Submitted: 1 December 2020
Accepted: 5 April 2021
Published online: 5 October, TAPS 2021, 6(4), 49-64
https://doi.org/10.29060/TAPS.2021-6-4/OA2443

Yasushi Matsuyama¹, Hitoaki Okazaki¹, Kazuhiko Kotani², Yoshikazu Asada³, Shizukiyo Ishikawa¹, Adam Jon Lebowitz⁴, Jimmie Leppink⁵ & Cees van der Vleuten⁶

¹Medical Education Center, Jichi Medical University, Japan; ²Center for Community Medicine, Jichi Medical University, Japan; ³Center for Information, Jichi Medical University, Japan; ⁴Department of General Education, Jichi Medical University, Japan; ⁵Hull York Medical School, University of York, United Kingdom; ⁶School of Health Professions Education, Maastricht University, The Netherlands

Abstract

Introduction: Previous studies indicate that professional identity formation (PIF), the formation of a self-identity with the internalised values and norms of professionalism, may influence self-regulated learning (SRL). However, it remains unclear whether a PIF-oriented intervention can improve SRL in clinical education. The aim of this study was to explore whether a PIF-oriented mentoring platform improves SRL in a clinical clerkship.

Methods: A mixed-methods study was conducted. Forty-one students in a community-based clinical clerkship (CBCC) used a PIF-oriented mentoring platform. They articulated the values and norms of professionalism in a professional identity essay, elaborated on future professional self-image, and reflected on their current compared to future selves. They made a study plan while referring to PIF-based self-reflection and completed it. The control group of 41 students completed CBCC without the PIF-oriented mentoring platform. Changes in SRL between the two groups were quantitatively compared using the Motivated Strategies for Learning Questionnaire. We explore how PIF elements in the platform affected SRL by qualitative analysis of questionnaire and interview data.

Results: A moderate improvement in intrinsic goal orientation (p = 0.005, ε² = 0.096) and a mild improvement in critical thinking (p = 0.041, ε² = 0.051) were observed in the PIF-oriented platform group. Qualitative analysis revealed that the PIF-oriented platform fostered professional responsibility as a key to expanding learning goals. Gaining authentic knowledge professionally fostered critical thinking, and students began to elaborate knowledge in line with professional task processes.

Conclusion: A PIF-oriented mentoring platform helped students improve SRL during a clinical clerkship.

Keywords:           Self-Regulated Learning, Professional Identity Formation, Clinical Clerkship

Practice Highlights

• Encourage students to verbalise their future self-image as a medical professional.
• Encourage students to reflect on their current selves compared with their perceived future ones.
• Promote in-depth communication between students and role models to foster self-regulated learning.
• Train mentors to become professional role models as self-regulated learners.

I. INTRODUCTION

Rapid advances in clinical knowledge require medical professionals to update their knowledge autonomously throughout their practice. Self-regulation in life-long learning has therefore become an important competency, and competency-based undergraduate medical education has emphasised students’ self-regulated learning (SRL) (Berkhout et al., 2018; Brydges & Butler, 2012; Frank, 2005; Sandars & Cleary, 2011). SRL is defined as learners’ active participation in their own learning processes from metacognitive, motivational, and behavioural perspectives (Zimmerman, 1989). In undergraduate education, SRL has been related to academic achievements (Artino, Cleary et al., 2014; Artino, Dong et al., 2012; Song et al., 2011; Turan & Konan, 2012), clinical skills (Cleary & Sandars, 2011) and emotional management (van Nguyen et al., 2015).

Several reports have claimed that drastic changes in learning context, from structured learning in preclinical years to less-structured and complex learning in clinical clerkships, may be too challenging for students and lead to insufficient learning (Berkhout et al., 2015, 2018; Cho et al., 2017; van Houten-Schat et al., 2018). This question appears more serious in East Asian countries, including Japan, where strong teacher instruction in pre-university education and teacher-centred curricula are the norm (Iwata & Doi, 2017; Lam & Lam, 2009; Tagawa, 2008). In order to make the typically limited clinical clerkship period a fruitful learning opportunity, remediation for struggling students from the perspective of SRL might be important (Durning et al., 2011; van Houten-Schat et al., 2018).

Several reports have shown that individualised mentoring intervention is effective in fostering SRL in clinical practice. For example, Aho et al. (2015) found that mentor-assisted SRL for surgical habits of residents led to more frequent practice and improved skills compared to peers. In Stuart et al. (2005), individualised guidance on strategies and learning plans raised students’ awareness of the learning process. However, the educational interventions undertaken in this study will focus on another contextual characteristic that may facilitate SRL – Professional Identity Formation (PIF) – defined according to Cruess et al. (2014, p.1447) as “a representation of self, achieved in stages over time during which the characteristics, values, and norms of the medical profession are internalised”.

In response to advances in medical science and the increasingly diverse needs of society, “professional” attributes such as autonomy, self-regulation, and social responsibility have been emphasised, in addition to traditional moral and ethical education emphasising healer roles (Cruess & Cruess, 1997, 2019). Furthermore, formation of professional identity can result in individuals thinking, acting, and feeling like physicians (Cruess et al., 2014; Cruess & Cruess, 2019). During the formation of professional identity, medical students begin to perceive belonging to a professional community and increase attention to role models (Jarvis-Selinger et al., 2012; Kalet, Buckvar-Keltz, Harnik et al., 2017; Kalet, Buckvar-Keltz, Monson et al., 2018). Emulation of role models’ self-regulation in learning behaviour is also expected.

People are more likely to interpret difficult experiences as task important when an accessible identity feels congruent to the task (Oyserman et al., 2017). In the context of this study, growing professional identity as a ‘physician-to-be’ might strengthen the perceived importance of engaging in challenges during clinical clerkships, and in self-regulating learning behaviours. In addition, when physicians perceive their identity as professionals, they begin to view daily learning tasks as high-stakes, and to self-regulate learning behaviours as coping strategies (Matsuyama et al., 2018). Another study has suggested that an explicit future professional self-image in medical students leads to self-reflection, increased attention to learning strategies of professional role models, and diversification of learning strategies (Matsuyama et al., 2019). Given that PIF is associated with motivational states, self-reflection, and diversified learning strategies, SRL may be facilitated by introduction of a PIF-oriented intervention.

This study specifically focused on PIF as a facilitating factor for SRL, because previous studies  have suggested possible benefits of PIF-oriented education even for East Asian medical students, who are generally considered to have less SRL due to influence of pre-university education, with its strong faculty instruction and in-university teacher-centred curricula (Matsuyama et al., 2018, 2019).

The purpose of this study was to examine whether SRL during clinical training can be fostered using a mentorship tool emphasising PIF, in addition to conventional mentorship by faculty members. In the pre- and post-clinical clerkship mentorship, students were asked to elaborate on their future self-image as professionals and compare their current and future selves to strengthen self-reflection under mentor support. Learners were aided in articulating their values and norms of medical professionalism by using the Professional Identity Essay (PIE) (Kalet, Buckvar-Keltz, Harnik et al., 2017; Kalet, Buckvar-Keltz, Monson et al., 2018), a self-administered questionnaire with 9 questions relevant to PIF. This encouraged mentors to understand the developmental stage of each learner’s professionalism and to provide individualised feedback on PIE and their future self-image. The feedback was also aimed at remediation for those whose self-images showed underdeveloped professionalism (low developmental stages in PIE). Study plans in the clinical clerkship were developed with reference to PIE-based self-images. We have named this platform ‘PIF-oriented mentoring platform for SRL (PIF-SRL)’. An overview of PIF-SRL is provided in Figure 1.

Figure 1. Overview of the PIF-SRL and research data collection

This studied centred on two research questions:

1. Does PIF-SRL improve SRL during the period around the clinical clerkship?
2. If so, how does the PIF-oriented elements in PIF-SRL improve SRL?

This study was approved by the ethics committee of Jichi Medical University (reference number: 19-001).

II. METHODS

A. Settings

1) Community-based clinical clerkship in Jichi Medical University: The mission of Jichi Medical University (JMU) is to educate students to become general practitioners competent in rural settings. Students are accepted per a quota system from each of Japan’s 47 prefectures. In the current curriculum at JMU, students complete lectures on almost every basic and clinical medicine area before the end of Year 3. From Year 4 to Year 6, students are permitted to participate in a clinical clerkship during which they receive training centred on taking patient histories and providing physical examination. Previously, most ward placements took place at the University’s affiliated hospital providing little opportunity for in-depth communication with role models in rural settings.

The community-based clinical clerkship (CBCC) was introduced in 1998 (Okayama & Kajii, 2011). For 2 weeks from late August to early September in Year 5, CBCC students stay at a community hospital or clinic in their home prefecture where JMU graduates work. Every year, two to five JMU graduates per prefecture are appointed to be CBCC mentors based on their motivation to teach in their prefectural communities. JMU faculty ensures the instructional quality of mentors by conducting annual face-to-face faculty development sessions. In addition, standards for learning activities are proposed, including ambulatory care, home care, hospital care, placement in mobile clinics, on-call work, rehabilitation, health education, health check-ups, vaccination, day services, and placement in welfare facilities (welfare institutions or nursing homes for the aged) (Okayama & Kajii, 2011).

Prior to the regular CBCC without PIF-SRL, students had several opportunities to communicate with mentors by telephone or e-mail. However, these communications did not provide sufficient opportunity for students to develop an image of future professionalism. We therefore felt that the communication framework in the regular CBCC did not fulfil its potential to stimulate PIF.

2) PIF-SRL for the CBCC: The PIF-SRL platform (Matsuyama et al., 2021) used an online communication platform, Google Forms. Before the CBCC began, mentors were briefed multiple times in writing and verbally on the purpose of the PIF-SRL to ensure their mentorship was PIF-oriented. They were also asked to read a manual which provided specific step-by-step responses from their first interaction with medical students on Google Forms in mid-July to their post-practice reflection in early to mid-September (Figure 1).

In the pre-clerkship phase, participants were asked to write their reflexive PIE. We used PIE because it is useful for helping learners articulate their own values and norms of medical professionalism, and for teachers providing feedback with rubrics based on Kegan’s constructive developmental theory (Kalet, Buckvar-Keltz, Harnik et al., 2017; Kalet, Buckvar-Keltz, Monson et al., 2018; Kegan, 1994). The present study used a Japanese version of the original English-language PIE form. Translation to Japanese was conducted by the main author (YM). To validate the translation accuracy, back-translation to English was conducted by a co-author (AJL), an American professor living in Japan who is literate in both English and Japanese. In accordance with in-depth talks based on PIE contents, students were encouraged to verbalise their future self-image and reflect on their current selves compared with their perceived future ones. The Question 6 of PART 2 in the PIF-SRL asked alumni mentors to describe their present self-image (Matsuyama et al., 2021). Students in PIF-SRL can also refer to this information when verbalising their future self-image.

Additionally, students in PIF-SRL were asked to create study plans for CBCC based on gaps between their current and future selves, and identify one or more learning goals. Referring to these plans, alumni mentors observed students and gave just-in-time feedback. Also, mentors provided students with learning strategies to help them overcome potential future challenges. Apart from these instructions, mentors were essentially independent in their education of the medical students. After the two-week clerkship, students were asked to re-articulate their own future image and received feedback from their mentors by Google Forms (Figure 1).

B. Subjects

First, PIF-SRL mentors were selected. In 2018 and 2019, 94 JMU graduates registered as attending rural physicians for the CBCC. Among them, 20 candidates for PIF-SRL mentors in 2018 and 2019 were randomly selected and informed consent for their contribution to PIF-SRL in this study was requested. Eventually, 17 and 13 JMU alumni agreed to participate in 2018 and 2019, respectively, 8 of whom participated in both years.

Independent of this study, the JMU Center for Community Medicine matched one alumnus with one to three students for the CBCC. The 30 PIF-SRL alumni-mentors were paired with 1 to 3 students each before informed consent was obtained. In this study, students paired with the 30 PIF-SRL alumni were chosen as candidates for the PIF-SRL group subjects. There were 22 and 20 candidates in 2018 and 2019, respectively. One candidate in 2019 declined participation. Eventually, 41 students were registered as subjects in the PIF-SRL group. Simultaneously, 41 control subjects were chosen from the same school year cohort and informed consent to participate was obtained. Control subjects experienced the regular CBCC mentorship without PIF-SRL. Because previous studies have shown that gender (Ray et al., 2003) and academic performance (Lucieer et al., 2016) might independently influence SRL development, participants in both groups were paired by gender and academic ranking from the previous year (Year 4).

C. Procedures

A convergent mixed method was chosen for the first research question ‘Does PIF-SRL improve SRL during the period around the clinical clerkship?’ to identify common data between quantitative and qualitative results (Creswell & Clark, 2017). Next, an explanatory mixed method was used to address the second research question ‘How does the PIF-oriented elements in PIF-SRL improve SRL?’. A rationale for this method is that follow-up qualitative approaches can explain quantitative results (Creswell & Clark, 2017). We conducted this mixed method study in the paradigm of pragmatism, which emphasises solutions to research questions and integrates qualitative and quantitative research results to obtain general findings (Shannon-Baker, 2016).

1) Quantitative approach: Learner SRL levels were measured with a Japanese-language version of the Motivated Strategies for Learning Questionnaire (MSLQ-J) before (mid-July) and after (mid-September) subjects participated in CBCC with or without PIF-SRL. The MSLQ (Pintrich et al., 1991) is composed of 81 items with seven-point Likert scales quantifying levels of 9 types of SRL strategy (rehearsal, elaboration, organisation, critical thinking, metacognitive self-regulation, time and study environment, effort regulation, peer learning, and help seeking), and 6 variables of motivation states (intrinsic goal orientation, extrinsic goal orientation, task value, control of learning beliefs, self-efficacy for learning and performance, and test anxiety). All 81 items of the MSLQ were used as done previously in a medical school context (Cho et al., 2017) because it was believed the 15 SRL-related categories could multi-dimensionally identify differences between the PIF-SRL group and control group. Translation to Japanese was conducted by the main author (YM) and back-translation to English by a co-author (AJL). For the MSLQ validation, the Cronbach alpha and McDonald omega were measured for 15 categories (Matsuyama et al., 2021).

2) Qualitative approach: To explore changes in motivation, strategies and reflective behaviours from self-reflection and study during the clinical clerkship, we created a questionnaire composed of seven questions (Matsuyama et al., 2021). All participants answered the questionnaire within two weeks after post-CBCC PIF-SRL mentoring. In late September 2019, one-on-one interviews were also conducted after intensive qualitative data analysis of the questionnaire from 41 participants in 2018 and 2019. Three interviewers familiar with the CBCC but not engaged in the assessment of Year 5 students conducted interviews in order to encourage interviewees to openly articulate their own perceptions. Twelve students in the 2019 PIF-SRL group consented to participate in interviews conducted in a semi-structured manner using an interview form with similar questions to those in the questionnaire (Matsuyama et al., 2021). The interviewers were instructed beforehand by the main author (YM) to obtain data about changes in perception regarding motivation, strategies and reflective behaviours after experiencing PIF-SRL. After collecting interview data from 10 students, the two main authors (YM and HO) found no additional meaningful codes emerging and, concluding that data saturation had been reached (Hennink et al., 2017), and stopped further interview data collection.

