanding of concepts typically assessed in classroom-based environments. Moving upwards, the tiers evolve into “competence” and subsequently “performance”, encompassing knowledge translation into practical skills through simulated clinical settings. The higher echelons of the pyramid, namely “action”, signify the culmination of clinical competence in real-world scenarios. Here, learners demonstrate their ability to apply theoretical knowledge and practical skills in authentic clinical environments. The Miller Pyramid’s distinction between cognitive and behavioural components is particularly noteworthy. The lower tiers, focusing on knowledge and competence, mention the importance of classroom-based assessments in gauging cognitive understanding. In contrast, the apex tiers of performance and action underline the significance of evaluating behavioural aspects within simulated and real clinical settings. This hierarchical structure provides a great understanding of competency development, guiding educators in designing competency-based curricula.

B. Accreditation Council for Graduate Medical Education (ACGME)

The ACGME plays a role in shaping the educational standards for healthcare professionals. ACGME has delineated six core competencies, transcending traditional disciplinary boundaries and applicable to various healthcare practitioners (Batalden et al., 2002). These competencies form a holistic approach to evaluating the proficiency of healthcare professionals and are integral to fostering well-rounded practitioners capable of meeting the complex demands of modern healthcare. The six core competencies identified by ACGME are Patient Care, Medical Knowledge, Professionalism, Interpersonal and Communication Skills, Practice-Based Learning and Improvement, and Systems-Based Practice. Patient Care centres on delivering compassionate, effective, evidence-based care to individuals and populations, while medical knowledge encompasses the understanding needed for sound clinical decision-making. Professionalism emphasises ethical behaviour, accountability, and a commitment to the well-being of patients. Interpersonal and Communication Skills are crucial for effective collaboration and patient interaction, whereas practice-Based Learning and Improvement involves the ability to critically assess and improve one’s own clinical practice continuously. Systems-Based Practice involves comprehending healthcare delivery systems and endorsing high-quality and cost-effective patient care within the broader healthcare system context. Customising these competencies for the dental context allows dental educators to align educational objectives, ensuring their curriculum imparts technical skills while cultivating the ethical, communication, and systemic perspectives essential for a well-rounded dental practitioner.

C. American Dental Education Association (ADEA) Competencies for the New General Dentist

The ADEA has crafted the Competencies for the New General Dentist, a set of guidelines tailored specifically for dental education (American Dental Education Association, 2017). Ratified by the ADEA House of Delegates on 2^nd April 2008, this framework is a decisive step in defining the essential competencies for individuals entering the dental profession as general dentists., This document reflects a departure from the 1997 competencies, aligned with patient care responsibilities, public oral health needs, and contemporary trends in dental practice and draws inspiration from the 2002 Institute of Medicine’s core competencies with a heightened emphasis on quality patient care and safety. Structured into six domains—Critical Thinking, Professionalism, Communication and Interpersonal Skills, Health Promotion, Practice Management and Informatics, and Patient Care—the competencies are thoughtfully organised, allowing for more flexible and adaptable integration into dental education curricula. This framework serves as a central resource for the ADEA at the national level and individual dental schools at the local level, fostering an environment conducive to innovation in predoctoral dental school curricula. Overall, the ADEA competencies serve as a benchmark, enabling dental educators to design curricula that not only meet but exceed the contemporary expectations and requirements of the dental profession.

D. The Graduating European Dentist Curriculum

The Graduating European Dentist Curriculum, under the auspices of the Association for Dental Education in Europe (ADEE), presents a contemporary framework embodying the optimal academic practices for undergraduate dental education in Europe (Field et al., 2017). This curriculum is structured across five integral domains, each contributing to a comprehensive educational experience: (1) Professionalism, (2) Safe and Effective Clinical Practice, (3) Patient-Centred Care, (4) Dentistry and Society, and (5) Research. Crafted through a collaborative process involving consultation, consensus-building, and collegial learning, this curriculum highlights the importance of patient safety, teamwork, and teaching excellence. Aligned with European Quality in Higher Education benchmarks, “The Graduating European Dentist” introduces an innovative approach reflecting the pinnacle of academic standards in European dental education. The revised framework features a more explicit linkage between “Learning Outcomes” and the defined curriculum, accompanied by detailed guidance specific to each competence domain, encompassing “Methods of Teaching and Learning” and “Methods of Assessment”. It is anticipated that this framework would facilitate an enriched educational experience for dental students across Europe.

IV. DESIGNING A COMPETENCY-BASED DENTAL CURRICULUM

To effectively design and develop a competency-based dental curriculum, educators need a comprehensive framework that aligns with the unique challenges and requirements of dental practice. The following components are some of the basic summarised steps that serve as foundational guides for the implementation of a competency-based curriculum:

A. Identifying Core Competencies

Begin by identifying the core competencies that future dental practitioners must possess. This involves collaboration with practitioners, educators, and stakeholders to ensure that the curriculum reflects the evolving needs of the dental profession. Core competencies might encompass knowledge acquisition, clinical skills, patient communication, ethical practice, and the ability to integrate new research findings into practice.

B. Defining Competency Levels

Once core competencies have been identified, it is crucial to define distinct competency levels for each skill or knowledge area. These levels serve as benchmarks for assessing student progress and proficiency. They facilitate a granular approach to education, where learning and assessment can be tailored to students’ individual needs, recognising that learners progress at different rates and may require differentiated levels of support to achieve competency.

C. Mapping Competencies to Learning Outcomes

Each identified competency should be mapped to specific learning outcomes within the curriculum. This mapping process ensures that the curriculum is logically structured, with a clear progression from foundational knowledge to applying skills in complex clinical scenarios. It allows educators to design courses and modules that systematically build upon each other, guiding students on a clear path towards achieving the essential competencies required for successful dental practice.

D. Selecting Effective Teaching Methods 

Adopt diverse and innovative teaching methods that cater to different learning styles and encourage active engagement. Techniques such as problem-based learning (PBL), case-based learning (CBL), team-based learning (TBL), simulation exercises, and hands-on clinical practice are effective in helping students develop critical thinking and practical skills. Incorporating technology, such as virtual reality (VR) and digital simulations, can also enhance learning experiences and prepare students for real-world challenges.

E. Utilising Assessment Strategies

Implement a variety of assessment methods to evaluate students’ competency levels. This may include practical exams, case-based assessments, and objective structured clinical examinations (OSCEs). These should be complemented by regular, formative assessments and feedback, which are instrumental in identifying areas where students may struggle and providing them with the support needed to overcome these challenges. The ultimate goal of assessment within a competency-based curriculum is not merely to test knowledge but to facilitate the development of skilled, reflective, and adaptable dental practitioners.

V. LIMITATIONS AND CHALLENGES IN IMPLEMENTING A COMPETENCY-BASED CURRICULUM

Authenticity and the ability to accurately measure skills have been identified as the primary challenges in CBE for dentistry. In this field, knowledge and skills are often assessed as separate entities, leading to a potential loss of authenticity throughout the learning process. While CBE incorporates a variety of subjective and objective evaluations, measuring certain soft skills, such as clinician-patient communication, ethics, and values, remains a challenge due to their complex and intangible nature. Moreover, implementing CBE in dental education may face additional obstacles, including the limited availability of established theoretical frameworks to guide the teaching-learning process, insufficient training for educators in adapting to this curriculum style, and resistance from both teaching staff and students. Addressing these challenges is essential for ensuring the successful adoption and integration of competency-based education within dental programs.