D. Analysis

1) Quantitative approach: The 15 MSLQ-J pre-intervention subcategory scores of the PIF-SRL group and control group were compared using Kruskal-Wallis one-way analysis of variance (ANOVA). After confirming that there were no statistically significant differences between the two groups, subtracted (post-pre) scores in the 15 MSLQ-J subcategories were compared between the two groups using Kruskal-Wallis one-way ANOVA. This non-parametric method was used because of considerable skewness in distribution in the scales of several items and outliers in other scales in MSLQ-J. A p-value < 0.05 was considered statistically significant. The effect sizes for comparisons were also calculated using ε² values, wherein small effect sizes ranged from 0.01 to <0.08, medium effect sizes ranged from 0.08 to <0.26 and large effect sizes ranged from ≥0.26. We used JAMOVI version 1.0.7.0 for statistical analysis.

2) Qualitative approach: Qualitative data from PIE, the questionnaire and interviews were analysed using thematic analysis. Anonymised qualitative data were analysed in accordance with the six phases proposed by Braun and Clarke (2006). Initial coding was conducted by the two Japanese researchers (YM and HO). YM, the lead author, was involved in the development of PIF-SRL and has previous experience with qualitative studies relevant to SRL. HO was not directly engaged in PIF-SRL but has had experience in qualitative studies relevant to SRL. The transcripts were thoroughly analysed using an inductive coding approach until agreement on coding was achieved through repetitive face-to-face meetings between the pair.

The focus was on changes in SRL (motivation, learning strategies, and reflective behaviours), and student opinion of the effects of PIF-SRL on SRL. Representative codes and statements were translated into English by an American professor literate in both English and Japanese (AJL). In the final phase, two other authors (JL and CV; education psychologists familiar with SRL) joined the discussion, and a higher-level synthesis of the codes was developed.

III. RESULTS

A. Quantitative Data

Mean averages, standard deviations, and median averages for fifteen MSLQ-J categories plus gender and academic rank data at pre-intervention are shown in Table 1. No categories significantly differed between the PIF-SRL and control groups.

The subtracted (post- minus pre-intervention) between-group scores in the 15 MSLQ-J categories are shown in Table 2. Improvements in 1. Intrinsic goal orientation and 10. Critical thinking were significantly better in the PIF-SRL group than the control group with ε² values 0.096 (p = .005) and 0.051 (p = .041), respectively. The quantitative data used in this study are accessible (Matsuyama et al., 2021).

A higher-level synthesis of the codes eventually resulted in three major themes corresponding to the second research question, ‘How does the PIF-oriented elements in PIF-SRL improve SRL?’ 

1) Active expansion of learning goals based on professional responsibility: The first theme consisted of subthemes which included learning motivated from responsibility, clear learning goals based on explicit self-images, and wider learning goals based on wider perceptions of professional roles.

Students viewed in-depth communication with mentors through the PIF-SRL platform with PIE helpful for imagining their future professional responsibilities in a positive and objective manner.

‘A lot of opening questions were, for example, what do you expect from work, what is the worst that can happen if you failed to live up to the expectations you have set for yourself, that’s the situation you’re working under when you’re a doctor, and the first time I really felt this was the time I really should be aware of this, it was positive, and actually although I was still just a student, I could objectively assess what I was thinking…’

(Interview, 1D-10)

During PIF-SRL mentoring, they were able to realise that knowledge beyond what they were currently learning in the curriculum was required of them as professionals. They were actively trying to set learning goals that they could connect to what they would need to learn in the future.

 

‘Knowing what skills and knowledge the region expects of you, you can create a working image of your future situation, and this becomes motivation to learn about new areas you weren’t aware of before.’

 (Questionnaire, 2019-19)

Aside from the expansion of perceived learning goals, students also began to see that self-study was required to ensure the authenticity of medical knowledge applicable to their future professional work. This was linked to Theme 3.

‘What I got was that incomplete understanding or recall wasn’t going to cut it when actually applying knowledge in the clinic. I began to train with the awareness that I wouldn’t be useful there if I didn’t understand and remember all I learned about disease.’

(Questionnaire, 2018-21)

2) Elaboration by linking future professional task processes to daily self-study contents: The second theme was comprised of subthemes which included focus on the task processes of role models and relating daily self-study content to future roles.

After PIF-SRL, students began to imagine what they would do as professionals in future medical practice at a task process-based level. Because their vivid future professional image helped them identify deep responsibilities for their professional tasks, they began to carefully observe mentors’ complete professional tasks in the clinical clerkship and articulate task processes. This in turn encouraged students to select learning strategies which linked information in daily self-study materials (e.g. textbooks) to professional task processes, which is referred to as ‘elaboration’ in MSLQ.

‘I started to learn in terms of what I would do if it were me. I also started to think about the details and not just the general flow of things, and to apply them as much as possible to reality.’

(Questionnaire, 2018-8)

‘Since the clerkship, I’ve been able to relate and recall what I actually encountered in the clinical clerkship, and when I was actually reading textbooks in self-study, I was able to align it with my future work content, and if there were things that applied, I would emphasise them… The study method that I use to impress upon myself was strengthened in the mentoring and clerkship…’

(Interview, 1D-3)

3) Critical thinking based on the pursuit of authentic medical knowledge: The third theme was comprised of subthemes which included realisation of the significance of authenticity pursuit, access to a wide variety of educational materials, and critical reflection.

Because they began to perceive that what they were learning would affect the lives of individual patients, they recognised the significance of gaining authentic knowledge that could be applied to each patient, differentiated from textbook-based universal knowledge.

‘It’s really important to learn about disease by studying the texts and gaining comprehensive knowledge, but since that tertiary material is insufficient for responding to clinical questions and individual patient backgrounds, I’m not sure that knowledge is useful in clinical practice. For that, what’s most meaningful are secondary materials like UpToDate, or if you still have doubts then primary material research papers.

(Questionnaire, 2019-1)

After beginning to pursue authenticity of medical knowledge, students found diversity and inconsistency in information from learning materials. To deal with this, they began to formulate inquiries focusing on self-study, a variety of information resources, and different viewpoints. Through this strategic shift, critical thinking emerged in an intrinsic manner.

‘I’ve come to think opinions are going to diverge to some extent as you get down to actually asking opinions of several different doctors, and these are choices you have to make, the stages you go through when studying.’

(Interview, 1C-7)

‘Having the ability to doubt, and because it’s science not taking everything at face value, becoming sceptical, I think that’s necessary.’

(Interview, 3C-14)

IV. DISCUSSION

Regarding the first research question ‘Does PIF-SRL improve SRL during the period around the clinical clerkship?’, our findings of a moderate improvement in intrinsic goal orientation and a mild improvement in critical thinking in the PIF-SRL group compared with the control group suggested that PIF-SRL promotes SRL. The qualitative analysis supports the MSLQ-J results. With regard to intrinsic goal orientation, students’ recognition of their future ‘professional responsibility’ was a key to fostering this. Further, recognition of professional responsibility led to critical thinking — critical evaluation of learning materials or their interpretation — as a means of pursuing authenticity of information for professional task processes. The consistency between quantitative and qualitative data was notable in understanding the outcomes of the PIF-oriented mentoring on SRL.

There was no statistical significance in the difference between the PIF-SRL and the control groups regarding elaboration in MSLQ-J data. However, qualitative analysis illuminated that PIF-SRL students’ attention to professional task processes triggered a strategy toward elaboration of knowledge in accordance with their future professional task processes. Reasons for this discrepancy might include the number of participants and sensitivity of the outcome measurement (Tonkin-Crine et al., 2016). Further research is needed to address these issues. However, we believe that in order to remediate learning strategies necessary for professional tasks or professionalism, it is useful to reflect on daily self-learning in accordance with the process of professional work shown by role models.

Recent research pertaining to educational intervention for SRL emphasises analysing the learning process of a particular task in detail and remediating the individual process (Artino et al., 2014; Durning et al., 2011; Gandomkar et al., 2016). While we generally concur with this, learning tasks that take place in clinical practice are limitless, so it would be beneficial to explore a foundational intervention applicable to a variety of tasks in clinical settings. The PIF-oriented mentoring in this study is presented as a foundational SRL intervention for a variety of clinical settings wherein learners can recognise professional identities and role models can suggest learning strategies.

The major strength of this study is that the subjects were Japanese students, who are considered to engage less in self-regulation than their Western counterparts (Iwata & Doi, 2017; Matsuyama et al., 2018; Tagawa, 2008). We believe that our study can provide educators with evidence that PIF-oriented educational schemes promote better learning behaviours in institutions desiring to promote undergraduate SRL. Another strength is that there were few formal classes or training programmes – i.e., intervening confounders — except for PIF-SRL and CBCCs between pre- and post-data collection (Figure 1). We believe the study schedule, without other educational interventions, optimised learning comparison outcomes between the two groups. For instance, changes in accessing learning materials for critical thinking (e.g. UpToDate) can be attributed mostly to the experiences in PIF-oriented mentoring and the subsequent CBCCs.

This study also has some limitations. First, we did not collect one-on-one interview data from 2018 cohort. Second, we did not examine student SRL changes from the mentor’s perspective, despite the fact that mentors’ perceptions of changes in students’ SRL would be as useful as, or more useful than students’ self-administered data. Third, reference to mentors’ self-images in the PIF-SRL could help students in PIF-SRL construct their professional self-image more clearly; however, this may cause bias student statements in the PIF-SRL form regardless of their real professionalism. Future research needs to measure PIF and SRL in more multifaceted and objective manners. Lastly, we do not have long-term outcomes of PIF-SRL. According to previous studies (Cruess et al., 2014; Cruess & Cruess, 2019; Kalet et al., 2017; Oyserman et al., 2017), identity is flexibly attuned to immediate situations rather than fixed in memory. Plus, frequently and fluently cued identities form stable ones. Accordingly, we speculate that the repetitive use of PIF-SRL could strengthen learners’ SRL. Validation of this notion would require a longitudinal cohort study.

Evaluation of these results suggests that the ability of PIF-SRL to work effectively requires that the quality of mentors be guaranteed. One reason for the success of the relatively random combination of students and mentors in this PIF-SRL group is that all are future rural physicians, and their mentors are also alumni of JMU in rural practice. On the other hand, for medical students from other universities who can follow diverse specialties and career paths, use of the PIF-SRL will require pairing medical students with appropriate mentors who can respond to students’ identities or future images. Also, it is important to pair students not only by their interest in future expertise, but also by looking at the mental and physical traits of individual students as they relate to motivation and student career choices (Henning et al., 2017). Moreover, in-depth conversations that would foster professionalism might not be done only through text messages in the PIF-SRL platform, but also through video calls and in-person meetings that would convey the participants’ voices, facial expressions, and mood. We think it is important for mentors to actively provide opportunities for direct dialogue with students. In light of this challenge, the present study supports PIF-oriented intervention as a method for improvement in SRL.

V. CONCLUSION

Allowing for these limitations and the need for further research, this study indicated that PIF-oriented education in a clinical clerkship with alumni mentors increased immediate intrinsic goal orientation and promoted a shift to SRL. Their SRL was characterised as task process-based elaboration, with critical thinking emerging from the pursuit of authenticity in medical practice.

Notes on Contributors

Yasushi Matsuyama reviewed the literature, designed the study, conducted both quantitative and qualitative data analysis, and wrote the manuscript.

Hitoaki Okazaki conducted qualitative data analysis.

Kazuhiko Kotani designed the study, and collected both quantitative and qualitative data.

Yoshikazu Asada collected both quantitative and qualitative data.

Shizukiyo Ishikawa collected both quantitative and qualitative data.

Adam Jon Lebowitz contributed to Japanese-English translation of data collection tools and qualitative data from questionnaire and interviews.

Jimmie Leppink reviewed the literature, designed the study, conducted both quantitative and qualitative data analysis, and wrote the manuscript.

Cees van der Vleuten reviewed the literature, designed the study, conducted both quantitative and qualitative data analysis, and wrote the manuscript.

All the authors have read and approved the final manuscript.

Ethical Approval

This study was approved by the ethics committee of Jichi Medical University (Reference number: 19-001). Consent was obtained from all participants for the research study.

Acknowledgements

We would like to express our sincere gratitude to Dr. Adina Kalet and Dr. Verna Monson for their consultation and provision of supplementary materials. We would also like to thank Drs. Yasuko Aoyama, Yoshitaka Maeda, and Maiko Watanabe for their support in conducting one-on-one interviews. We would also like to thank Ms. Akemi Watanabe and Yasuko Koguchi for their helpful assistance. 

Funding

This work was supported by JSPS KAKENHI [Grant number JP17K08924]. 

Declaration of Interest

The authors report no conflicts of interest.

Data availability

The quantitative data used in this study, Supplemental files are available at https://doi.org/10.6084/m9.figshare.14312507

Representative qualitative data translated into English are shown in the Result section (Matsuyama et al., 2021). All qualitative data written in Japanese are available from the corresponding author on reasonable request.

A preprint of the previous version of our manuscript, which is not peer-reviewed, is available at https://www.researchsquare.com/article/rs-12667/v1

References

Aho, J. M., Ruparel, R. K., Graham, E., Zendejas-Mummert, B., Heller, S. F., Farley, D. R., & Bingener, J. (2015). Mentor-guided self-directed learning affects resident practice. Journal of Surgical Education, 72(4), 674–679. https://doi.org/10.1016/j.jsurg.2015.01.008o

Artino, A. R., Jr., Cleary, T. J., Dong, T., Hemmer, P. A., & Durning, S. J. (2014). Exploring clinical reasoning in novices: A self-regulated learning microanalytic assessment approach. Medical Education, 48(3), 280–291. https://doi.org/10.1111/medu.12303

Artino, A. R., Jr., Dong, T., DeZee, K. J., Gilliland, W. R., Waechter, D. M., Cruess, D., & Durning, S. J. (2012). Achievement goal structures and self-regulated learning: Relationships and changes in medical school. Academic Medicine, 87(10), 1375–1381. https://doi.org/10.1097/ACM.0b013e3182676b55

Berkhout, J. J., Helmich, E., Teunissen, P. W., van den Berg, J. W., van der Vleuten, C. P., & Jaarsma, A. D. (2015). Exploring the factors influencing clinical students’ self-regulated learning. Medical Education, 49(6), 589–600. https://doi.org/10.1111/medu.12671

Berkhout, J. J., Helmich, E., Teunissen, P. W., van der Vleuten, C., & Jaarsma, A. (2018). Context matters when striving to promote active and lifelong learning in medical education. Medical Education, 52(1), 34–44. https://doi.org/10.1111/medu.13463

Braun, V., & Clarke, V. (2006). Using thematic analysis in psychology. Qualitative Research in Psychology, 3(2), 77-101. https://doi.org/10.1191/1478088706qp063oa

Brydges, R., & Butler, D. (2012). A reflective analysis of medical education research on self-regulation in learning and practice. Medical Education, 46(1), 71–79. https://doi.org/10.1111/j.1365-2923.2011.04100.x

Cho, K. K., Marjadi, B., Langendyk, V., & Hu, W. (2017). Medical student changes in self-regulated learning during the transition to the clinical environment. BMC Medical Education, 17(1), 59. https://doi.org/10.1186/s12909-017-0902-7

Cleary, T. J., & Sandars, J. (2011). Assessing self-regulatory processes during clinical skill performance: A pilot study. Medical Teacher, 33(7), e368–e374. https://doi.org/10.3109/0142159X.2011.577464

Creswell, J. W., & Clark, V. L. P. (2017). Designing and conducting mixed methods research. SAGE Publications.