VI. CONCLUSION

The transition towards competency-based dental education marks a significant paradigm shift aimed at equipping future dental professionals with the practical skills, ethical understanding, and critical thinking abilities necessary for success in the contemporary dental landscape. Future recommendations include the further integration of technology-enhanced learning tools, the development of global health competencies, and the emphasis on sustainability and ethical practices within the curriculum. Additionally, establishing robust feedback mechanisms and promoting continuous professional development among educators will be crucial in maintaining the curriculum’s relevance and effectiveness.

Notes on Contributors

GSSL and TWL were involved in the conception and design of the study. GSSL, TWL and MMB reviewed the literature, collected the data, and wrote the original draft. TWL edited the original draft. All authors have read and approved the final manuscript.

Funding

No funding is required for this paper.

Declaration of Interest

All authors have no conflicts of interest.

References

American Dental Education Association. (2017). ADEA competencies for the new general dentist. Journal of Dental Education, 81(7), 844-847. https://doi.org/10.1002/j.0022-0337.2017.81.7.tb06299.x

Batalden, P., Leach, D., Swing, S., Dreyfus, H., & Dreyfus, S. (2002). General competencies and accreditation in graduate medical education. Health Affairs (Millwood), 21(5), 103-111. https://doi.org/10.1377/hlthaff.21.5.103

Chuenjitwongsa, S., Oliver, R., & Bullock, A. D. (2018). Competence, competency‐based education, and undergraduate dental education: A discussion paper. European Journal of Dental Education, 22(1), 1-8. https://doi.org/10.1111/eje.12213

Field, J. C., Cowpe, J. G., & Walmsley, A. D. (2017). The graduating European dentist: A new undergraduate curriculum framework. European Journal of Dental Education, 21 Suppl 1, 2-10. https://doi.org/10.1111/eje.12307

Miller, G. E. (1990). The assessment of clinical skills /competence/performance. Academic Medicine, 65(9), S63-67. https://doi.org/10.1097/00001888-199009000-00045

*Galvin Sim Siang Lin
Department of Restorative Dentistry,
Kulliyyah of Dentistry,
International Islamic University Malaysia,
Kuantan Campus, Pahang, Malaysia
Email: galvin@iium.edu.my

Submitted: 5 July 2024
Accepted: 25 November 2024
Published online: 1 April, TAPS 2025, 10(2), 13-16
https://doi.org/10.29060/TAPS.2025-10-2/GP3456

Eng Koon Ong^1-4,7 & Wen Shan Sim^4-6

¹Division of Supportive and Palliative Care, National Cancer Centre Singapore, Singapore; ²Office of Medical Humanities, SingHealth Medicine Academic Clinical Programme, Singapore; ³Division of Cancer Education, National Cancer Centre Singapore, Singapore; ⁴Duke-NUS Graduate Medical School, Singapore; ⁵Maternal Fetal Medicine, KK Women’s and Children’s Hospital, Singapore; ⁶PGY1 Programme, SingHealth, Singapore; ⁷Assisi Hospice, Singapore

Abstract

Introduction: The medical humanities (MH) have the potential to support medical education (ME) by developing observational skills, promote reflective practice and transformative growth. However, contextual content and methods relevant to our local and regional learners and teachers are lacking.

Methods: We describe three MH-based ME programmes within SingHealth to illustrate our considerations in the choice of conceptual frameworks and content selection in programme development and evaluation.

Results: Highlighting pertinent challenges in developing the field due to poor awareness, lack of resources and research capability, we emphasise the importance of interdisciplinarity, engaging leadership, and generating research output. Broad strategies to achieve these goals are then presented.

Conclusion: Highlighting challenges due to the lack of awareness, administrative and funding support, and research capability, we propose strategies to overcome such barriers and hope that readers will be inspired to contribute to this developing landscape where science and art intersect.

Practice Highlights

• Established frameworks and methods should be employed in programme development and evaluation.
• Art, literature, and theatre may be employed in medical humanities-programmes.
• Interdisciplinarity, leadership engagement and development of research capability are essential.
• Alignment with organisational needs and vision will ensure relevance and sustained support.
• The impact of the humanities on fostering wellbeing should not be neglected.

I. INTRODUCTION

The medical humanities (MH) is an interdisciplinary field characterised by critical enquiry and engagement of humanities disciplines. In medical education (ME), content or pedagogy derived from the arts and humanities may be employed to develop observational skills, promote reflective practice and transformative growth, and support humanistic clinical practice and communications (Dennhardt et al., 2016). However, while the integration of the MH in ME in Western countries has been widely supported and reported, a similar movement within Asian countries appears to be lacking and challenging. Educators in Arab-Muslim environments have lamented the lack of culturally-relevant content and concepts that remain predominantly Western-centric (Daher-Nashif & Kane, 2022), while additional challenges cited in China, Hong Kong, and Taiwan include limited awareness exacerbated by conflicting priorities of academic institutions (Tan et al., 2021; Wu & Chen, 2018). These factors result in a lack of impetus for higher education reform and slow research advancement of the field. To address these gaps, we first describe three educational programmes to highlight how local content and methods of co-facilitation may be employed. Next, we list the respective conceptual frameworks, learning objectives and programme evaluation methods selected. Finally, we discuss strategies to increase awareness, maintain leadership and participant interest, secure sustained funding, and promote scholarly efforts. We hope that this article will support and inspire like-minded clinician educators with structurally relevant guidance that is currently lacking in the literature.

II. PROGRAMME DESCRIPTION

One of the first programmes we implemented was the HAPPE (Humanistic Aspirations as a Propellor for Palliative care Education) workshop, a 1.5-hour small group discussion session for junior doctors in a palliative care rotation at the Division of Supportive and Palliative Care, National Cancer Centre Singapore, facilitated by an accredited clinical psychologist and art therapist. Schon’s theory of Reflective Practice defined by reflection-in-action and reflection-on-action guided the discussions that focused on the participants’ experience with challenging clinical encounters that they expressed through readings of literary work and art-based craftwork. Parts of Gagne’s model of lesson planning such as the importance of gaining the learner’s attention, stimulating recall, presenting stimulus, and providing learning guidance were aptly supported by our choice of materials and facilitation. The themes of empathy and wellbeing were discussed and highlighted the importance of reflective practice on past challenging encounters. As a pilot educational intervention started since 2018, we chose to investigate the feasibility and acceptability of the MH-based workshop using self-reported quantitative scales such as the Consultation and Relational Empathy (CARE) Measure and Jefferson Physician Empathy Scale (JPES) pre- and post-workshop. Both scores improved after attendance of the workshop, supporting continual efforts for future runs of the workshop.