Cruess, R. L., & Cruess, S. R. (1997). Teaching medicine as a profession in the service of healing. Academic Medicine, 72(11), 941–952. https://doi.org/10.1097/00001888-199711000-00009

Cruess, R. L., Cruess, S. R., Boudreau, J. D., Snell, L., & Steinert, Y. (2014). Reframing medical education to support professional identity formation. Academic Medicine, 89(11), 1446–1451. https://doi.org/10.1097/ACM.0000000000000427

Cruess, S. R., & Cruess, R. L. (2019). The development of professional identity. In T. Swanwick., K. Forrest., B. C. O’Brein (Eds.), Understanding medical education; Evidence, theory, and practice (3^rd ed., pp. 239–254). https://doi.org/10.1002/9781119373780.ch17

Durning, S. J., Cleary, T. J., Sandars, J., Hemmer, P., Kokotailo, P., & Artino, A. R. (2011). Perspective: Viewing “strugglers” through a different lens: How a self-regulated learning perspective can help medical educators with assessment and remediation. Academic Medicine, 86(4), 488–495. https://doi.org/10.1097/ACM.0b013e31820dc384

Frank, J. R. (2005). The CanMEDS 2005 physician competency framework. Better standards. Better physicians. Better care. The Royal College of Physicians and Surgeons of Canada.

Gandomkar, R., Mirzazadeh, A., Jalili, M., Yazdani, K., Fata, L., & Sandars, J. (2016). Self-regulated learning processes of medical students during an academic learning task. Medical Education, 50(10), 1065–1074. https://doi.org/10.1111/medu.12975

Henning, M. A., Krägeloh, C. U., Booth, R., Hill, E. M., Chen, J., & Webster, C. S. (2017). Profiling potential medical students and exploring determinants of career choice. The Asia Pacific Scholar, 2(1), 7-15. https://doi.org/10.29060/TAPS.2017-2-1/OA1019

Hennink, M. M., Kaiser, B. N., & Marconi, V. C. (2017). Code saturation versus meaning saturation: How many interviews are enough? Qualitative Health Research, 27(4), 591–608. https://doi.org/10.1177/1049732316665344

Iwata, K., & Doi, A. (2017). Can hybrid educational activities of team and problem based learning program be effective for Japanese medical students? International Journal of Medical Education, 8, 176–178. https://doi.org/10.5116/ijme.591b.2bc8

Jarvis-Selinger, S., Pratt, D. D., & Regehr, G. (2012). Competency is not enough: Integrating identity formation into the medical education discourse. Academic Medicine, 87(9), 1185–1190. https://doi.org/10.1097/ACM.0b013e3182604968

Kalet, A., Buckvar-Keltz, L., Harnik, V., Monson, V., Hubbard, S., Crowe, R., Song, H. S., & Yingling, S. (2017). Measuring professional identity formation early in medical school. Medical Teacher, 39(3), 255–261. https://doi.org/10.1080/0142159X.2017.1270437

Kalet, A., Buckvar-Keltz, L., Monson, V., Harnik, V., Hubbard, S., Crowe, R., Ark, T. K., Hyuksoon, Song, H. S., & Yingling, S. (2018). Professional Identity Formation in medical school: One measure reflects changes during pre-clerkship training. MedEdPublish, 7(1), 41. https://doi.org/10.15694/mep.2018.0000041.1

Kegan, R. (1994). In over our heads: The mental demands of modern life. Harvard University Press.

Lam, T. P., & Lam, Y. Y. (2009). Medical education reform: The Asian experience. Academic Medicine, 84(9), 1313–1317. https://doi.org/10.1097/ACM.0b013e3181b18189

Lucieer, S. M., Jonker, L., Visscher, C., Rikers, R. M. J. P., & Themmen, A. P. N. (2016). Self-regulated learning and academic performance in medical education. Medical Teacher, 38(6), 585–593. https://doi.org/10.3109/0142159X.2015.1073240

Matsuyama, Y., Nakaya, M., Okazaki, H., Leppink, J., & van der Vleuten, C. (2018). Contextual attributes promote or hinder self-regulated learning: A qualitative study contrasting rural physicians with undergraduate learners in Japan. Medical Teacher, 40(3), 285–295. https://doi.org/10.1080/0142159X.2017.1406074

Matsuyama, Y., Nakaya, M., Okazaki, H., Lebowitz, A. J., Leppink, J., & van der Vleuten, C. (2019). Does changing from a teacher-centered to a learner-centered context promote self-regulated learning: A qualitative study in a Japanese undergraduate setting. BMC Medical Education, 19(1), 152. https://doi.org/10.1186/s12909-019-1550-x

Matsuyama, Y., Okazaki, H., Kotani, K., Asada, Y., Ishikawa, S., Lebowitz, A. J., Leppink, J., & van der Vleuten, C. (2021). Professional identity formation-oriented mentoring technique as a method to improve self-regulated learning: A mixed-method study. [Data set]. Figshare. https://doi.org/10.6084/m9.figshare.14312507

Matsuyama, Y., Okazaki, H., Kotani, K., Asada, Y., Ishikawa, S., Lebowitz, A. J., Leppink, J., & van der Vleuten, C. (2020). Education in professional identity formation enhances self-regulated learning: A mixed-method exploratory study from a community-based clinical clerkship in Japan. [Preprint]. Research Square. January 28, 2020. [cited June 10, 2020] Available from: https://doi.org/10.21203/rs.2.22088/v1

Okayama, M., & Kajii, E. (2011). Does community-based education increase students’ motivation to practice community health care? A cross sectional study. BMC Medical Education, 11(1), 19. https://doi.org/10.1186/1472-6920-11-19

Oyserman, D., Lewis, Jr., N. A., Yan, V. X., Fisher, O., O’Donnell, S. C., & Horowitz, E. (2017). An identity-based motivation framework for self-regulation. Psychological Inquiry, 28(2-3), 139-147. http://doi.org/10.1080/1047840X.2017.1337406

Pintrich, P. R., Smith, D. A. F., Garcia, T., & McKeachie, W. J. (1991). A manual for the use of the Motivated Strategies for Learning Questionnaire (Technical Report 91-B-004). The Regents of the University of Michigan. https://files.eric.ed.gov/fulltext/ED338122.pdf

Ray, M. W., Garavalia, L. S., & Gredler, M. E. (2003, April 21-25). Gender differences in self-regulated learning, task value, and achievement in developmental college students. Annual Meeting of the American Educational Research Association. https://files.eric.ed.gov/fulltext/ED476176.pdf

Sandars, J., & Cleary, T. J. (2011). Self-regulation theory: Applications to medical education: AMEE Guide No. 58. Medical Teacher, 33(11), 875–886. https://doi.org/10.3109/0142159X.2011.595434

Shannon-Baker, P. (2016). Making paradigms meaningful in mixed methods research. Journal of Mixed Methods Research, 10(4), 319-334. https://doi.org/10.1177/1558689815575861

Song, H. S., Kalet, A. L., & Plass, J. L. (2011). Assessing medical students’ self-regulation as aptitude in computer-based learning. Advances in Health Sciences Education: Theory and Practice, 16(1), 97–107. https://doi.org/10.1007/s10459-010-9248-1

Stuart, E., Sectish, T. C., & Huffman, L. C. (2005). Are residents ready for self-directed learning? A pilot program of individualized learning plans in continuity clinic. Ambulatory Pediatrics, 5(5), 298–301. https://doi.org/10.1367/A04-091R.1

Tagawa, M. (2008). Physician self-directed learning and education. The Kaohsiung Journal of Medical Sciences, 24(7), 380–385. https://doi.org/10.1016/S1607-551X(08)70136-0

Tonkin-Crine, S., Anthierens, S., Hood, K., Yardley, L., Cals, J. W., Francis, N. A., Coenen, S., van der Velden, A. W., Godycki-Cwirko, M., Llor, C., Butler, C. C., Verheij, T. J., Goossens, H., Little, P., & GRACE INTRO/CHAMP consortium (2016). Discrepancies between qualitative and quantitative evaluation of randomised controlled trial results: Achieving clarity through mixed methods triangulation. Implementation Science, 11, 66. https://doi.org/10.1186/s13012-016-0436-0

Turan, S., & Konan, A. (2012). Self-regulated learning strategies used in surgical clerkship and the relationship with clinical achievement. Journal of Surgical Education, 69(2), 218–225. https://doi.org/10.1016/j.jsurg.2011.09.003

van Houten-Schat, M. A., Berkhout, J. J., van Dijk, N., Endedijk, M. D., Jaarsma, A. D. C., & Diemers, A. D. (2018). Self-regulated learning in the clinical context: A systematic review. Medical Education, 52(10), 1008–1015. https://doi.org/10.1111/medu.13615

Van Nguyen, H., Laohasiriwong, W., Saengsuwan, J., Thinkhamrop, B., & Wright, P. (2015). The relationships between the use of self-regulated learning strategies and depression among medical students: An accelerated prospective cohort study. Psychology, Health & Medicine, 20(1), 59–70. https://doi.org/10.1080/13548506.2014.894640

Zimmerman, B. J. (1989). A social cognitive view of self-regulated academic learning. Journal of Educational Psychology, 81(3), 329.

*Yasushi Matsuyama
3311-1
Yakushiji, Shimotsuke,
Tochigi, 329-0498
Email: yasushim@jichi.ac.jp

Submitted: 2 November 2020
Accepted: 8 February 2021
Published online: 5 October, TAPS 2021, 6(4), 37-48
https://doi.org/10.29060/TAPS.2021-6-4/OA2425

Stephen Bradley¹, Aaron Ooi², Kerry Stafford³, Shuvayon Mukherjee¹ & Marcus A. Henning⁴

¹Department of Paediatrics, Lakes District Health Board, New Zealand; ²Department of Paediatrics, Waikato District Health Board, New Zealand; ³Department of Paediatrics, Christchurch Hospital, New Zealand; ⁴Centre for Medical and Health Sciences Education, University of Auckland, New Zealand

Abstract

Introduction: The paediatric team handover process is a crucial workplace practice and comprises the transfer of patient information from one shift to another involving medical professionals and students.  A qualitative study was performed to analyse the feasibility, functionality, benefits and limitations of the dramaturgical approach when applied to examining a handover session. 

Methods: Data relating to one handover were collected and analysed from video and audio recordings, notes created by two independent observers and a de-identified copy of the handover sheet. 

Results: The dramaturgical constructs and subsequent findings allowed us to make informed inferences about the dynamics of the handover procedure. The directors/lead actors consisted of a consultant and a registrar.  One consultant was transitory and the remaining 12 attendees were either major support, support or bit actors.  The students (bit actors/audience) were included when a learning point was emphasised.  The script was informal and improvised as the discussion emphasised certain facets of patient care or accentuated learning points.  The staging involved the seating arrangement, a whiteboard, computer screen and ongoing data presentation.  The performance suggested a handover of two halves: one emphasising learning and the other allocation of patient care responsibility. 

Conclusion: We concluded that the real-life drama occurring within a handover was feasibly analysed, with its functionality demonstrated, using the dramaturgical investigative system.  The multifaceted recordings enabled researchers to review the ‘authentic’ handover system without censorship. These findings have implications for educational and organisational research.

Keywords:           Dramaturgical, Handover, Paediatric, Methodology

Practice Highlights

• Dramaturgical methodology provided a unique, authentic and detailed analysis of the handover.
• The dramaturgical research methodology used to evaluate the handover was feasible and functional.
• This research methodology can be used to analyse education within similar team based settings.
• This research methodology can be applied to the team handovers and other complex health meetings.
• This research methodology identifies important clinical/educational roles and dynamics within teams.

I. INTRODUCTION

Hospital team handovers involve effective transfer of information and responsibility from one health professional to another, ensuring continuity of patient care (Australian Medical Association Limited, 2006; Hilligoss & Cohen, 2011). The level of communication needs to be comprehensive, unambiguous and coherent so that patient information is easily understood, thus optimising patient care through the meaningful and efficient transfer of patient information (Fujikawa et al., 2021). This is crucial given the ramifications for optimising patient care and minimising potential treatment error, including miscued transfer of knowledge, insertion of faulty or misleading information, treatment delay, and poor patient outcomes (Arora et al., 2005; Bomba & Prakash, 2005). To explore the nuances occurring in handover practice from organisational behaviour and educational perspectives, different methodological approaches need to be developed.

In this paper, we propose that the dramaturgical approach can optimally analyse handover dynamics, as it is an integrated, pragmatic and multidimensional approach. This approach uses multi-source feedback from video and audio recordings, observer records, and transcripts of analysis. The dramaturgical approach argues that the individuals present in the activity assume different roles that influence the way they communicate and behave (Canary et al., 2008; Goffman, 1959; Henderson, 2005). Using this approach, the handover activity can be analysed much like a drama or element of theatre. The dramaturgical approach has the potential to offer insights into the clinical and educational handover components, much like the insights drawn when applying this approach to analysing healthcare simulations (Crea, 2017), decision-making aspects of an emergency department triage (Forde, 2014), and behaviour of radiographers and their patients (Murphy, 2009). This analytical approach enables the researcher to be present at the moment of the occurrence, rather than relying on retrospective data obtained when subsequently interviewing participants. Interviews can be a powerful means of obtaining information, but require participants to accurately retell their experiences of the activity (DiCicco‐Bloom & Crabtree, 2006).  The dramaturgical approach tells it for what it is, and allows researchers the ability to see and hear the authentic process of communication (Goffman, 1959; Murphy, 2009). We surmised that the dramaturgical approach would be a more comprehensive evaluative system and thus well suited for collecting observational data that could inform training and development initiatives within hospital systems.

The research aim of this study was to explore the feasibility and functionality of the dramaturgical methodological system of analysis not yet applied to the handover procedure. 

The research questions driving this study include:

1. How can the dramaturgical approach feasibly be applied to the handover system?
2. How does the dramaturgical approach describe the functional dynamics of the handover procedure?
3. What are the benefits and limitations associated with applying this research methodology?

 

II. METHODS

A. Phenomenon of Interest

Feasibility, functionality and quality were informed by examples taken from one handover involving team discussion regarding patients admitted to a general paediatric ward (20 beds) and a Special Care Baby Unit (8 cots) in a New Zealand secondary-level hospital (Hensher et al., 2006).

B. Sample/Participants

All the health professionals and medical students involved in one handover were asked to volunteer for the study, with eligibility determined by consent and approval from hospital management. Informed consent was obtained after eligible participants read a detailed information sheet, provided by an administrator, followed by a consent form that they then signed. 