One year later, the half-day ADEPT (Arts and Drama to Enable Perspective Taking) workshop was implemented. In contrast to HAPPE, ADEPT was conducted for final year medical students from the Duke-NUS medical school within their core rotation to palliative care. Addressing the lack of adequate clinical exposure and role-modelling due to the brevity of the week-long rotation, a full recording of a local play A Good Death which portrayed theatrical presentations of severe pain, end-of-life conversations, and physician burnout was shown to the students. They then participated in small group discussions about perceptions of palliative care, professional identity formation, clinical communications, and physician wellbeing. These discussions were co-facilitated by a palliative care specialist, trained counsellor, and the director of the play and served to dispel myths about palliative care, promote self-awareness, and introduce coping strategies. The workshop was guided by Knowles’ theory of adult-learning and we ensured that a sense of agency and empowerment was promoted, with the students participating in self-directed reflection and learning. Building on the quantitative results of the HAPPE workshop, ADEPT was evaluated through a qualitative lens where students were invited to participate in individual semi-structured interviews by an independent interviewer to share their experiences of the workshop.

Finally, the full-day HEARTEN (Harnessing Educational approaches with the Arts to encourage End of life Conversations) workshop was started in 2022 and employed theatre-based techniques to address healthcare professionals’ discomfort in initiating advanced care planning (ACP) conversations with patients. The workshop marked our first formal collaboration with a local professional theatre group (ArtsWok) external to the SingHealth Duke-NUS Academic Medicine Centre and was attended by physicians, nurses, and various allied health professionals. This collaboration further cemented our approach of engaging local content and co-facilitators. Together, the team of physicians, social workers, art therapists, humanities researchers, and a theatre director employed Mezirow’s framework of transformational change to design experiential theatre- and acting-based exercises to trigger discussions about deep-seated perceptions and misgivings about initiating ACP discussions. We evaluated participants’ change in confidence levels in ACP discussions pre- and post-workshop through the Self-Competence in Death Work Scale (SC-DWS) survey quantitatively. An open-ended question was also embedded within the post-workshop survey to allow triangulation of the quantitative data collected. Preliminary data analysis showed an improvement in the SC-DWS surveys, with participants reflecting that their pre-existing concerns about triggering unhappiness and anxiety in patients might have been unfounded.

III. CHALLENGES

The HAPPE, ADEPT, and HEARTEN workshops illustrate a spectrum of MH-based ME programmes in terms of scale (5 to 20 participants per workshop; workshop durations of 1.5 to 8 hours), learning objectives, involvement of co-facilitators, choice of materials, and evaluation methods. In addition, all three workshops were supported by local institutional academic research funding, the amount of which increased over the years (SGD$5,000 – $42,000). By clearly enunciating our choice of educational conceptual frameworks and validated scales for programme evaluation, and consistently incorporating local content and engaging local stakeholders, we posit that some of the challenges such as the lack of contextually relevant content and frameworks and rigor in programme development and evaluation may be addressed.

However, several pertinent challenges exist. Firstly, awareness about the MH remains poor, with its integration into ME at a nascent stage compared to Western countries. Competing with other educational programmes that are better established, the small group size and similar pools of participants who enrolled in our programmes risk the case of “preaching to the choir.” This in turn may lead to challenges in garnering leadership support to encourage staff participation. In addition, securing sustained programme funding is challenging as education grants are limited to smaller, project-based programmes. Relative to clinical research, institutional management and administrative teams have less experience and expertise in supporting medical education research. Often, the project team members find themselves overwhelmed with administrative tasks including financial processes and manpower recruitment. These barriers towards research capacity building may deter interested but busy clinician educators from contributing to scholarly work that is crucial to support the growth of the field.

IV. PROPOSED STRATEGIES

We propose three areas of consideration that we have found helpful in navigating challenges in the landscape. While our experience stems from a single local healthcare centre, similar cultural, societal, and systemic factors in other parts of the Asia-Pacific region will allow applicability and relevance to other clinician educators.

A. Promoting Interdisciplinary Teaching and Learning

The MH is defined by an interdisciplinary approach and we adopt a collaborative approach in engaging various stakeholders such as local and regional humanities scholars, creative arts therapists, professional artistes, and community arts organisations. This allows us access to content from diverse subjects including anthropology, literature, history, philosophy, and other social sciences and to methods such as narrative inquiry, close reading, narrative therapy, and conversational analysis which were previously unfamiliar to us. Learners have described our programmes as refreshing and eye-opening.  However, we are also mindful that some may not take to the arts and humanities naturally. Thus, co-facilitators take extra care to emphasise that learners need not be experts in the arts to engage in reflective practice, and co-facilitators from the humanities are always paired with a clinician educator to ensure the discussions are balanced and relevant.

B. Alignment with Individual Needs and Organisational Goals

An awareness about existing needs and organisational vision is crucial to ensure relevance of the MH programmes. In the SingHealth Duke-NUS Academic Medicine Centre (AMC), our programmes support pillars of the medical education (ME) masterplan such as interprofessional education, educational excellence, and fostering wellbeing. By including other health professions besides doctors, approaching programme development and evaluation through established educational frameworks and methods, and promoting wellbeing by engaging in the arts, the ADEPT workshops have now been adopted by the SingHealth College of Allied Health and Singapore Institute of Technology for allied health professionals and trainees respectively. Notably, the impact of the arts in fostering wellbeing by providing an avenue for expression of difficult emotions, building a sense of community, and processing grief for healthcare professionals provides further impetus for leadership support of our programmes. While MH programmes are not psychotherapy-based per se, participants have shared that the experience was therapeutic and with an increased awareness about struggles, some have been prompted to seek support from professional mental health professionals after programme attendance. Seeing the value of the MH, various offices of the medical humanities have been set up within the AMC since 2019. In 2023, the SingHealth Duke-NUS Medical Humanities Institute was established to further provide centre-wide administrative and funding support for MH programmes within ME. Supported by social media platforms, these offices have organised webinars, colloquiums, and Medical Humanities conferences that increase the visibility of our endeavours and continue to engage leadership, increase interest, and sustain awareness of MH-based programmes.

C. Developing Research Capability

Despite its rich history and diverse cultural perspectives, research in the medical humanities (MH) in medical education (ME) within Asian countries remains at a nascent stage compared to our Western counterparts. To develop research capability, we adopt a two-pronged approach. Firstly, all of our programmes follow a best practice approach towards development and evaluation guided by established educational theoretical frameworks and methods respectively. Secondly, all of our programmes include a scholarly component, as illustrated above. We are currently analysing qualitative data collected from the ADEPT and HEARTEN workshops and preliminary findings suggest that more data is needed to guide the choice of content, teaching methods, learning objectives, and matching of these aspects to different learner populations. Future funding from the MH offices coupled with national and regional funding on a larger scale made possible by our cross-institutional and interdisciplinary collaborations will allow us to embark on further research to address these gaps.

V. CONCLUSION

The medical humanities (MH) have the potential to impact medical education (ME) learning and teaching outcomes but contextual content and methods relevant to our local and regional learners are lacking. We have described three MH-based ME programmes to illustrate considerations in programme development and evaluation. Highlighting considerations in awareness, administrative and funding support, and research capability, we propose strategies to overcome such challenges and hope that readers will be inspired to contribute to this developing landscape where science and art intersect.

As Carlo Rubbia, Nobel prize winner in physics says,

“Science for me is very close to art. Scientific discovery is an irrational act. It’s an intuition which turns out to be reality at the end of it – and I see no difference between a scientist developing a marvellous discovery and an artist making a painting.”

Notes on Contributors

Both OEK and SWS contributed to the conceptualisation of the paper through their experience and work in both undergraduate and postgraduate training. With repeated discussions, the approach towards explaining the value of the paper and learning points for readers were finalised. Both authors worked on the initial draft of the manuscript, before refining the contents though an iterative process of literature review and discussions with other educators and participants of the various programs. The final draft of the paper was reviewed by both authors who reached the consensus that the paper was ready for submission for publication. Both authors agree to be accountable for all aspects of the paper.

Acknowledgements

We would like to thank Ms Chiam Min and Ms April Thant Aung for proofreading the article.

Funding

No funding was received.

Declaration of Interest

Both OEK and SWS state no conflicts of interest.

References

Daher-Nashif, S., & Kane, T. (2022). A culturally competent approach to teach humanities in international medical school: Potential frameworks and lessons learned. MedEdPublish, 12(6). https://doi.org/10.12688/mep.18938.1

Dennhardt, S., Apramian, T., Lingard, L., Torabi, N., & Amtfield, S. (2016). Rethinking research in the medical humanities: A scoping review and narrative synthesis of quantitative outcome studies. Medical Education, 50(3), 285-299. https://doi.org/10.1111/medu.12812

Ong, E. K., & Anantham, D. (2019). The medical humanities: Reconnecting with the soul of medicine. Annals of the Academy of Medicine Singapore, 48(7), 233-237.

Tan, M. K. B., Tan, C. M., Tan, S. G., Yoong, J., & Gibbons, B. (2021). Connecting the dots: The state of arts and health in Singapore. Arts & Health, 15(2), 119-134. https://doi.org/10.1080/17533015.2021.2005643

Wu, H. Y. J., & Chen, J. Y. (2018). Conundrum between internationalisation and interdisciplinarity: Reflection on the development of medical humanities in Hong Kong, Taiwan and China. MedEdPublish, 7(184). https://doi.org/10.15694/mep.2018.0000184.1

*Ong Eng Koon
National Cancer Centre Singapore
30 Hospital Blvd, Singapore 168583
Email: ong.eng.koon@assisihospice.org.sg

Submitted: 7 April 2024
Accepted: 5 February 2025
Published online: 1 April, TAPS 2025, 10(2), 34-45
https://doi.org/10.29060/TAPS.2025-10-2/RA3272

Jasmin Oezcan¹, Marcus A. Henning² & Craig S. Webster²

¹Pediatric Department, Erlangen University Hospital, Erlangen, Germany; ²Centre for Medical and Health Sciences Education, School of Medicine, University of Auckland, New Zealand

Abstract

Introduction: Paediatric practice presents unique challenges for clinical reasoning, including the collection of clinical information from multiple individuals during history taking, often in emotionally charged circumstances, and the variable presentation of signs and symptoms due to the developmental stage of the child. Communication skills are clearly important but the most effective methods of teaching clinical reasoning in paediatrics remains unclear. Our review aimed to examine the existing methods of teaching clinical reasoning in paediatrics, and to consider the evidence for the most effective approaches.

Methods: We performed a scoping review and evidence synthesis drawn from reports found during a systematic search in five major databases. We reviewed 211 reports to include 11.

Results: Students who received explicit training in clinical reasoning showed a significant improvement in their experiential learning, diagnostic ability, and reflective clinical judgement. More specifically, key findings demonstrated frequent student-centered interactive strategies increased awareness of the critical role of communication skills and medical history taking. Real case-based exercises, flipped classrooms, workshops, team-based or/and bed-side teaching, and clinical simulation involving multisource feedback were effective in improving student engagement and performance on multiple outcome measures.

Conclusion: This review provides a structured insight into the advantages of different teaching methods, focusing on the multistep decision process involved in teaching clinical reasoning in paediatrics. Our review demonstrated a relatively small number of studies in paediatrics related to clinical reasoning, underlining the need for further research and curricular developments that may better meet the known unique challenges of the care of paediatric patients.

Keywords:           Clinical Reasoning, Paediatrics, Teaching Methods, Medical Students

Practice Highlights

• Clinical reasoning in paediatrics involves unique challenges including the collection of clinical information from multiple people (child, parents and care givers), symptoms that may present differently due to children’s stage of development, and complex pharmacokinetics.
• The efficacy of paediatric training could be increased by combining student-centered methods like flipped-classroom, team-based or bed-side teaching and simulation.
• Low stakes training such as simulation that allows repetition and learning from mistakes is particularly effective and engaging for students.
• Our review demonstrated a relatively small number of studies specifically related to clinical reasoning in paediatrics, underlining the need for further research and curricular developments that may better meet the known unique challenges of the care of paediatric patients.

Submitted: 5 March 2024
Accepted: 14 October 2024
Published online: 1 April, TAPS 2025, 10(2), 17-33
https://doi.org/10.29060/TAPS.2025-10-2/RA3261

Cheng Li & Gunjeong Lee

School of Nursing, Ewha Womans University, Republic of Korea

Abstract

Introduction: This study aims to explore the development of nurse prescribing and identify nurse prescribing implementation and challenges in China.

Methods: Conducted as a systematic review adhering to the PRISMA, this study involved a comprehensive literature search across various databases. A timeline mapping and a region mapping were conducted.

Results: A total of 28 articles from databases were included in the study. The growth of nursing education and research, the emergence of specialty nurses, and the establishment of nurse-led clinics have contributed to the advancement of nurse prescribing in China. Presently, approximately half of the 34 regions in China are either actively researching or preparing for nurse prescribing involving medication.

Conclusion: Based on the findings, several tasks have been identified for the implementation of nurse prescribing in China. Firstly, it is imperative to elevate the overall level of nursing education and revise the existing curriculum to equip nursing students with the necessary knowledge and skills required for prescribing. Secondly, it is crucial to establish a systematic qualification system for prescribing nurses, defining the roles of specialty nurses and advanced practice nurses. Thirdly, the development of nurse prescribing includes scope of nursing practice and prescribing protocols are essential. Lastly, extension of the geographic reach of legislation and pilot projects is needed to realise the nationwide implementation of nurse prescribing.

Keywords:           Nursing, Health Professional, Prescribing

Practice Highlights

• Nurse prescribing is fueled by the emergence of specialty nurses and nurse-led clinics.
• There are regional disparities in readiness for nurse prescribing.
• The key tasks are enhancing nursing education, qualification systems, and prescribing protocols.

I. INTRODUCTION

A. Background

Prescribing is a complex process requires deep understanding of pharmacology and disease, clinical judgement on risks and benefits of a treatment under an unpredictable context (Abuzour et al., 2018). The International Council of Nurses (ICN) stated that prescribing is an evolving process involving information gathering, clinical decision-making, communication, and evaluation which results in the initiation, continuation, or cessation of a medication (International Council of Nurses, 2021).

The extension of prescriptive authority to nurses has taken place for several reasons. First, nurse prescribing contributes to efficient and effective patient care and the quality and continuity of care (Gielen et al., 2014). Second, nurse prescribing accommodates nurses’ professional skills, increases nurses’ autonomy, and minimises unnecessary time waste for medical practitioners and patients (Kilańska et al., 2022). Third, the patient outcome of nurse prescribing is indicated as similar or better compared to the prescribing of other healthcare professionals (Ling et al., 2018; McMenamin et al., 2023).

The legislative expansion of prescriptive authority for nurses has taken place in the 1980s in the USA, 1990s in the UK, at the turn of the 21st Century in Canada, Europe, Australia, New Zealand, some countries of Africa, and Spain. As of 2021, 44 countries were reported to have formal laws or regulations that authorise nurse prescribing (International Council of Nurses, 2021; Maier, 2019).