C. Data Collection

Data were obtained from several sources.

1. Five video cameras were situated in the handover room to obtain multiple angles of the handover. Two audio recorders were placed in the room and served as the primary sources of data for transcription.
2. The final transcription of events was checked by all authors using data from the cameras.
3. Notes on the salient aspects of handover interactions were made by two present ‘unknown’ observers (i.e., one medical student and one medical educationalist).

A diagram of the seating positions of each participant was constructed (see Figure 1).

Figure 1: Handover room layout depicting seating arrangements, participants (P1-P15, with original position participants sat in), 2 observers (Ob1 and Ob2) and equipment.

Submitted: 17 October 2020
Accepted: 12 April 2021
Published online: 5 October, TAPS 2021, 6(4), 26-36
https://doi.org/10.29060/TAPS.2021-6-4/OA2420

Chee Yang Chin¹, Si Qi Tan², Swee Leng Kui^1,2, Kurugulasigamoney Gunasegaran¹ & Jill Cheng Sim Lee³

¹Department of Cardiovascular Medicine, National Heart Centre Singapore, Singapore; ²Ministry of Health Holdings, Singapore; ³Department of Obstetrics and Gynaecology, KK Women’s and Children’s Hospital, Singapore

Abstract

Introduction: Sleep deprivation impacts clinical performance. However, literature is conflicting, with insufficient focus on patient outcomes. The aim of this study was to assess if patient satisfaction and prescription errors in outpatient clinics were adversely affected when consulting post-call versus non-post-call registrars.

Methods: This prospective, quantitative study was set in a large teaching hospital in Singapore. Between November 2015 and February 2016, patients from clinics run by a registrar after 24-hour shift were recruited to post-call group. Patients from non-post-call clinics run by the same registrar were controls. Outcome measures were patient satisfaction, using 5-item 4-point Likert scale questionnaire, and prescribing error rate, defined as number of errors over number of orders. Differences were analysed using chi-squared test.

Results: 103 of 106 (97%) patients in 9 post-call clinics and 93 of 105 (90%) patients in 9 non-post-call clinics were recruited. Questionnaire completion rate was 99%. 536 and 526 prescriptions were ordered in post-call and non-post-call groups, respectively. Percentage of top-box responses (greatest satisfaction) was higher in post-call group overall (79.3% versus 62.4%, p<0.001), and for each questionnaire item. There was no significant difference in prescribing errors (1.31% versus 2.28%, p=0.23).

Conclusion: Patient satisfaction and prescribing error rates in outpatient clinics were not detrimentally affected. This provides some objective evidence that patients may safely consult post-call registrars. True impacts of sleep deprivation remain poorly understood, and larger, longer term, multicentre studies would inform generalisability. Qualitative studies of fatigue may shed light on complex interactions of emotions that compensate for tiredness.

Practice Highlights

• Studies of sleep deprivation and work-hour restrictions are conflicting, with few on patient outcome.
• We compared patient satisfaction and prescribing errors of clinics post-call, versus non-post-call.
• We demonstrate quantitative evidence that patients may safely consult post-call registrars in clinic.
• Impairment may be mitigated by adaptive effort to be conscientious and post call euphoria.
• No recommendations were made to change the current practice of registrars running post-call clinics.

I. INTRODUCTION

Sleep deprivation and fatigue are thought to have detrimental effects on trainee doctors’ performance. It was previously shown that the Epworth Sleepiness Scale score in junior doctors was equivalent to that of patients with sleep apnoea and narcolepsy (Mustafa et al., 2005). Indeed, cognitive psychomotor performance after 24 hours of sustained wakefulness was found to be equivalent to a blood alcohol concentration twice the prohibited level of alcohol intoxication (Dawson & Reid, 1997). The performance and safety to practise of fatigued trainee doctors, especially at the end of a long shift, is thus of utmost concern.

Increasing awareness of fatigue-related medical errors has led to reforms in trainee doctor working hours. Work hours were limited by the Accreditation Council for Graduate Medical Education (ACGME) in the USA in 2003 to 80 hours per week, and by the European Working Time Directive (EWTD) in 2009 to 48 hours per week. A subsequent ACGME stipulation in 2017 further restricted work periods to 24 consecutive hours for first‐year residents (Rosenbaum & Lamas, 2012). Still, doubts remain as to the clinical impact of these restrictions (Baldwin et al., 2011; Fletcher et al., 2005). A systematic review of ACGME’s 2011 work hour restrictions found no improvements in patient care or resident well-being, and in fact revealed unintended negative impacts on resident education (Bolster & Rourke, 2015). Indeed, low job satisfaction was found to be associated with a higher rate of attrition from training (Lee et al., 2019). Thus, the optimal working hours and working patterns for trainee doctors remain ill-defined.

Studies on the impact of sleep deprivation and fatigue on trainee doctors’ performance and wellbeing have yielded mixed results. Chronic sleep deprivation was shown to be particularly detrimental to tasks requiring sustained concentration (Bertram, 1988). After an extended night shift, intensive care unit physicians made 36% more serious medical errors (Landrigan et al., 2004), were 61% more likely to suffer a percutaneous injury (Ayas et al., 2006) and 2.3 times more likely to have a motor vehicle collision (Barger et al., 2005). Hostility and anger in trainee doctors were also more prevalent after a night’s sleep loss (Saadat et al., 2016; Samkoff & Jacques, 1991). Cardiologists were particularly prone to sleep deprivation due to frequent call coverage responsibilities, and in a recent 2019 survey of 481 cardiologists, 46% felt work performance hindrance and 8.6% described sleep-deprivation related adverse events (Lobo et al., 2019).

Yet, other studies have not observed a similar impairment of ability amongst fatigued trainee doctors. There were fewer errors in cognitive tests and cardiopulmonary resuscitation (CPR) manoeuvres in residents after on-call duty (Domínguez et al., 2009; Hamui-Sutton et al., 2013), and psychomotor performance and acquisition of laparoscopic and robotic simulator skills in post-call trainee doctors were also found to be no different from non-post-call trainee doctors (Robison et al., 2018; Yi et al., 2013).

Notably, the outcome measures in the vast majority of these published studies were either subjective through interviews with the trainee doctors themselves, which introduces bias in results, or based on performance on robotic surgical simulators, which is not reflective of true patient contact. Few studies focused on actual patient outcome measures.

Trainee doctors (“registrars”) at our institution, a high volume tertiary referral centre for cardiovascular medicine in Singapore, may be expected to run busy outpatient clinics after a 24-hour continuous in-hospital shift. Typically, up to 20 patients are seen within 4 hours in these clinics. Concerns linger regarding the suitability of post-call registrars running these high-intensity clinics, both in terms of psychomotor ability as well as proneness to error.

With the lack of published literature on the impact of fatigue on trainee doctor performance in outpatient clinics, we aimed to study for ourselves whether patient outcomes were adversely affected if they consulted a post-call registrar, versus a non-post-call registrar. To achieve this, we decided on two practical and measurable outcomes: patient satisfaction and prescribing error rates. Quantifying patient satisfaction allowed an assessment of the registrars’ ability to communicate and show empathy despite their fatigued state. Prescribing error rates allowed an objective evaluation of patient safety. Using two very different outcome measures was a means to allow some triangulation of results and to reduce bias.

Our hypothesis was that both patient outcome measures – patient satisfaction and prescribing error rate – would be worse off in the clinics run by registrars when they were post-call versus when they were not post-call.

II. METHODS

A. Study Setting and Population Design

This study was set in a high volume, specialised Cardiology clinic in a large teaching hospital in Singapore. Registrars, who are trainee doctors in the final stages of training prior to specialist accreditation, work overnight in-hospital shifts as part of service and training commitments. “On-call” duties last from 7am to 1pm the following day (30 continuous hours), during which they are responsible for all urgent inpatient and Emergency department Cardiology referrals. “Post-call” refers to the last 6 hours of the continuous 30-hour shift, during which they may be posted to run busy outpatient clinics.

B. Patient Recruitment

Between November 2015 and February 2016, all patients who attended clinics run by a post-call registrar were recruited to the post-call group. Patients who attended clinics run by the same registrar on a non-post-call day were recruited as controls into the non-post-call group. This provided internal control by comparing performances by the same registrar post-call and non-post call. Patients were approached for participation after their clinic consultation so as not to bias the consultation. They were informed of the purpose of the study but not informed whether the registrar they had just consulted was post-call or not, so as not to bias their responses. All patients, whether new or established, were approached.

C. Patient Satisfaction Questionnaire

Patient satisfaction was evaluated using a 5 item questionnaire (Appendix A). These questions were adapted from the Hospital Consumer Assessment of Healthcare Providers And Systems (HCAHPS), a well-established standardised instrument for the measurement of patient perspectives on hospital care (Giordano et al., 2009; Goldstein et al., 2005).

1) During today’s consultation, did the doctor treat you with courtesy and respect?

2) During today’s consultation, did you feel the doctor listened carefully to you?

3) During today’s consultation, were you given the opportunity to ask your questions?

4) During today’s consultation, did the doctor explain things in a way you could understand?

5) How would you rate your overall satisfaction with today’s consultation?

For each item, as per the HCAHPS questionnaire format, patients were asked to rate responses on a 4-point Likert scale. Smiley faces were incorporated to provide visual representations. The questionnaire was in English and Chinese text, which would have been understood by the vast majority of the patient population. Relevant translations in Chinese, Malay or Tamil languages were provided by research assistants for illiterate patients or those who required further clarification, with care not to influence the patients’ responses. Only fully completed questionnaires were included in the data analysis.

D. Prescribing Error Rates

All prescription orders entered electronically were logged. As is standard procedure for our outpatient clinics, all prescriptions are reviewed by the Pharmacy Department prior to dispensing. All suspected prescription errors will be verified via a phone call to the prescribing doctor, who will confirm whether that prescription was intended or if it truly was an error. All verified prescription errors, including medication name, dose or frequency, or omission of a necessary drug, were recorded regardless of severity. The Pharmacy Department conducts regular internal audits to ensure that this process is accurate and consistent.

The total number of medications ordered and total number of errors were retrospectively summed. Prescribing error rate was calculated by dividing total number of prescribing errors by total number of medications ordered.

E. Consent and Ethics

In accordance with local Institutional Review Board (IRB) guidelines, the study protocol was exempted from full IRB review as it was non-interventional and intended primarily for medical education. All recruited patients provided informed consent to participate. All data were anonymised, with no personal identifiers recorded.

F. Data Analysis

For the patient satisfaction questionnaire, the “top-box” response was defined as the most positive response on the Likert scale (for example “all of the time” or “very satisfied”). The proportions of “top-box” responses were calculated and reported for each questionnaire item and overall items. Only “top-box” responses were sought, to target a higher quality of performance.

For both patient satisfaction and prescribing error outcomes, comparisons between post-call and non-post-call groups were tested for statistical significance with p<0.05 using the chi-squared test. All statistical analyses were reviewed by a biostatistician.

III. RESULTS

The recruitment period consisted of 9 outpatient clinics run by 8 post-call registrars. Two of these clinics were run by the same registrar who was post-call on separate days. We then identified a further 9 clinics run by the same registrars during days when they were not post-call. Thus, 7 registrars had one post-call clinic and one non-post-call clinic studied, while 1 registrar had two post-call clinics and two non-post-call clinics studied.

All patients seen were invited to participate. 103 of 106 (97%) patients in the post-call group and 93 of 105 (90%) in the non-post-call group consented. The number of patients seen per clinic ranged from 7 to 20 (median 11) in the post-call group, and 7 to 17 (median 10) in the non-post-call group.

Basic demographic data on the registrars and the distribution of patients in these clinics were summarised in Table 1.

Table 1: Basic demographic data of registrars and distribution of patients seen and number of medications ordered per clinic.

Note: ^{[1] †}Numbers in brackets indicate number of patients who declined participation. *C1 and C2 refer to the same registrar, who had 2 post-call and 2 non-post-call clinics from whom patients were recruited for the study.

Figure 1: Summary of patient questionnaire responses according to registrars’ post-call status. Questionnaire items were shown on the y-axis and percentage of top-box responses were shown on the x-axis.

B. Prescribing Error Rates

536 and 526 medications were ordered in the post-call and non-post-call group respectively. Seven prescribing errors were made in the post-call group and 12 in the non-post-call group (Table 2).

Overall, there was no significant difference in prescribing error rates (1.31% versus 2.28%, p=0.231).

Table 2: Distribution of medications ordered and prescribing errors made according to registrar.

IV. DISCUSSION

To our knowledge, this is one of very few studies on post-call trainee doctor performance in the context of a realistic outpatient setting, centred on patient outcomes. In our study, the results of both patient satisfaction and prescription errors were congruent in demonstrating that these measurable patient outcomes were not adversely affected when patients were seen by a post-call registrar in an outpatient clinic setting.

A. Patient Satisfaction

Patient satisfaction is an important measure as it demonstrates a doctor’s ability to communicate, which is a key element of any patient-doctor encounter. Fatigue leading to increased stress levels and hostility could have negatively influenced this.

In our study, rather than create a novel and unvalidated questionnaire, we adapted the HCAHPS, a well-established standardised instrument for the measurement of patient perspectives on hospital care (Giordano et al., 2009; Goldstein et al., 2005). As per HCAHPS, only the proportions of top-box responses (i.e., the percentage of patients who rated a particular questionnaire item the most positively) were taken into account in the analysis. This was a means of assessing and aiming for the highest quality of care possible.

The results from overall and individual item top-box responses in our questionnaire demonstrated that patient satisfaction was statistically significantly (p-value <0.001) higher in the post-call group. Indeed, 6 out of 8 registrars had higher percentages of overall top-box responses when post-call, adding consistency to this finding. Nonetheless, given the small cohort of registrars surveyed, there were still the likelihood that this was a chance finding, and previous studies in this area had shown only subtle differences in patient satisfaction (Hoellein et al., 2004; Liu & Wissow, 2011). The key take away point was that patient satisfaction in our study was not adversely affected when patients saw a post-call registrar.

There were two other studies examining post-call trainee doctors in outpatient clinics. In Liu and Wissow’s study (2011), 170 pre-recorded paediatric clinic consultations were analysed to reveal that parents were twice as likely to request a post-call doctor to repeat explanations, both post-call doctors and parents used paraphrasing more frequently to check that they understood each other, and trainee doctors were perceived as less willing to help the patient accomplish their goals during the visit. This suggested that communication was less effective when trainee doctors were post-call. The earlier study by Hoellein et al. (2004), using a 7-item 10-point Likert scale questionnaire, found that patients were significantly less satisfied (mean score 8.99) when seen by a post-call trainee doctor than when seen by a non-post-call trainee doctor (mean score 9.31). Differences in study design and clinic setup could explain the discrepancy between our findings and those of these 2 previous studies. In these 2 studies, patient volume was low at 3 to 7 per clinic, trainee doctors and patients were aware that they were being recorded, and some clinics surveyed were the trainee doctors’ “continuity clinics” where visits were more likely returning patients with already established rapport. In our clinic setting, patient volumes were higher, patients were only approached after the consultation, and none of the clinics were “continuity clinics”.