Nurse prescribing is identified by scholars as sensitive to the country’s context and the healthcare culture, defining and implementing of nurse prescribing follows a distinctive pattern in different countries (International Council of Nurses, 2021; Nissen et al., 2010). The common areas of prescription include medications, therapies and therapeutics, durable medical equipment, appliances and certain dressings, foods designated for specific therapeutic purposes, and electrolytes (International Council of Nurses, 2021). Due to its complexity, the following frameworks and models are formed by scholars and institutions to enhance the understanding of nurse prescribing.

The ICN published the ‘Guidelines on Prescriptive Authority for Nurses’ in 2021, suggesting a framework with five components including education, regulation, authorisation,, scope of practice, and continuing professional development. This guideline adopted a four-category prescribing model (Nissen et al., 2010). This model consists of four categories: independent prescribing, supplementary prescribing (dependent), prescribing via a structured prescribing arrangement (protocol), and prescribing to administer. Each of these four categories in order requires increased skill level, decision-making ability, and accountability of prescriber.

The qualification system of prescribing nurses in different countries and regions is diverse (Maier, 2019). ICN differentiates the post-basic level nurse prescribing from the advanced practice level nurse prescribing. Prescribing nurses at the post-basic level are those who have completed their basic nursing education, and practice nursing as registered nurses (RNs). Prescribing nurses at the advanced practice level are those with a certain period of clinical experience, holding higher credentials such as APN (advanced practice nurse), NP (nurse practitioner) or specialty nurse (International Council of Nurses, 2021).

In China, nurse prescribing is defined as nurses diagnosing and making decisions on diet, psychological health, treatment, disease, and care level of the patients (Ma & Ding, 2018). In 2022, Shenzhen of China passed a medical regulation. This is seen as the first legislation in China that grants prescriptive authority to nurses. The growth of nursing education and research, the emergence of specialty nurses, and the establishment of nurse-led clinics have contributed to the advancement of nurse prescribing in China.

B. Nursing in China

By 2021, the number of registered nurses in China doubled in the last decade and exceeded 5.02 million, nurses fill about 45% of the total number of health professionals and the number of registered nurses per 1,000 population reached 3.56 (National Health Commission of the People’s Republic of China, 2022). The number of RN with a bachelor’s degree or higher has steadily grown for decades, nearly 180,000 in 2010 and 1.36 million in 2020 (National Health Commission of the People’s Republic of China, 2022), 30.4% of whom have received a baccalaureate or higher credential. An increased number of nurses with higher education level accelerates the development of nursing research (Wu, 2022).

Referring to advanced practice nursing in some developed countries, specialty nursing in China umbrellas registered nurses who have received specialised training and been certified by the training institutions, appeared first in the 1990s (Wu, 2022). Oncology, wound ostomy, PICC (Peripherally inserted central catheter), and blood purification are the most common and comparably developed specialties (Wang et al., 2018). Around 8000 nurses participated in specialty nurse (专业护士) training programs run by the Chinese Nursing Association in 2021 (Wu, 2022).

Advanced practice nursing, on the other hand, in 2007, the Guangdong Health Commission worked with the Hong Kong Hospital to prepare 614 APNs of 14 specialties over 4 years (Wong, 2018). To attain an APN credential, nurses are suggested to have a bachelor’s degree, a minimum of 8 years of clinical experience, and 2 years of specialised clinical experience (Wong, 2018). Beijing University in 2017 admitted two candidates to an advanced practice nursing program (Zhang et al., 2022).

A nurse-led clinic is defined as a clinical practice facility where nurses have their own formalised and structured standards to address the healthcare needs of patients and their families (Hatchett, 2003). The common NLCs (护理门诊) of China are run as divisions of outpatients by hospitals. NLCs accommodate specialty nurses and are one of the main settings where pilot nurse prescribing takes place in China (Chen & Peng, 2023; Ling et al., 2018). China first initiated NLCs on maternal health in 1995, psychiatric NLCs in 1997. In 2016, over 900 NLCs in 19 provinces were open, an average number of 2.8 NLCs were operated at each hospital, each NLC accommodated 36 clients a day, and 75.5% of these clinics were PICC NLCs (Gao et al., 2017). 69.3% of the NLC nurses reported that the lack of prescriptive authority is a major challenge they face in NLC nursing (Dong et al., 2022).

Given this global and domestic context, the objective of this study is to examine nurse prescribing in China, offering an overview of its development and implementation, identifying the challenges associated with it.

II. METHODS

The aim of this study is to review, identify, and synthesise the evidence presented in the included literature on nurse prescribing, so to

1. Track the development of nurse prescribing in China;
2. Describe nurse prescribing implementation in China; &
3. Identify challenges faced in nurse prescribing of China

A systematic review was conducted in accordance with the procedure of the PRISMA Statement 2020 (Page et al., 2021). The flow diagram was utilised for the literature search and the checklist was followed as an overall guide of this study.

A. Data Collection

The literature search was conducted on Medline (PubMed), CINAHL, CNKI (China National Knowledge Infrastructure), and Wanfang Data. The records with titles or abstracts containing the terms ‘nurs* prescri*’ (护*处方*）and ‘Chin*’ were expected in this process. The database and document search were conducted from 1 January to 17 June 2023. Articles are included when they present nurse prescribing in China and the full text is available in either Chinese or English. Articles are excluded when the focus is nurse prescribing out of China, or is a single group of a client population or a particular medicine.

B. Data Analysis

A quality assessment was conducted after the screening process, using the Mixed Methods Appraisal Tool 2018 (Hong et al., 2018).

For data analysis, timeline and region mapping were used in former studies to approach nurse prescribing of other countries. In this study, a timeline mapping was conducted to chart the progression of nurse prescribing practices over time. A region mapping was performed focusing on the geographical distribution and implementation of nurse prescribing practices. An overall nurse prescribing profile of China was provided and a discussion on the current practice and indicated challenges was applied.

III. RESULTS

A. Search Outcomes

As a result, a total of 441 studies were taken into the identification process (Figure 1). At the end of the screening, a total number of 28 articles from the databases were included for analysis.

Figure 1. Screening Flow Diagram

CINAHL – Cumulative Index to Nursing and Allied Health Literature

CNKI – China National Knowledge Infrastructure

No	Authors	Origin	Purpose	Research design	Disciplinary home	Method/ framework	Major finding
1	Chen L. & Peng G. (2023)	Guangdong	To describe nurse prescribing at NLCs in Guangdong	Quantitative	Nursing	No	Detailed nurse prescribing in Guangdong (content focused)
2	Wang, X. et al. (2022)	Shanxi	To construct general clinical practice training program for drug prescribing applicants of nurses in China	Qualitative	Nursing	Delphi method	Three-level indexed training program development and comparison with the US, UK and Ireland.
3	Zhang, Q. et al. (2022)	Shanxi	To interpret ICN guideline to promote common understanding of nurse prescribing in China	Qualitative	Nursing	ICN Guideline	Analyses nurse prescribing in China providing interpretation of the guide and comparison of other countries
4	Han, S. et al. (2022)	Shanxi	To review main research results and application on nurse decision making and prescribing	Qualitative	Nursing	No	Further research and practice in nursing education, APN, nurse prescribing is needed
5	Fan, Y. et al. (2022)	Henan	To review development of nurse prescribing globally and summarise theory and practice evidence	Qualitative	Nursing	No	Provides suggestion for the government, nursing institutions and scholars.
6	Xing, M. et al. (2022)	Zhejiang	To identify nurse prescribing challenges and advantages in China.	Qualitative	Nursing	SWOT analysis	Summarises internal and external challenges and advantages and provides future strategies. S-O, W-O, S-T, W-T strategies are proposed.
7	Han, S. et al. (2021)	Shanxi	To further explore nurse prescribing contents	Qualitative	Nursing	Delphi method	Conducted a list of nurse prescribing medications, suggested forms and training curriculums of nurse prescribing. 348 nurse prescribing medications, 6-unit training
8	Wang, L. et al. (2021)	Zhejiang, Liaoning	To identify regulatory challenges in nurse prescribing, suggest effort on liability system and institutional mechanism	Qualitative	Law	No	Redefines nurse prescribing in China, suggests regulatory support and clarification on liability
9	Wang, Y. et al. (2021)	Shanxi	To construct the general training syllabus for nurses’ prescription right of applicants for prescription right in different clinical specialist nurses	Qualitative	Nursing	Delphi method	The constructed training syllabus for clinical specialist nurses was reliable, which could provide basis for prescription right training of clinical specialist nurses. A training guide of nurse prescriber is provided.
10	Wang, X. et al. (2021)	Shanxi	To conduct a global analysis of nurse prescribing training	Qualitative	Nursing	No	Identifies challenges, provides suggestions on practical training of nurse prescribing
11	Hou, X. (2021)	Sichuan	To investigate scope and related factors of nurse prescribing in third-level hospitals	Qualitative	Nursing	Phenomenological analysis, Colaizzi	Nurse prescribing in China is in its infancy.
12	Zhong, M. et al. (2020)	Guangdong	To understand nurses’ belief in and attitudes towards nurse’s prescription right so as to provide a reference for medical decision makers to formulate relevant policies and expand the scope of nursing service	Quantitative	Nursing	Scale of nurses’ attitudes and belief towards nurse prescribing	Nurses have positive attitudes and beliefs in nurse’s prescription. A minimum of 10 years’ clinical work experience, a professional title of supervisor nurses and a bachelor’s degree are suggested as entry qualifications for the right
13	Wang, Y. et al. (2020)	Shanxi	To discuss training in nurse prescribing under global context to provide evidence for domestic application	Qualitative	Nursing	/	Standardised trainings to nurses with different education backgrounds are needed
14	Wang, S. et al. (2020)	Shandong	Discuss the content of the prescription right of nurses and provide references for relevant decision-making	Qualitative	Nursing	Delphi method	Content table of medical and non-medical nurse prescribing: 27 nursing intervention prescriptions, 15 examination prescriptions, 21 medical device prescriptions and 35 drug prescriptions were identified.
15	Wan, Z. & He, Y. (2020)	Beijing	To summarise the classification, development data and qualification of nurse prescribing at home and abroad	Qualitative	Nursing	/	4 suggestions on nurse prescribing
16	Feng, S. et al. (2020)	Shandong	To summarise practical exploration and theoretical research of nurse prescribing in China	Qualitative	Nursing	/	Stresses both education curriculum and continuing training on prescribing for nurses
17	Li, M. (2019)	Guizhou	To compare nurse prescribing at home and abroad: the US, Australia, England	Qualitative	Medicine	/	Comparison on prescriber qualification, specialization, contents.
18	Han, S. & Hou, Y. (2019)	Shanxi	Advantages, disadvantages, opportunities and threats of granting prescription rights to clinical nurses in China	Qualitative	Nursing	SWOT analysis	Construction of nurses team the development of specialist nurses and the training of highly educated personnel in China all should be strengthened
19	Tian, Y. et al. (2019)	Henan	To investigate the status quo of clinical nurses’ cognition of nurse prescribing	Quantitative	Nursing	/	262 nurses lack of knowledge on nurse prescribing while showing a strong will for it.
20	Wang, M. et al. (2018)	Anhui	To explore attitudes of doctors and nurses towards nurses’ qualification of prescribing	Quantitative	Nursing	/	1056 medical staff from 14 hospitals in Anhui
21	Li, H. & Ding, P. (2018)	Anhui	Overview nurse prescribing under NLC context	Qualitative	Nursing	/	NLC nurse prescribing overview and future suggestions
22	Ma, D. & Ding, P. (2018)	Anhui	To identify the scope of authority on prescription right of nurses in Anhui	Qualitative	Nursing	/	Zoom in on Anhui trail
23	Cheng, Z. & Xia, H. (2017)	Shanghai	To review nurse prescribing in England, Canada, Australia and the US.	Qualitative	Nursing	/	Provides details of prescriber qualification, content, format, extension of nurse prescribing, suggests regulations and trials on nurse prescribing in China
24	Gong, S. et al. (2016)	Jilin	To review nurse prescribing in England, so to provide evidence for domestic application	Qualitative	Nursing	/	Provides details of prescriber qualification, content, format, extension of nurse prescribing in England. Identifies 3 challenges of China.
25	Wei, X. (2016)	Gansu	Explore certain prescriptions that meet nurse’s capability in China	Qualitative	Nursing	/	Suggests certain prescriptions nurse should practice within extended prescribing. 11 prescriptions for extended prescribing
26	Zhang, G. et al. (2012)	Shanxi	To gain opinions on baccalaureate curriculum for nurse prescribing from experts	Qualitative	Nursing	Delphi method	Provides evidence for baccalaureate curriculum in preparation of nurse prescribing. 3 categories, 11 subjects
27	* Zhang, G. et al. (2012)	Shanxi	To study on qualification of nurse prescribing applicants	Qualitative	Nursing	Delphi method	Provides evidence on minimised qualification of nurse prescriber. Baseline of nurse prescribing applicants
28	Han, S. & Li, X. (2011)	Shanxi	To probe into the promotion factors of nurse prescribing implementation in China	Qualitative	Nursing	Delphi method	Categorises and lists factors of nurse prescribing in China. 43 promoting factors of nurse prescribing

Table 1. Summary of included studies

*NLC (Nurse-Led Clinics), Shanxi (山西省), ICN (International Council of Nurses), US (United States), UK (United Kingdom), SWOT (Strengths, Weaknesses, Opportunities, and Threats), AHP (Analytic Hierarchy Process)

The 28 (100%) articles were all in Chinese, published between 2010 and 2023, eleven papers (39.3%) were conducted in the Shanxi (山西) Province. Four (14.3%) studies are designed quantitative and 24 (85.7%) are qualitative. Two articles (7.1%) were conducted in the medicine or law disciplines, the rest 26 (92.9%) were conducted in nursing. Seven studies (25.0%) applied Delphi method and 2 (7.1%) applied SWOT analysis. The studies on nurse prescribing fall mostly into the reviews of nurse prescribing abroad. This research work provides evidence for the qualification of prescribing nurses, the prescription protocols and the challenges in nurse prescribing.