Another possible explanation for the lack of reduction in patient satisfaction in our study was the phenomenon of “post-call euphoria”, where trainee doctors experience an upbeat mood associated with being able to look forward to the end of a long 30-hour shift and finishing work earlier than usual, at 1 p.m. instead of at 6 p.m. They may be emotionally less stressed in clinic than if they had a long day of work ahead, particularly if they were just starting an on-call shift. In Liu and Wissow’s study (2011), trainee doctors reported more anxiety and frustration when running morning clinics when they still had the rest of the day’s work ahead of them. Additionally, they described themselves as tired, but not more unhappy, when they were post-call as opposed to when they had left on time the day before. Furthermore, post-call trainee doctors made attempts to cope with their fatigue, adaptively or maladaptively, and were seemingly able to compensate for compromised abilities. This counter-intuitive psychological effect warrants further study.

B. Prescribing Error Rates

Prescribing errors were evaluated as a marker of patient safety. Errors have been shown to be provoked by situations of high workload, stress and fatigue (Keers et al., 2013; Tully et al., 2009). Overall case volume in particular was associated with increased rate of major diagnostic discrepancies for junior residents (Hanna et al., 2016), which is relevant to our high-volume clinic setting. The questionnaire among anaesthesiologists from Santa Catarina by Erdmann et al. (2016) revealed that most respondents committed more than one error in drug administration, with distraction and fatigue being the highest contributing factor of 64.9%. Interns made substantially more serious medical errors in the intensive care unit when they worked frequent shifts of 24 hours or more, than when they worked shorter shifts (Landrigan et al., 2004). There was only one other study that dealt specifically with medication errors in the post-call setting. In a retrospective study of 8,195 inpatient prescriptions, trainee doctors were found to be significantly more likely to commit an error on-call and post-call, than when they were off-call, by 2.16%, with odds ratio 1.44 (Hendey et al., 2005).

Our study in the outpatient setting revealed no statistically significant difference in prescribing error rates between patients who had seen a post-call registrar (1.31%) and those who had seen a non-post-call registrar (2.28%) across 536 and 526 prescriptions respectively. The overall prescribing error rate seen in our study was comparable to that of Hendey et al. (2005) (1.79% versus 2.16%, respectively), supporting the validity of our results. Importantly, prescribing error rates were low in both groups, providing reassurance for patient safety.

Previous studies on the impact of fatigue on clinical performance show mixed results. Surgical trainees awake the previous night made 20% more errors in stimulators (Taffinder et al., 1998). Gastroenterologists who performed emergent procedures the previous night had a significant 24% decrease in adenoma detection rates on colonoscopies performed post-call (Benson et al., 2014). While long work hours may contribute to mistakes, the lack of supervision, faulty handovers and large patient caseloads were important factors that further compounded these errors.

Yet, other studies have observed that performance was no worse amongst fatigued trainee doctors. Yi et al. (2013) found no significant difference in psychomotor performance of general surgery residents performing laparoscopic simulator tasks after a 24-hour call work shift versus a 12-hour night-float shift. Robison et al. (2018) reported no significant difference in acquisition of robotic simulator skills between pre-call and post-call general surgery residents despite higher levels of fatigue, and Domínguez et al. (2009) and Hamui-Sutton et al. (2013) observed fewer errors in cognitive tests and CPR manoeuvres in residents after on-call duty. This paradox of improved execution might be explained by an increased motivation to execute tasks as efficiently as possible, even if cognitive processes were theoretically impaired by sleep deprivation (Ayas et al., 2006; Barger et al., 2005; Taffinder et al., 1998).

Additionally, it was postulated that alertness and task performance were impaired immediately in the first 2 hours of awakening due to sleep inertia, but these detrimental effects dissipate with time (Jewett et al., 1999). Post-call residents in our study might therefore have had a chance to recover by the time clinic started.

C. Strengths and Limitations

A particular strength of our study was that registrars who had post-call clinics surveyed also had a non-post-call clinic surveyed. This enabled them to act as controls for themselves and reduced potential bias that may be introduced as a result of differences in registrar demographics, such as age, gender and training experience. Second, there was a high patient participation rate in both the post-call group (97%) and non-post-call group (90%), with a high questionnaire return rate (99% in both groups). This increased the validity of our findings. Third, our study measured two different patient outcomes as a means of triangulation, and both were congruent in showing better outcomes in the post-call group. Fourth, we approached patients for their participation only after their clinic consultation, so as not to have influenced their interaction with the doctor. Fifth, patients were not informed if the registrar that they had just consulted was post-call or not, so as not to influence their questionnaire responses.

Nonetheless, being a single-centre study, caution should be exercised when attempting to generalise these findings to other healthcare settings. Second, only 8 of 18 eligible registrars in the department had clinics surveyed during the study period; thus the findings may not be reflective of the entire cohort. Third, there may have been factors outside the doctor-patient encounter that affected overall patient satisfaction, such as waiting times. Fourth, we did not quantify how busy each registrar’s on-call shift was and what amount of rest they obtained; the results might have been influenced by the amount of rest obtained. Fifth, we could not control for the complexity of the patients seen in the clinics; it is perceivable that a clinic with more straightforward patients would have been more easily managed by a fatigued registrar and vice versa.

For future studies, increasing cohort size of registrars over a longer period of time, and at more categories of call status (such as post-call, on-call and neither post- nor on-call) could improve the generalisability of the findings and reveal influences of call status on performance. In addition, incorporating qualitative data on registrars’ emotions and perceptions of their own performances in clinic would improve understanding of potential factors that may influence performance.

V. CONCLUSION

Our study showed that patient satisfaction and prescription error rates were not adversely affected when patients consulted a post-call registrar versus a non-post-call registrar in an outpatient clinic. This provides reassurance that the current practice of post-call trainee doctors running clinics is not harmful to patients. Complex interactions of associated positive and negative emotional factors could possibly compensate for any physical and mental tiredness. Impairment may be mitigated by adaptive effort to be conscientious. In our institution, no recommendations were made to change the current practice of registrars running post-call clinics. Ultimately, the relationship between being post-call with physician performance and patient outcomes remains poorly understood.

Notes on Contributors

Dr. Chin Chee Yang is a Consultant in Cardiology at the National Heart Centre Singapore and Clinical Assistant Professor at Duke-NUS Medical School. He has a Master of Science in Clinical Education. CCY designed and directed the study, implemented the research, data analysis and writing of the manuscript.

Dr. Tan Si Qi is a Medical Officer with the Ministry of Health Holdings, Singapore. TSQ contributed to the data analysis and writing of the manuscript.

Dr. Kui Swee Leng is a senior resident in Cardiology at Singhealth. She is an Adjunct Research Fellow with Singhealth Duke-NUS Cardiovascular Sciences Academic Clinical Programme (ACP) and Singhealth Associate in Education. KSL contributed to design and implementation of the research.

​Assistant Professor Kurugulasigamoney Gunasegaran is a Senior Consultant at the National Heart Centre Singapore. KG contributed to the design and overall supervision of the research.

Dr. Jill Cheng Sim Lee is a Consultant in Obstetrics and Gynaecology and Associate Programme Director to the SingHealth Obstetrics and Gynaecology Residency Programme. She has a Master of Science in Clinical Education. JCSL contributed to the design of the research and writing of the manuscript.

All authors have read and approved the final manuscript.

Ethical Approval

The study was categorised as an educational study hence formal Institutional Board Review (IRB) was exempted. We have attached the Local IRB Exception waiver document.

Funding

No funding source was utilised in this study. 

Declaration of Interest

Authors report no declaration of interest.

Data Availability

In our study, all raw data from questionnaires was collected on hard copies and not scanned into a repository. All other data are presented in the direct manuscript.

References

Ayas, N. T., Barger, L. K., Cade, B. E., Hashimoto, D. M., Rosner, B., Cronin, J. W., Speizer, F. E., & Czeisler, C. A. (2006). Extended work duration and the risk of self-reported percutaneous injuries in interns. Journal of the American Medical Association, 296(9), 1055–1062. https://doi.org/10.1001/jama.296.9.1055

Baldwin, K., Namdari, S., Donegan, D., Kamath, A. F., & Mehta, S. (2011). Early effects of resident work-hour restrictions on patient safety: A Systematic review and plea for improved studies. The Journal of Bone and Joint Surgery-American Volume, 93(2), e5(1)-e5(9). https://doi.org/10.2106/JBJS.J.00367

Barger, L. K., Cade, B. E., Ayas, N. T., Cronin, J. W., Rosner, B., Speizer, F. E., & Czeisler, C. A. (2005). Extended work shifts and the risk of motor vehicle crashes among interns. New England Journal of Medicine, 352(2), 125–134. https://doi.org/10.1056/NEJMoa041401

Benson, M., Grimes, I., Gopal, D., Reichelderfer, M., Soni, A., Benson, H., Austin, K., & Pfau, P. (2014). Influence of previous night call and sleep deprivation on screening colonoscopy quality. The American Journal of Gastroenterology, 109(8), 1133–1137. https://doi.org/10.1038/ajg.2014.28

Bertram, D. A. (1988). Characteristics of shifts and second-year resident performance in an emergency department. New York State Journal of Medicine, 88(1), 10–14.

Bolster, L., & Rourke, L. (2015). The Effect of Restricting Residents’ Duty hours on patient safety, resident well-being, and resident education: An updated systematic review. Journal of Graduate Medical Education, 7(3), 349–363. https://doi.org/10.4300/JGME-D-14-00612.1

Dawson, D., & Reid, K. (1997). Fatigue, alcohol and performance impairment. Nature, 388(6639), 235–235. https://doi.org/10.1038/40775

Domínguez, P., Grosso, M. L., Pagotto, B., Taliercio, V., & Allegri, R. (2009). Efectos de la privación de sueño en el desempeño de los médicos residentes de pediatría [Effects of sleep deprivation on medical performance of pediatric residents]. Archivos Argentinos De Pediatria, 107(3), 241–245.

Erdmann, T. R., Garcia, J. H. S., Loureiro, M. L., Monteiro, M. P., &amp; Brunharo, G. M. (2016). Profile of drug administration errors in anesthesia among anesthesiologists from Santa Catarina. Brazilian Journal of Anesthesiology (Elsevier), 66(1), 105–110. https://doi.org/10.1016/j.bjane.2014.06.011

Fletcher, K. E., Underwood, W., Davis, S. Q., Mangrulkar, R. S., McMahon, L. F., & Saint, S. (2005). Effects of work hour reduction on residents’ lives: A systematic review. Journal of the American Medical Association, 294(9), 1088–1100. https://doi.org/10.1001/jama.294.9.1088

Giordano, L. A., Elliott, M. N., Goldstein, E., Lehrman, W. G., & Spencer, P. A. (2009). Development, implementation, and public reporting of the HCAHPS survey. Medical Care Research and Review, 67(1), 27–37. https://doi.org/10.1177/1077558709341065

Goldstein, E., Farquhar, M., Crofton, C., Darby, C., & Garfinkel, S. (2005). Measuring hospital care from the patients’ perspective: An overview of the CAHPS® hospital survey development process: Measuring hospital care from the patients’ perspective. Health Services Research, 40(6p2), 1977–1995. https://doi.org/10.1111/j.1475-6773.2005.00477.x

Hamui-Sutton, L., Barragán-Pérez, V., Fuentes-García, R., Monsalvo-Obregón, E. C., & Fouilloux-Morales, C. (2013). Efectos de la privación de sueño en las habilidades cognitivas, psicomotoras y su relación con las características personales de los médicos residentes [Sleep deprivation effects on cognitive, psychomotor skills and its relationship with personal characteristics of resident doctors]. Cirugia Y Cirujanos, 81(4), 317–327.

Hanna, T. N., Loehfelm, T., Khosa, F., Rohatgi, S., & Johnson, J. (2016). Overnight shift work: factors contributing to diagnostic discrepancies. Emergency Radiology, 23(1), 41-47. https://doi.org/10.1007/s10140-015-1355-0

Hendey, G. W., Barth, B. E., & Soliz, T. (2005). Overnight and postcall errors in medication orders. Academic Emergency Medicine, 12(7), 629–634. https://doi.org/10.1197/j.aem.2005.02.009

Hoellein, A. R., Feddock, C. A., Griffith, C. H., Wilson, J. F., Barnett, D. R., Bass, P. F., & Caudill, T. S. (2004). Are continuity clinic patients less satisfied when the resident is postcall? Journal of General Internal Medicine, 19(5p2), 562–565. https://doi.org/10.1111/j.1525-1497.2004.30165.x

Jewett, M. E., Wyatt, J. K., Ritz-De Cecco, A., Khalsa, S. B., Dijk, D. J., & Czeisler, C. A. (1999). Time course of sleep inertia dissipation in human performance and alertness. Journal of Sleep Research, 8(1), 1–8. https://doi.org/10.1111/j.1365-2869.1999.00128.x

Keers, R. N., Williams, S. D., Cooke, J., & Ashcroft, D. M. (2013). Prevalence and nature of medication administration errors in health care settings: A Systematic review of direct observational evidence. Annals of Pharmacotherapy, 47(2), 237–256. https://doi.org/10.1345/aph.1R147

Landrigan, C. P., Rothschild, J. M., Cronin, J. W., Kaushal, R., Burdick, E., Katz, J. T., Lilly, C. M., Stone, P. H., Lockley, S. W., Bates, D. W., & Czeisler, C. A. (2004). Effect of reducing interns’ work hours on serious medical errors in intensive care units. New England Journal of Medicine, 351(18), 1838–1848. https://doi.org/10.1056/NEJMoa041406

Lee, J. C. S., Kee, X. L. J., Wiener-Ogilvie, S., Chern, B. S. M., & Chin, C. Y. (2019). What drives attrition amongst obstetrics and gynaecology residents in Singapore. The Asia Pacific Scholar, 4(1), 34–41. https://doi.org/10.29060/TAPS.2019-4-1/OA2005

Liu, C.-C., & Wissow, L. (2011). How post-call resident doctors perform, feel and are perceived in out-patient clinics: Post-call residents seeing outpatients. Medical Education, 45(7), 669–677. https://doi.org/10.1111/j.1365-2923.2010.03912.x

Lobo, A. S., Sandoval, Y., Burke, M. N., Sorajja, P., Mooney, M., Traverse, J., Henry, T. D., Chavez, I., Gössl, M., Lips, D. L., Bradley, S. M., Poulose, A., Wang, Y., & Brilakis, E. S. (2019). Sleep deprivation in cardiology: A multidisciplinary survey. The Journal of Invasive Cardiology, 31(6), 195–198.