B. Development of Nurse Prescribing in China

Nurse prescribing as well as nurse-led clinic nursing are being practiced since 1996 in Hong Kong (Parker & Hill, 2017; Wong & Chung, 2006). As for the mainland, the realization of nurse prescribing started in 2005 (Han et al., 2022). Research teams formed in 2005 and started research on decision-making in the patient classification system among nurses (Han et al., 2022). In 2007, a research team proposed that nurses should be the decision maker of nursing care, and divided nursing interventions into 16 independent and 11 integrated categories for decision making (Han et al., 2022). In 2020, a list of nurse prescriptions was provided (Wang et al., 2022), it consists of 27 prescriptions for nursing interventions, 15 for tests and examinations, 21 for medical aids and instruments, and 35 for medicine.

For medicine nurse prescribing, starting in 2008, researchers have looked into the contents and forms of prescribing (Han et al., 2022). They identified the contents in 7 acute and 4 chronic illnesses, modified the qualification of prescribing nurses (Han et al., 2022). They also provided a list of nurse prescriptions with 348 medicines and proposed a four-level prescribing model: independent prescribing, supplementary prescribing, extended prescribing, and adjusted prescribing (Han et al., 2022).

As for the qualification of prescribers, prescribing nurses should be those who work at third level hospitals, have bachelor’s degrees in nursing, and have 5 years of clinical work experience after obtaining the intermediate profession rank (Zhang et al., 2012). Researchers also proposed to add courses in nursing education to prepare nurses to prescribe, such as laws and regulations, nursing intervention, dosage calculation and substance abuse (Han et al., 2022).

In July 2017, Anhui Province initiated a trial as the landing of nurse prescribing in China. By the end of 2017, Anhui arranged 78 specialty nurses into 22 community health centers, opened 7 nurse-led clinics, and authorised these nurses limited prescribing (Ma & Ding, 2018). Guangdong Province is known as the first region opened traditional Chinese medicine NLCs in 2006. In 2022, the Shenzhen City of Guangdong Province authorises specialty nurses with the examination, treatment, and external medicine prescribing (Shenzhen Municipal People’s Congress, 2022). A survey conducted in Guangdong indicates 88.54% of the NLC nurses practice independent nurse prescribing (Chen & Peng, 2023).

Figure 2. Nurse Prescribing Timeline in China

*The left presents events in policy and practice, right in education and research.

C. Present Nurse Prescribing in China

Nurses have shown their positive intention in nurse prescribing in several research. A sample of nurses responded with an intermediate to a positive level of faith and attitude toward nurse prescribing (Zhong et al., 2020). The same study also emphasises that higher professional ranking and longer clinical experience led to a stronger intention and faith in nurse prescribing.

In the Anhui trial, the nurse prescribing is limited to non-medicine prescription for hypertension, diabetes, stroke, wound stoma, mental illness, gestational diabetes, and childbirth (Ma & Ding, 2018). Prescribers are limited to a group of nurses who have over 15 years of clinical experience, had received specialty nurse training with certificates, and have advanced communication skills (Ma & Ding, 2018). Prescribers make decisions and provide interventions on dressing changes, general physical examination, health education and consultation, test result and report reading, history taking, and physical or mental examination in chronic diseases (Ma & Ding, 2018).

In Guangdong Province, the NLC nurse prescribing includes medicine, tests and treatments, medical aids and devices, home medical devices, dressings, therapeutic diet prescriptions, and health education (Chen & Peng, 2023). Nurses prescribe several external medicines and limited injected medicines (normal saline solution, heparin injection, peritoneal fluid, etc.) (Chen & Peng, 2023).

In the Shenzhen legislation, specialty nurses are regulated to be the only qualified prescribing nurses, specifically those who have a baccalaureate degree or above in nursing, more than five years of clinical experience and more than two years in relevant specialised departments, meanwhile having intermediate profession ranks or above (Shenzhen Municipal People’s Congress, 2022).

More than half of the 34 provinces run nurse-led clinics and about 70% of nurses at these clinics report independent nursing practice (Gao et al., 2017). Currently, about half of the total 34 regions are recognised in the research or preparation phase for the implementation of nurse prescribing on medicine (Figure 3). Trials and legislative move are seen to take place in regions with intermediate research activity.

Figure 3. Nurse Prescribing Region Mapping of China in 2023

D. Indicated Challenges

Despite the positive intentions, nurses and nursing students lack knowledge of nurse prescribing and lack confidence in it (Hou, 2021; Tian et al., 2019). A percentage 60.7 of registered nurses reported it necessary for nurses to have prescriptive authorization and 58% are willing to have it, but about half, 49.2% of the nurses have not heard about nurse prescribing by the time they were surveyed (Tian et al., 2019). A qualitative study indicates all participated specialty nurses advocated for nurse prescribing (Hou, 2021). Less than 35% of medical and nursing students had heard of nurse prescribing, and less than 5% had heard of the Anhui trial (Tian et al., 2019).

The current nursing education level is a major concern in nurse prescribing (Feng et al., 2020; Y. P. Wang et al., 2020; Zhang et al., 2012). In China, as of 2020 and 2021, respectively, 71.2% and 69.5% of the nurses had credentials below baccalaureate, 28.7% and 30.1% had a baccalaureate degree, 0.2% and 0.3% had a master’s or a higher credential (National Health Commission of the People’s Republic of China, 2022).

For the education curriculum, researchers suggest multi-level prescribing training due to the diversity of current nursing education levels. Researches focus on curriculum design for baccalaureate nursing education (Zhang et al., 2012) or the design for specialty nurse training (Wang et al., 2022), most suggest including pharmacology and related legislation (Zhang et al., 2012).

For the nurse prescribing training, an education program is recommended to reach a performance set standard for the nurse seeking prescriptive authority (International Council of Nurses, 2021). A prescribing-specific training is suggested in some studies (Wang et al., 2021; Wang et al., 2022), most of these studies take the training system of the United Kingdom (UK) as their reference.

The current qualification system for prescribing nurses has been identified as problematic in several studies (Gong et al., 2016; Xing et al., 2022; Zhong et al., 2020). Some studies suggest a combination of a master’s degree and the highest professional rank (Cheng & Xia, 2017). Some suggest specialty nurses (Cheng & Xia, 2017) practice prescribing in their specialties. Some others suggest a baccalaureate degree and 5 years of clinical experience with intermediate profession rank (Wang et al., 2018; Zhang et al., 2012).

The present nurse prescribing implementation is limited within the extended category (Wang et al., 2021) due to the lack of organizational preparation (Han et al., 2022; Hou, 2021). These organizational conditions include the current nursing education level, the lack of systematic qualification of prescribers (Zhang et al., 2012), the clear scope of nursing practice (Fan et al., 2022; Wei, 2016), guidelines and protocols (Han et al., 2021), and solutions on extension and geographic expansion (Wang et al., 2021).

Under the limited pilot practice and the absence of national legislation, current nurse prescribing in China requires both expansion and extension. This session summarised the implementation of nurse prescribing and analysed the indicated challenges. The improvement of nurses’ knowledge of prescribing, the current nursing education level, and the training and qualification of prescribing nurses are indicated as the priorities.

IV. DISCUSSION

Previous studies on nurse prescribing have primarily focused on developed countries, however, it is worth noting that developing countries have shown a slightly higher rate of nurse prescribing authorization, with 38% compared to 31% in developed countries (International Council of Nurses, 2021). This study reviewed the development and implementation of nurse prescribing and identified the challenges China is facing to further practice nursing prescribing.