Mustafa, M., Erokwu, N., Ebose, I., & Strohl, K. (2005). Sleep problems and the risk for sleep disorders in an outpatient veteran population. Sleep and Breathing, 9(2), 57–63. https://doi.org/10.1007/s11325-005-0016-z

Robison, W., Patel, S. K., Mehta, A., Senkowski, T., Allen, J., Shaw, E., & Senkowski, C. K. (2018). Can fatigue affect acquisition of new surgical skills? A prospective trial of pre- and post-call general surgery residents using the da Vinci surgical skills simulator. Surgical Endoscopy, 32(3), 1389–1396. https://doi.org/10.1007/s00464-017-5820-6

Rosenbaum, L., & Lamas, D. (2012). Residents’ Duty hours — Toward an empirical narrative. New England Journal of Medicine, 367(21), 2044–2049. https://doi.org/10.1056/NEJMsr1210160

Saadat, H., Bissonnette, B., Tumin, D., Thung, A., Rice, J., Barry, N., & Tobias, J. (2016). Time to talk about work-hour impact on anesthesiologists: The effects of sleep deprivation on Profile of Mood States and cognitive tasks. Pediatric Anesthesia, 26(1), 66–71. https://doi.org/10.1111/pan.12809

Samkoff, J. S., & Jacques, C. H. (1991). A review of studies concerning effects of sleep deprivation and fatigue on residents’ performance. Academic Medicine, 66(11), 687–693. https://doi.org/10.1097/00001888-199111000-00013

Taffinder, N., McManus, I., Gul, Y., Russell, R., & Darzi, A. (1998). Effect of sleep deprivation on surgeons’ dexterity on laparoscopy simulator. The Lancet, 352(9135), 1191. https://doi.org/10.1016/S0140-6736(98)00034-8

Tully, M. P., Ashcroft, D. M., Dornan, T., Lewis, P. J., Taylor, D., & Wass, V. (2009). The causes of and factors associated with prescribing errors in hospital inpatients: A Systematic Review. Drug Safety, 32(10), 819–836. https://doi.org/10.2165/11316560-000000000-00000

Yi, W. S., Hafiz, S., & Sava, J. A. (2013). Effects of night-float and 24-h call on resident psychomotor performance. Journal of Surgical Research, 184(1), 49–53. https://doi.org/10.1016/j.jss.2013.03.029

*Chin Chee Yang
National Heart Centre Singapore
5 Hospital Drive, Singapore 169609
Tel: +65 6704 8962
E-mail: chin.chee.yang@singhealth.com.sg

Submitted: 18 October 2020
Accepted: 1 March 2021
Published online: 5 October, TAPS 2021, 6(4), 17-25
https://doi.org/10.29060/TAPS.2021-6-4/OA2418

Xin Rong Goh¹, Chee Wai Ku^2,4, Rajeswari Kathirvel^1,2,4,5 & Kok Hian Tan^1,3,4

¹Lee Kong Chian School of Medicine, Nanyang Technological University, Singapore; ²Department of Obstetrics and Gynaecology, KK Women’s & Children’s Hospital, Singapore; ³Department of Maternal Fetal Medicine, KK Women’s & Children’s Hospital, Singapore; ⁴Duke-NUS Medical School, Singapore; ⁵Yong Loo Lin School of Medicine, National University of Singapore, Singapore

Abstract

Introduction: Disease outbreaks (DO) result in unprecedented changes to the healthcare industry with far-reaching implications for medical education. The need to adapt to the fluidity during DO requires the delivery of the clinical medical curriculum to be flexible and effective. There is a lack of well-established guidelines on how medical education should be delivered during DO. This study aimed to explore the efficacy of teleconferencing-based platforms (TBP) as a teaching modality to overcome the challenges of clinical year medical education amidst a global pandemic and possibility of its use when there are no disease outbreaks (NDO).

Methods: A cross-sectional survey amongst 144 undergraduate clinical year students from a medical school in Singapore was conducted from May to June 2020, to explore their perspectives on TBP compared to physical venue-based platforms (PVBP). The survey consisted 5-point Likert scale and open-ended questions. Statistical and thematic analyses were performed.

Results: TBP provides greater convenience in travelling, note-taking and ability to overcome administrative challenges. Students strongly recommended its use in DO and NDO. However, students faced increased distractibility, decreased engagement and ease of raising questions, with a lower efficacy in content delivery. The above is dependent on the type of lessons delivered – clinical skills-based or didactic sessions.

Conclusion: TBP is a promising teaching modality for DO with promising possibility of extending its use to NDO. We propose a tri-faceted approach to target improvement in content delivery on TBP, mainly with measures to target propensity for decreased engagement and increased distractibility and to address the technology-related concerns.

Keywords:           Medical Education, Teleconferencing, Teaching Modalities, Medical Students, COVID-19, Disease Outbreaks, Pandemics

Practice Highlights

• TBP was strongly recommended as substitute teaching modality during disease outbreaks.
• Students recommended TBP as a supplement for teaching even when there are no disease outbreaks.
• TBP enabled more convenience in travelling, note-taking and overcoming administrative challenges.
• Decreased engagement and increased distractibility noted when sessions are conducted on TBP.
• TBP can be improved via use of teaching aids and contextualising it to the lesson type.

I. INTRODUCTION

Singapore has experienced the escalation of its Disease Outbreak Response System Condition (DORSCON) status to ‘Orange’ due to COVID-19 outbreak on 7th February 2020. This has had significant implications in multiple sectors of the healthcare industry, including that of medical education (Samarasekera, Goh & Lau, 2020). It called for the rapid remodelling of the delivery of the medical education curriculum during a time when social containment and avoidance of large groups gatherings were enforced (Samarasekera & Gwee, 2021). In particular, to contain and prevent the spread of COVID-19, clinical rotations in healthcare institutions were temporarily suspended during the DORSCON Orange period (Chandratre, 2020; Samarasekera, Goh, Yeo et al., 2020).

Many institutions had since employed teleconferencing-based platforms (TBP) to deliver curriculum (Kanneganti et al., 2020; Srinivasan, 2020). TBP is defined as an avenue of e-learning that is ‘internet and local-networking based’ (Al-Shorbaji et al., 2015), enabling the provision of ‘synchronous’ (Dhir et al., 2017) real time audio-visual online interactions across different locations (Lamba, 2011). The literature exploring the use of TBP during DO is limited. Most studies on TBP focused on its use when there are no disease outbreaks (NDO). They described its facilitation of direct teacher-student engagement with quieter students (Fox, 2004) and raised its comparable effectiveness in fulfilling learning outcomes to traditional face-to-face lectures (Bertsch et al., 2007). TBP nonetheless faces deterrents to its implementation, including those of financial implications (Lim et al., 2009) and technical difficulties (Boatin et al., 2015; Lamba, 2011). During DO, it had helped to overcome concerns of social distancing and allowed the continuation of medical training (Kanneganti et al., 2020; Lim et al., 2009).

In spite of the above, it should be recognised that the temporary suspension of clinical rotations represent the absence of a cornerstone in delivery of the medical curriculum (Govindarajan et al., 2018; Jacobs & Samarasekera, 2012; Lim et al., 2009; Rawekar et al., 2016). This study thus chose to specifically focus on the clinical year students owing to the potential application of these findings to post-graduate clinical trainings. Furthermore, the different content and focus during the pre-clinical years (e.g. lack of clinical rotations, presence of anatomy and science practical) would likely raise concerns that are unique and non-generalisable to students in the clinical years. Pre-clinical students were therefor excluded from the current study.

While the use of TBP is largely commended (Fatani, 2020), it is pertinent to compare its efficacy to traditional physical venues-based platforms (PVBP) as a potential replacement or supplement for the delivery of the clinical curriculum during DO. This study aims to understand the ground-up perspective of clinical year students on TBP as an education tool during DO, as compared to PVBP. It also explored TBP’s suitability and effectiveness for the delivery of the undergraduate medical education when there are no disease outbreaks (NDO).

II. METHODS

A. Ethics Review

The following study was approved by NTU Institutional Review Board (IRB Reference number: 2020-05-003) with an exempt status.

B. Survey Design and Study Population

All undergraduate clinical year medical students from the Lee Kong Chian School of Medicine who had used teleconferencing as a part of their curriculum were invited to participate in an online survey via email and social-messaging platform that included an explanation of the study’s details. Informed consent was implied when the participant accessed the online survey administered via SurveyMonkey^Ó platform. Personal identifiers were not collected.

The cross-sectional survey consisted of a mix of 5-point Likert scale questions and open-ended questions. It was anticipated to be completed in 10 minutes. The questions were designed to evaluate their familiarity with teleconferencing and their opinions on teleconferencing as an educational tool as compared to physical venue-based sessions, e.g. traditional lectures, bedside and small group tutorials, and team-based learning. Their willingness to extend teleconferencing as a supplementary delivery tool for medical education in both DO and NDO situations were also explored.

The survey questions were developed de-novo with reference to the existing literature. The themes of platform accessibility and ease of raising questions were adapted from Al-Neklawy (2017) while that of engagement and distractibility were adapted from the Danielson’s Framework for Teaching – The classroom environment (Alvarez & Anderson-Ketchmark, 2011). The survey was then piloted amongst a group of medical students and faculty to assess content and face validity.

C. Statistical Analysis

Self-reported estimates on the number of prior use of teleconferencing were divided by 52 to determine weekly usage. Numerical values were awarded for the 5-point Likert scale as follows: Strongly agree (5), agree (4), neutral (3), disagree (2) and strongly disagree (1).

Paired 2 tailed T test was performed to determine the significance of difference in subjective efficacy of PVBP and TBP. To compare effect of gender on subjective efficacy for the two platforms and recommendations for TBP, independent T test and Fisher’s exact test were performed respectively. Pearson Correlation testing was performed to look for correlations between the variables. Kruskal-Wallis H test was used to study the effect of year of study on the responses. A p value of < 0.05 indicated statistical significance. Data analysis was performed using SPSS^TM software (V.24.0).

D. Qualitative Analysis

Thematic analysis was performed for the elaborations and justifications provided by survey respondents. Concepts that were similar were used to guide the development of themes.

III. RESULTS

A. Sociodemographic Characteristics

A total of 144 out of 315 clinical year medical students completed the survey over a 3-week period from May to June 2020 (Year 3: n = 51; Year 4: n = 64; Year 5: n = 29).  The survey response rate was 45.7%. Majority of students who responded were female (58.3%) and Year 4 (44.4%).

B. Teleconferencing Usage Patterns

Majority (73.6%) of students had used a teleconferencing platform, for educational and non-education purposes, in the past year prior to declaration of DORSCON Orange. The top three teleconferencing platforms by corrected mean weekly usage prior to DORSCON orange were Skype^© (0.2), FaceTime^© (0.2) and ZOOM^© (0.1). During DOSRCON orange, the top three platforms for educational purposes by corrected mean weekly usage were ZOOM^© (4.0), Skype^© (0.3), Facetime^© (0.1). (Table 1)

Table 1. Use of teleconferencing-based platforms by medical students

Corrected weekly usage was calculated as follows: (A) Total usage divided by 52, (B) Total usage divided by number of weeks from declaration of DOSRSCON orange to point of survey (For example: 1 week + 1 day would be considered as 2 weeks)

Others included: Whatsapp©, Microsoft Teams©, Google Hangouts©, WebEx©, Discord©, Houseparty©

Table 2: Comparison of subjective efficacy of physical venue-based vs teleconferencing based platforms by clinical year medical students surveyed from May to June 2020 on a 5-point Likert Scale

Numerical values were assigned as follows: Strongly disagree (1), Disagree (2), Neutral (3), Agree (4), Strongly agree (5)

D. Correlations Between Responses

Based on Pearson’s correlation, students who were engaged on PVBP, tend to be more comfortable in raising questions (r = 0.301, p <0.001) and less distracted (r = -0.337, p <0.001) with PVBP. Similarly, students who felt engaged on TBP tend to feel comfortable in raising questions on TBP (r = 0.301, p <0.001), less distracted (r = – 0.353, p <0.001) and agree on its efficacy in content delivery (r = 0.570, p <0.001).  Students who felt more distracted on PVBP tend to also be more distracted on TBP (r = 0.176, p <0.05). No significant correlations were found between prior teleconferencing experience on self-reported rating of PVBP and TBP.

Kruskal-Wallis H test showed a statistically significant difference in rating of convenience for TBP between different years of study (χ2 (2) = 18.1, p <0.001, mean (Year 3) 87.1, (Year 4) 69.8, (Year 5) 53.0). There were no statistically significant effects of gender on the responses.

E. Recommendations of Teleconferencing Platform

An overwhelming majority of students recommended use of TBP in DO (n = 143, 99.3%), 54.9% (n = 79) recommended it as a substitute, and 44.4% (n = 64) as a supplement for learning, whereas one student did not recommend it at all. A significant proportion continued to favour its use even during NDO (n = 121, 84.0%), although there was a slight shift in preference for it to be used as a supplement (Supplement: n = 108, 75%; Substitute: n = 13, 9.0%). (Table 3A)

There were no statistically significant effects of gender or year of study on the responses.

Table 3. Recommendations and suggested improvements for use of teleconferencing platforms during disease and non-disease outbreak situations by clinical year medical students surveyed from May to June 2020

N refers to the total number of elaborations provided for each type of recommendations, of which percentage (%) calculated reflects the percentage of respondents who raised a particular theme in their elaborations. n refers to the number of times the theme appeared per respondent.

Representative elaborations were quoted and tagged by the respondent’s demographic (Recommendation, Year of Study, Gender)

F. Qualitative Analysis

Thematic analyses revealed 10 main areas of discussion. These were categorised into three main themes that were common for both DO and NDO: convenience, content delivery and context of lesson (Table 3B). For the analysis for DO recommendations, a new theme materialised: Pandemic-specific considerations. Suggestions for improvements of TBP mainly fell into 3 categories – enhanced use of TBP teaching aids, ZOOM^© fatigue and connectivity and technological concerns.

1) Convenience: Students indicated that TBP reduced their need to travel to teaching destinations, thereby saving on expenditure and time. This was especially useful when they were scheduled with a full day of lectures that did not require any clinical setting training, and during the exam period. For example, one student reported, “I value the time saved on travelling… more than the increased concentration and engagement of a face-to-face tutorial, given that exams are looming.” (Year 4, Female)

The ability to stream these sessions from home was advantageous as students could take additional measures to help sustain their attention, including the ease of taking refreshment breaks. Students valued the ease of taking notes as elaborated by one student as “easier to take screenshots of the slides so we don’t waste time copying the points.” (Year 5, Female)

Students noted TBP to be more convenient in arranging lectures across institutions. Specific to NDO, TBP was suggested as a potential mean to allow “teaching very large groups of people… combined stream classes” (Year 3, Male) and across medical schools. TBP also offered flexible scheduling arrangements. Examples included situations where participants are “feeling unwell but are worried about missing class” (Year 3, Female), “tutors with very busy or unpredictable schedules… which would require students to meet at odd or inconvenient timings” (Year 4, Male), hence minimising need for students to “stay back” (Year 5, Female) in the late evening.