Unlike other countries that initiated nurse prescribing decades ago, in China, the exploration of nurse prescribing appeared late. Nurse prescribing related regulations can be traced to the 2006 Prescription Administrative Policy, the Article 2 indicates that physicians are the only prescribers of medicine in China. The Nursing Regulation indicates nurses are obliged to implement necessary first aid in emergencies and remain critical on instructions of doctors according to Article 17.

On June 23, 2022, the Municipal People’s Congress of Shenzhen passed the Medical Regulation of Shenzhen Special Economic Zone that came into force on January 1, 2023. This is the first legislation in China that grants prescriptive authority for nurses according to Article 65. It also provides a general qualification guide of specialty nurses, clarified in Article 64.

For the implementation, nurses and nursing students show limited knowledge and confidence in nurse prescribing. This is seen caused by the current nursing education level and the content of the education curriculum. For nursing education level, referring to the nursing education level in the United States, 2016 is reported as the year when all the states in the US practice nurse prescribing. In 2015, an estimated 65% of nurses had obtained a baccalaureate or higher degree (National Council of State Boards of Nursing, 2016). In 2017, the number of RNs with a master’s degree in nursing has increased to 17.1% and 1.1% had a Doctorate in Nursing Practice, 10.0% held an APRN credential (National Council of State Boards of Nursing, 2018).

As for the training of prescribing nurses, the UK applies prescribing-specific training. The training follows a structured framework governed by regulatory bodies such as the Nursing and Midwifery Council (NMC) and involves a combination of theoretical and practical components (Courtenay et al., 2007). The training program typically consists of two parts: the academic component and the clinical component (Nursing and Midwifery Council, 2018).

For qualification of prescribing nurses, thirty-one of the 44 countries authorise nurse prescribing at post-basic levels, to nurses who have completed their basic nursing education; 13 countries at advanced practice levels; 11 countries allow nurses to prescribe at both the post-basic and advanced practice levels (International Council of Nurses, 2021). In the United States by 2016, all 50 states and the District of Columbia authorise certain levels of independent prescribing to APNs (American Nurses Association, 2018). Canada has a broad advanced practice level prescriptive authority for NPs federally and in recent years at a post-basic level for RNs provincially in Alberta and Ontario (Canadian Nurses Association, 2015). In Europe, prescribing by nurses has been recognised legally in 15 countries at a post-basic level (Gielen et al., 2014).

In the UK, the NMC outlines the requirements and standards that nurses must meet to become qualified prescribers. Upon successful completion of an NMC-approved prescribing course delivered by a recognised educational institution, nurses are eligible to apply for the relevant prescribing qualification from the NMC (Nursing and Midwifery Council, 2018). These qualifications determine the scope of prescribing authority for nurses, specifying the range of medications they can prescribe and any limitations or restrictions.

In China, specialty nurses are recognised as prescribing nurses in the Shenzhen legislation. Although prerequisite 2 years of clinical experience, 2 to 3 months training period is seen in most specialty nurse training programs, current evidence shows there is no modified training, qualification, or scope of practice for specialty nurses at a national level (Han & Hou, 2019; Han & Li, 2011).

The confusion in specialty nursing and advanced practice nursing is seen in former studies. The specialty nurse system should be well differentiated from the advanced practice nurse system in China. In a long-term stance either form a linked structure to umbrella both specialty nurses and APNs as equal prescribing nurses or assign respective categories of prescriptive authorities to each group. As a result, the qualifications of prescribing nurses can be modified at a national level.

Evidence on the outcome and evaluation of the current trial practice and the region-specific analysis were rare. The possibility and plan for the expansion of nurse prescribing over the country were not observed in former research. Despite expansion, the extension to other levels of nurse prescribing is needed. In the US, some states allow advanced practice registered nurses (APRNs) to practice independently (independent), some others require APRNs to work within a collaborative agreement with a physician (supplementary), 16 states allow RNs to dispense some medications (protocol) including contraceptives and drugs for sexually transmitted infection care in outpatient settings, such as a health department or a family planning clinic (Guttmacher Institute, 2023).

A. Limitation & Implication

Despite the scarcity of research on nurse prescribing in China and the lack of recent studies addressing the latest updates, this study overviewed nurse prescribing in China through a review of the development, the implementation, and the challenges, provides insights with global relevance. As healthcare systems worldwide face increasing demands and evolving roles for healthcare professionals, understanding diverse implementations of nurse prescribing offers crucial comparative perspectives. This article not only provides evidence on how nurse prescribing is integrated within China’s unique healthcare landscape but also serves as a benchmark for evaluating similar practices across different countries. For researchers and policymakers, these findings contribute to a broader understanding of effective healthcare strategies, policy development, and the global advancement of nursing roles.

As for the limitation, bias might exist in the screening and analysis process as they were conducted by two reviewers. In China, the community healthcare setting is regulated as one of the nurse prescribing settings in the Shenzhen legislation. More investigation on nurse prescribing in community settings seems necessary.

V. CONCLUSION

This systematic review followed the PRISMA 2020 Statement, analysed 28 articles. The 28 articles were assessed by the MMAT 2018 for synthesis. Both a time and a region mapping of nurse prescribing in China were conducted. This study provides an overview of the implementation and challenges of nurse prescribing in China.

Along with the development of specialty nursing, more than half of the province-level regions run hospital-based nurse-led clinics and about 70% of the nurses at these clinics practice independently. As for nurse prescribing, post a long research and preparation period, Anhui Province started a trial in July 2017 and practices non-medicine prescriptions for certain diseases and conditions. In June 2022, the Congress of Shenzhen City passed a medical regulation authorises specialty nurses with examination, treatment, and external medicine such as ointment and dressing prescribing, as the first legislative move in China. About half of the total 34 regions are in research or preparation phase for the implementation of medicine nurse prescribing.

The lack of knowledge and confidence related to nurse prescribing among nurses and nursing students, the current nursing education level and curriculum, and the training and qualification of prescribing nurses are recognised as the major concerns of nurse prescribing in China. Limited research, pilot practice, and legislative move of nurse prescribing are observed.

To meet the growing need for nurse prescribing in China, the following tasks are identified. First, improvement in nursing education level and curriculum is necessary. Second, a systematic qualification system for prescribing nurses should be established based on the clarification of specialty nurses and advanced practice nurses. Third, the scope of nursing practice consists of prescribing and the protocols for prescribing are in need. Fourth, the geographic expansion of legislation and pilot project are expected to reach nurse prescribing implementation at a national level. Last, future research should focus on nurse prescribing in community healthcare settings.

Notes on Contributors

CL performed the literature search and analysis, wrote the original manuscript, prepared the figures and tables, and worked on the review and editing. GJL supervised the conceptualisation and the methodology, provided suggestions on the validation and visualization.

Ethical Approval

As this study is a systematic review, ethical approval and IRB application was not applicable.

Data Availability

Data set that support the findings of this study are openly available in Figshare repository https://doi.org/10.6084/m9.figshare.25310869

Funding

No funding sources are associated with this study.

Declaration of Interest

No conflicts of interest are associated with this paper.

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*Gunjeong Lee
School of Nursing, Ewha Womans University
52, Ewhayeodae-gil, Seodaemun-gu,
Seoul 03760 Republic of Korea
Email: gunjeong@ewha.ac.kr