2) Content delivery: Students discussed how triadic interactions between tutors and students, and amongst themselves were better afforded on PVBP. Nuances of social cues like facial expressions were cited as potentially beneficial for tutors to gauge students’ engagements. One student shared that “the tutor can gauge whether or not the content is appropriate based on the body language/facial expressions of the students which may be hard to do so on an online platform.” (Year 5, Female) Students also noted how TBP changed the nature of social interactions, making participants “less likely to speak up or participate… [with] the tutor [feeling] more distant.” (Year 4, Female)

The interactions between students as a reinforcement for learning surfaced as a crucial component. As one student shared, PVBP gave the “chance for the team to meet and learn from each other… quizzing each other, clarifying doubts, or sharing fun facts and important information [that]… cannot be done over teleconferencing.” (Year 3, Female)

Students reported that it was harder to stay focused during TBP sessions as one was in a “more comfortable location with no one monitoring your movements and actions” (Year 3, Male), unable to see the tutor in person and may have concomitant activities surrounding them. The implications of such distractibility were noted that TBP made it easier “to hide away and therefore not be present.” (Year 4, Female)

3) Context of lesson: Students felt their subjective assessment of TBP versus PVBP should factor in the type of lessons being delivered. It was unanimous that clinical-based teachings required use of PVBP to develop soft skills and appreciate clinical signs. To illustrate, one student shared, “medicine is an apprenticeship – there are many skills that cannot be learnt theoretically but must be observed in a clinical setting… Physical sessions are still very important to teach such skills, and should proceed with adequate safety measures in place. Otherwise, we will become doctors with good theoretical knowledge but poor practical/people skills” (Year 5, Female). However, many agreed that didactic lectures which involved pure unidirectional delivery of content could be suitably delivered over TBP as “lecturer… can still speak and present slides as usual.” (Year 3, Male)

4) Pandemic specific considerations: Students acknowledged the risk-benefit ratio of disease transmission and accommodation for the schedule of clinical tutors. One student summarised, “Additional benefits gained through physical venue-based outweighed by risks of disease transmission due to physical interaction.” (Year 3, Male) TBP was hence considered to be a safe and only suitable alternative to ensure continuity of curriculum delivery during DO.

5) Identified areas of improvement: Students raised suggestions to overcome the drawbacks of TBP in 3 main domains. Firstly, they recommended the enhanced used of teaching aids to increase engagement peer-peer interactions. Secondly, they raised the phenomenon of “ZOOM^© fatigue” and the need to manage scheduling of tutorials. For example, one student shared, “People seem to think that online lectures are less mentally taxing since you’re at home, and proceed to pack the entire day full of lectures for couple weeks on end… there is no time to consolidate knowledge especially in the absence of opportunity to apply in a clinical setting.” (Year 4, Male) Hence, students suggested tutors to avoid “bombarding students with back-to-back tutorials, leading to information overload” (Year 4, Female) and decrease the maximum time per day to less than 4-5 hours. The inclusion of breaks between sessions as a mental break since tutors who are “swapping in… would not know if students are still engaged or fatigued.” (Year 4, Male)

Lastly, presence of poor connectivity contributed to streaming lags, with negative implications on students “concentration and ability to follow the lecture.” (Year 4, Female) The possibility of increasing tutors’ familiarity with the platform was cited to have facilitated a smoother conduct of lessons.

IV. DISCUSSION

A. Summary of Results

An overwhelming majority of students recommended the continued use of TBP during both DO and NDO. This is most likely due to the increased convenience in travelling, taking down notes, overcoming administrative challenges, and its suitable replacement for didactic lectures. The student’s perception of convenience of TBP correlated to the year of study, with the earlier clinical year students finding it more convenient than the final year students. Nevertheless, this should be evaluated against the background that end users range from enthusiastic ‘technophiles’ to ‘technophobes’, which influences the receptiveness towards e-learning platforms (Bruce, 1997; Fox, 2004).

Specifically during DO, it was viewed to be the best available alternative when considering the disease transmission risk and the busy schedules of the clinical tutors as they may have new responsibilities as front-liners in pandemics (Branch et al., 1997; Cook, 2006; Goh, 2020; Harden & Crosby, 2000; Ramani & Leinster, 2008).

The shift in preference of use of TBP as a substitute to supplement during NDO was noticeable. This can be due to many factors. There is a decreased engagement due to the reduced ability of tutors to assess nuances of social cues (Fox, 2004),  greater distractibility and decreased ease of raising questions on TBP. Notably, peer-peer interaction is lost over TBP. Each student’s interaction is multidirectional: student with resource materials, with educator, and between students (Dhir et al., 2017). The value of such interactions and study groups in medical education should be duly taken into consideration (Burgess et al., 2014). Poorer engagement were further compounded by challenges with technology-related concerns and risks of “ZOOM^© fatigue”.

Distractibility on TBP could be due to learning in a non-classroom environment (Fox, 2004) with a device that could also be used for non-educational purposes (Walsh, 2015). “ZOOM^©  fatigue” was likely due to lack of pre-fixed maximal time duration and the tendency for tutors to over-deliver and pile extra study materials (Fox, 2004)  causing student’s to “feel tired and restless” (Srinivasan, 2020).

Interestingly, students’ innate personality and learning attitudes potentially influenced their perceptions of PVBP and TBP. Students who were more engaged on a platform, also felt more comfortable raising questions, were less distracted and believed that the platform was efficacious in delivering content. This demonstrates the difference between the “active and engaged learners” and the majority who are “silent lurkers (Fox, 2004).  Similarly, students who felt more distracted on PVBP appeared to also be more distracted on TBP.

B. Recommendations

TBP as a teaching modality has an indisputable role during both DO and NDO. It is well-established that medical students experience significant psychological impact during DO (AlAteeq et al., 2020; Ullah & Amin, 2020), possibly related concerns on the impact of their studies (Lyons et al., 2020). Hence with the increased use of TBP, it is imperative that medical educators develop a deeper understanding on the potential short-comings of the platform and how best to maximise its utility as a teaching modality.

Nonetheless, it is vital to recognise that the efficacy of any new education tool depends on both educators and students. It would be better facilitated if the end user is familiar with the platform. It should be considered in light of its application and configuration (Cook, 2006) and ideally be managed and monitored by trained staff (Dhir et al., 2017; Harden, 2018). Moving forward, we recommend a tri-faceted approach to improve the content delivery of TBP during both DO and NDO (Figure 1).

Figure 1. Correlation of domains assessed for efficacy of teleconferencing-based platforms (TBP) with themes identified and suggestions to improve content delivery on TBP

1) Domain 1: Contextual use of TBP: Disease outbreak situations:

• Where physical appreciation of clinical skills through bedside tutorial or real-life clinical interactions might not be feasible, consider use of media and standardised patients to simulate clinical exposure.
• The supplemental use of standardised patients (Peters & Thrien, 2020) hones student’s clinical competence while facilitating the training of relevant skills needed for future practice (Khoo et al., 2020), a notable example in these evolving recent times also includes that of telemedicine (Williams & Song, 2016).

No disease outbreak situations

• TBP should mainly be used for didactic or team-based learning sessions, large group teaching sessions and for students who are unable to physically attend the lecture.

2) Domain 2: Targeting decreased engagement and increased distractibility:

• Use of multi-modal teaching aids, e.g. virtual quizzes, breakout rooms for small group engagement, drawing functions to better visually illustrate explanations.
• Monitoring of students’ current fatigue level in session via live polls at regular hourly intervals.
• Engagement of a central coordinator to regulate the maximum hours of online sessions per day, with considerations of suitable breaks between sessions.
• Prior assessment of student’s learning attitudes and class dynamics to enable tailored use of teaching aids.

3) Domain 3: Smoothening transition to TBP:

• Engagement of central coordinator to brief tutors on the functionality of TBP of choice to minimise technology unfamiliarity and maximise its utility in conducting sessions.
• Educational institutions to consider providing infrastructural support to students and educators, including dedicated spaces, electronic devices with internet connections, and easy access to technical support. These would help minimise network connectivity challenges and providing a conducive study environment for those who might face difficulties accessing TBP off-campus.
• Selective use of TBP as a supplement during NDO to increase both students and educator’s familiarity with the platform and as a learning tool, thereby enabling a smoother transition during DO.

C. Limitations

Our study has few limitations. We surveyed clinical year students from a single medical school and therefore, our study may not reflect the views of students from other medical schools with different teaching pedagogies and those of pre-clinical year students. Future studies should consider exploring the opinions of clinical tutors on PVBP and TBP and their perspective as educators in delivering such curriculum. In addition, given our limited sample size, some statistically significant sub-group patterns may not have been evident.

V. CONCLUSION

TBP is an important teaching modality during DO and NDO, especially with its increased convenience. However, it has certain issues including context-specific use, decreased engagement, increased distractibility and technological challenges. Our proposed potential interventions may help to maximise its utility and facilitate transition of its use in subsequent DO.

Notes on Contributors

Xin Rong Goh designed the study, recruited the participants, administered the survey, analysed the data and wrote the first and subsequent drafts of the manuscript. Rajeswari Kathirvel and Chee Wai Ku contributed to analysis of the data and writing of the manuscript. Kok Hian Tan contributed to the study design and reviewed the manuscript. All authors have read and approved the final manuscript.

Ethical Approval

The following study was approved by NTU Institutional Review Board (IRB Reference number: 2020-05-003) with an exempt status. 

Data Availability

The ethical approval by NTU Institutional Review Board was based on the conditions that while the data is deidentified data, only study team members will have access to the raw data that will be stored on a password protected PC. The data could thus not be uploaded on a public data sharing platform.

Acknowledgement

The authors acknowledge Dr Joel Shi Quan Tan, Yong Loo Lin School of Medicine, National University of Singapore, for his contribution to the statistical analysis of the paper. 

Funding

No funding sources was used for this research study. 

Declaration of Interest

The authors have no conflicts of interest to declare.

References

AlAteeq, D. A., Aljhani, S., & AlEesa, D. (2020). Perceived stress among students in virtual classrooms during the COVID-19 outbreak in KSA. Journal of Taibah University Medical Sciences, 15(5), 398–403. https://doi.org/10.1016/j.jtumed.2020.07.004

Al-Neklawy, A. F. (2017). Online embryology teaching using learning management systems appears to be a successful additional learning tool among Egyptian medical students. Annals of Anatomy, 214, 9–14. https://doi.org/10.1016/j.aanat.2017.07.001

Al-Shorbaji, N., Atun, R., Car, J., Majeed, A., & Wheeler, E. (2015). eLearning health professional for undergraduate education. World Health Organistion. https://www.who.int/hrh/documents/14126-eLearningReport.pdf

Alvarez, M. E., & Anderson-Ketchmark, C. (2011). Danielson’s framework for teaching. Children and Schools, 33(1), 61–63. https://doi.org/10.1093/cs/33.1.61

Bertsch, T. F., Callas, P. W., Rubin, A., Caputo, M. P., & Ricci, M. A. (2007). Applied research: Effectiveness of lectures attended via interactive video conferencing versus in-person in preparing third-year internal medicine clerkship students for clinical practice examinations (CPX). Teaching and Learning in Medicine, 19(1), 4–8. https://doi.org/10.1080/10401330709336616

Boatin, A., Ngonzi, J., Bradford, L., Wylie, B., & Goodman, A. (2015). Teaching by teleconference: A model for distance medical education across two continents HHS public access. Open Journal of Obstetrics and Gynecology, 5(13), 754–761. https://doi.org/10.4236/ojog.2015.513106

Branch, W. T., Kroenke, K., & Levinson, W. (1997). The clinician-educator – Present and future roles. Journal of General Internal Medicine, 12(Suppl. 2), 1–4. https://doi.org/10.1046/j.1525-1497.12.s2.16.x

Bruce, B. C. (1997). Literacy technologies: What stance should we take? Journal of Literacy Research, 29(2), 289–309.

Burgess, A., McGregor, D., & Mellis, C. (2014). Medical students as peer tutors: A systematic review. BMC Medical Education, 14,115. https://doi.org/10.1186/1472-6920-14-115

Chandratre, S. (2020). Medical students and COVID-19: Challenges and supportive strategies. Journal of Medical Education and Curricular Development, 7. https://doi.org/10.1177/2382120520935059

Cook, D. A. (2006). Where are we with web-based learning in medical education? Medical Teacher, 28(7), 594–598. https://doi.org/10.1080/01421590601028854

Dhir, S. K., Verma, D., Batta, M., & Mishra, D. (2017). E-learning in medical education in India. Indian Pediatrics, 54(10), 871–877. https://doi.org/10.1007/s13312-017-1152-9

Fatani, T. H. (2020). Student satisfaction with videoconferencing teaching quality during the COVID-19 pandemic. BMC Medical Education, 20(1), 396. https://doi.org/10.1186/s12909-020-02310-2

Fox, R. (2004, December). SARS epidemic: Teachers’ experiences using ICTs. In R. Atkinson., C. McBeath., D. Jonas-Dwyer. & R. Phillips (Eds.), Beyond the comfort zone: Proceedings of the 21st Annual Conference of the Australasian Society for Computers in Learning in Tertiary Education (ASCILITE) (pp. 319-327). Australasian Society for Computers in Learning in Tertiary Education. http://www.ascilite.org.au/conferences/perth04/procs/fox.html

Goh, C. T. (2020, May 3). COVID-19: Guarding against burnout, compassion fatigue and trauma in frontline healthcare workers. Channel News Asia. https://www.channelnewsasia.com/news/singapore/covid-19-guarding-against-burnout-trauma-ttsh-ncid-frontline-12669280

Govindarajan, S., Vasanth, G., Kumar, P. A., Priyadarshini, C., Radhakrishnan, S. S., Kanagaraj, V., Balasubramanian, N., Kumar, P. N., Divya, T. J., & Aishwarya, C. N. (2018). Impact of a comprehensive early clinical exposure program for preclinical year medical students. Health Professions Education, 4(2), 133–138. https://doi.org/10.1016/j.hpe.2017.06.002

Harden, R. M. (2018). Medical teacher E-learning-caged bird or soaring eagle? Medical Teacher, 30(1), 1–4. https://doi.org/10.1080/01421590801938878

Harden, R. M., & Crosby, J. (2000). AMEE guide no 20: The good teacher is more than a lecturer – The twelve roles of the teacher. Medical Teacher, 22(4), 334–347. https://doi.org/10.1080/014215900409429

Jacobs, J. L., & Samarasekera, D. D. (2012). How we put into practice the principles of embedding medical students into healthcare teams. Medical Teacher, 34(12), 1008–1011. https://doi.org/10.3109/0142159X.2012.731097

Kanneganti, A., Sia, C.-H., Ashokka, B., & Ooi, S. B. S. (2020). Continuing medical education during a pandemic: An academic institution’s experience. Postgraduate Medical Journal, 96, 384- 386. https://doi.org/10.1136/postgradmedj-2020-137840

Khoo, S. A., Aswin, W., Shen, G. Q. Y., Haq, H. M., Junaidah, B., Yiew, J. L., Abiramy, M., & Sashikumar, G. (2020). Improving provider-patient communication skills among doctors and nurses in the children’s emergency department. The Asia Pacific Scholar, 5(3), 28–41. https://doi.org/10.29060/TAPS.2020-5-3/OA2160

Lim, E. C. H., Oh, V. M. S., Koh, D. R., & Seet, R. C. S. (2009). The challenges of “continuing medical education” in a pandemic era. Annals of the Academy of Medicine Singapore, 38(8), 724–726.

Lyons, Z., Wilcox, H., Leung, L., & Dearsley, O. (2020). COVID-19 and the mental well-being of Australian medical students: Impact, concerns and coping strategies used. Australasian Psychiatry, 28(6), 649–652. https://doi.org/10.1177/1039856220947945

Lamba, P. (2011). Teleconferencing in medical education: A useful tool. Australasian Medical Journal, 4(8), 442–447. https://doi.org/10.4066/AMJ.2011.823

Peters, T., & Thrien, C. (2020). The digital use of simulated patients in times of the corona pandemic – Considerations and proposals. GMS Journal for Medical Education, 37(7), Doc 93. https://doi.org/10.3205/zma001386

Ramani, S., & Leinster, S. (2008). AMEE guide no. 34: Teaching in the clinical environment. Medical Teacher, 30(4), 347–364. https://doi.org/10.1080/01421590802061613

Rawekar, A., Jagzape, A., Srivastava, T., & Gotarkar, S. (2016). Skill learning through early clinical exposure: An experience of Indian medical school. Journal of Clinical and Diagnostic Research, 10(1), JC01–JC04. https://doi.org/10.7860/JCDR/2016/17101.7022

Samarasekera, D. D., Goh, D. L. M., & Lau, T. C. (2020). Medical school approach to manage the current COVID-19 crisis. Academic Medicine, 95(8), 1126–1127. https://doi.org/10.1097/ACM.0000000000003425

Samarasekera, D. D., Goh, D. L. M., Yeo, S. P., Ngiam, N. S. P., Aw, M. M., Lim, M. M., Pillai, S., Lee, S. S., Mahadevan, M., Kow, A., Chong, Y. S., & Lau, T. C. (2020). Response and lessons learnt managing the covid-19 crisis by school of medicine, National University of Singapore. MedEdPublish, 9(1), 92, https://doi.org/10.15694/mep.2020.000092.1

Samarasekera, D. D., & Gwee, M. C. E. (2021). Adapting to change during challenging times. The Asia Pacific Scholar, 6(1), 1-2. https://doi.org/10.29060/TAPS.2021-6-1/EV6N1

Srinivasan, D. K. (2020). Medical students’ perceptions and an anatomy teacher’s personal crisis experience using an e-learning platform for tutorials during the Covid-19 crisis. Anatomical Sciences Education, 13(3), 318-319. https://doi.org/10.1002/ase.1970

Ullah, R., & Amin, S. (2020). The psychological impact of COVID-19 on medical students [Letter]. Psychiatry Research, 288, 113020. https://doi.org/10.1016/j.psychres.2020.113020

Walsh, K. (2015). Mobile learning in medical education: Review. Ethiopian Journal of Health Sciences, 25(4), 363–366. https://doi.org/10.4314/ejhs.v25i4.10

Williams, B., & Song, J. J. Y. (2016). Are simulated patients effective in facilitating development of clinical competence for healthcare students? A scoping review. Advances in Simulation (London, England), 1, 6. https://doi.org/10.1186/s41077-016-0006-1

*Goh Xin Rong
11 Mandalay Road,
Singapore 308232
Email: xinronggoh@yahoo.com.sg

Submitted: 26 September 2020
Accepted: 1 March 2021
Published online: 5 October, TAPS 2021, 6(4), 7-16
https://doi.org/10.29060/TAPS.2021-6-4/OA2415

Rasika Manori Jayasinghe¹, Indika Priyanthi Thilakumara¹, Bandara Dhanushka Leuke², Gishan Edirisinghe³, Manil Christopher Nishan Fonseka³, Manjula Attygalla⁴ & Ruwan Duminda Jayasinghe²

¹Department of Prosthetic Dentistry, Faculty of Dental Sciences, University of Peradeniya, Sri Lanka; ²Department of Oral Medicine and Periodontology, Faculty of Dental Sciences, University of Peradeniya, Sri Lanka; ³Department of Restorative Dentistry, Faculty of Dental Sciences, University of Peradeniya, Sri Lanka; ⁴Department of Oral Surgery, Faculty of Dental Sciences, University of Peradeniya, Sri Lanka

Abstract

Introduction: E-learning resulted in a revolution in dental education with continuous educational experiences. General objective of this study was to assess the perspective of undergraduate dental students on effectiveness of e-learning in the Bachelor of Dental Surgery (BDS) programme. Specific objectives were to identify students’ opinion on the factors that promote e-learning, awareness on the effectiveness of using different platforms and social media, barriers imposed and suggestions for the improvement of e-learning in the BDS programme.

Methods: This was a cross sectional descriptive study among undergraduate dental students of the Faculty of Dental Sciences, University of Peradeniya, Sri Lanka using a self-administered pre-tested questionnaire administered via a web-based survey form. Frequencies and percentages were obtained for categorical data and Chi-square test was used to determine the association between variables.

Results: The majority received the e-learning experience well. Fifty-four percent of the participants felt it was better compared to traditional face-to-face learning and the difference between the semesters (p=0.000) and genders was statistically significant (p=0.000). Difference in overall satisfaction on e-learning material across the different semesters was statistically significant. Students felt that e-learning should be used as a supplementary tool mainly by means of procedural videos during delivery of the skill component. Fifty percent participants felt that conducting assessments online is fair for all the students.

Conclusion: A positive learning experience was achieved through the e-learning modalities in comparison to traditional face-to-face learning though in terms of skills training, e-learning modalities should only be considered as a supplementary tool.

Keywords:           E-Learning, Perspective, Dental Undergraduates, Dental Education

Practice Highlights

• Majority felt e-learning was better compared to traditional face-to-face learning.
• Majority were satisfied with interactions with teachers and teacher responses to clarifications.
• Students felt that e-learning used as a supplementary tool during delivery of the skill component.

I. INTRODUCTION

E-learning has resulted in a revolutionising dental education to an extent that more interactive and intuitive e-learning options have evolved which provide students with an enjoyable and meaningful continuum to their educational experience. During the current COVID-19 pandemic electronic learning tools have been invaluable in the delivery of knowledge in many higher education institutions (Li & Lalani, 2020). One of the great advantages of e-learning is the possibility of transferring knowledge and skills to a large number of recipients irrespective of the time of delivery of knowledge (Asiry, 2017). In addition, students can repeatedly peruse the material and follow it in their own pace at a relatively low cost. This is considered an excellent method of overcoming certain difficulties faced with the traditional system of teaching such as the lack of space especially within the lecture halls and a shortage of human resources (Asiry, 2017). However, socio-economic factors play an important role in deciding the type of teaching. Students in the developed countries prefer e-learning modalities while students in the developing countries prefer it as a supplementary method (Schlenz et al., 2020). A study by Asiry (2017) identified e-learning as a helpful supplementary learning method among Saudi Arabian dental students rather than a replacement for traditional teaching methods. According to authors’ experience, though there was much resistance in adopting to e-learning at its infancy, it has now been universally accepted as a learning modality not only by teachers but also by the students. Many are of the view that assimilation of knowledge could be best achieved purely through e-learning modalities where as it should be supplementary in nature in skills acquisition. The popularity of books and hard copies of journals have seen a steady decline due to the availability of e-learning resources and even publishers have realised this trend and supply both hard and electronic versions of their publications which in future may progressively be replaced by electronic educational materials.

The success of e-learning is dependent on a multitude of factors. Computer literacy, availability of appropriate technology, accessibility and having a good high bandwidth internet connection are some of the key factors (Asiry, 2017; Linjawi & Alfadda, 2018). According to a study by Gunawardane and Wijekoon (2017), it was revealed that dental students in the Faculty of Dental Sciences, University of Peradeniya, Sri Lanka had adequate computer literacy and facilities. Although Linjawi and Alfadda (2018) identified that the perceived impact of e-learning and readiness for e-learning though popular and satisfactory among Saudi Arabian dental students, declined as they proceeded to higher semesters. Imparting the skills component has been identified as a major challenge in using e-learning and students were in need of more support in the skills domain (Linjawi & Alfadda, 2018).  Students have been shown to have better skills and motivation for use of online tools for personal or non-educational purposes than for learning purposes. Thus, this should be carefully considered when developing a successful strategy to motivate them for e-learning (Linjawi & Alfadda, 2018). Apart from the above mentioned factors, student characteristics, cognitive factors (performance expectations) and the social environment (learning climate) are considered as some predictors of the perceived satisfaction among students (Venkatesh et al., 2019). Most of the students prefer a combined approach comprising traditional and e-learning methods than relying on e-learning methods alone. Some of the preferred methods of delivery of e-learning resources for pre-clinical dental undergraduates were online flash lectures and procedural videos (Asiry, 2017). Video demonstrations enabled students to reflect on their predominant learning approaches, which emphasise self-directed learning and avoid surface learning techniques (Chonkar et al., 2019). Some dental schools in the developed countries have introduced tools such as Technology Enhanced Learning (TEL) in both pre-clinical and clinical courses with the development of innovative learning platforms and they further assess and monitor student performance in relation to the new approach (Wong et al., 2020). Further, Faculty of Dentistry, National University of Singapore has implemented a multi-stage framework for the academic staff to grasp technology in various aspects such as reflecting teaching practice, designing new technology options and identifying learner impact with changes on teaching methods. 

However, not everyone is in agreement with the benefits of e-learning. University administrators and experts in information technology working in universities have varying opinion (ranging from majority of teaching on traditional classroom mode to predominant e-learning mode) regarding the need of administrational change created by e-learning, generation of resources, impact on enrolment, responsibility for course design and content and the impact on the mission of the university. However, there is a general agreement on challenges such as the requirement of resources and cost of maintenance, need for motivating the teachers to keep abreast with the latest technology and the necessity for cooperation to improve e-learning (Hillenburg et al., 2006). 

The COVID-19 pandemic has made it necessary to impart changers in the modalities of education all over the world. Since schools and universities have been closed to prevent the spread of infection, conducting e-learning sessions has become the prime mode of teaching. The situation in Sri Lanka was without exception. Most programmes including the Bachelor of Dental Surgery had to comply with this requirement in order to provide the students a continuous educational experience during the pandemic situation. E-learning has been used in a very primitive level in the Faculty of Dental Sciences, University of Peradeniya for a long time but had not been utilised to its full potential. As dentistry is mostly a skill based professional degree programme, delivering course content online was a challenge. In addition, resistance to change was evident among the staff due to the fact that they were comfortable with the traditional time tested methods. However, with the new norms, e-learning platforms such as Zoom, Google Meet and WhatsApp discussions were used at the Faculty of Dental Sciences for the learning along with narrated PowerPoint presentations, video demonstrations and online quizzes uploaded onto the existing e-learning platform Dent Moodle. Due to this novel experience, it was considered important to analyse the students’ opinion on e-learning, the difficulties faced by them and expectations to improve e-learning in the field of dentistry. Further, it would be beneficial to identify barriers of e-learning when designing and revising the dental undergraduate curriculum in the future.

II. OBJECTIVES

General objective of the study was to assess the undergraduate dental students’ perception on the effectiveness of e-learning utilised in the Bachelor of Dental Surgery (BDS) programme. The specific objectives were to identify students’ opinion on the factors that promote e-learning, awareness on the effectiveness of using different platforms and social media, barriers imposed and suggestions for the improvement of e-learning in the BDS study programme.

III. MATERIALS AND METHODS

A cross sectional descriptive study was carried out on a  sample comprising of undergraduate dental students of the Faculty of Dental Sciences, University of Peradeniya who had enrolled and followed all online lectures and assignments based on the content taught via e-learning in the first, third, fifth and seventh semesters. A self-administered and pre-tested (25 students representing all batches for the pilot and their responses were excluded from the study sample) questionnaire was administered via a web-based survey form. A covering letter, information sheet and consent form were also annexed to this form. Those respondents who gave the informed consent were able to fill the questionnaire. The survey link was disseminated among the dental students via the email by the faculty administration unit. The questionnaire used in this study comprised of 23 close-ended questions which consisted of demographic data and specific questions on awareness, attitude and practice of e-learning. Examples of e-learning platform stated in the questionnaire were live Zoom presentations, Google Meet, Power Point presentations with voice narrations and supplementary material such as web links, video demonstrations and YouTube and other video links.

Confidentiality and anonymity of the data provided were assured by keeping the questionnaire anonymous. No identification details were included in the questionnaire. Data management and statistical analysis was performed using the statistical software SPSS version 21.0. Frequencies and percentages were obtained for categorical data and Chi-square test was used to determine the association between variables. Ethical clearance was obtained from the Ethics Review Committee of the Faculty of Dental Sciences, University of Peradeniya (ERC/ FDS/UOP/I/2020/21).

IV. RESULTS

The response rate was 82% (250 participants out of 305 of all undergraduates). The sample comprised 19% from the first semester, nearly 25% from the third semester, 26% from the fifth semester and nearly 30% from the seventh semesters of the Bachelor of Dental Surgery (BDS) programme. Seventy-two percent (72%) were females. Approximately 41% claimed that they have either very good or excellent literacy on information technology (IT). Fifty-four percent of the respondents claimed that their English language literacy is very good or excellent. A majority of the population accessed e-learning content using their mobile devices. Half of the sample had experienced some kind of interruptions during e-learning.

A. Satisfaction on E-learning

Seventy-one percent (71%) responded that they were either satisfied or highly satisfied about e-learning materials they received. More than one third of the respondents (39%) felt encouraged to collaborate and interact with their teachers during e-learning time compared to the in-class teaching sessions. A similar percentage of respondents felt that they were more encouraged to work on course materials compared to the traditional learning sessions received at the university. Around 74% of the students felt that the teachers were friendly during e-learning sessions. Moreover, 62% of them were either satisfied or highly satisfied with the provision to ask questions during e-learning sessions. Sixty percent (60%) of respondents was satisfied or highly satisfied with the answers received for the clarifications they requested. Seventy percent (70%) of the students claimed that the interactions between the lecturers and students during question and answer sessions, case scenarios and case discussions were essential for the success of e-learning experience. Fifty-five percent (55%) of them were satisfied with the interactions they experienced during e-learning sessions in their study period. Interestingly, more than one third of the respondents were of the opinion that online lectures were more effective than traditional live lectures. Moreover, 54% of the sample felt that the overall e-learning experiences was better than the traditional learning opportunities they received in the university and the possibility of following the coursework at their own pace (14.8%) was chosen as the main reason for this response.

Females had better overall e-learning experiences than the learning opportunities they received at the university compared to male students and this difference was statistically significant (p=0.000) (Table 1).

Surprisingly, only 1% of the respondents had identified social media as a positive influence on e-learning.

Table 1 describes participants’ response to the questionnaire according to their gender.

Table 1. Comparison of participants’ response according to their gender (in percentages)

B. Preference on Methods of E-learning

Sixty-four percent (64%) of the participants were familiar with Zoom as an e-learning platform. Majority of the students preferred PowerPoint presentations with narrations (68%) to receive lectures. In addition, 69% felt that e-learning materials had helped them to improve their knowledge on the course content specified in the Intended Learning Outcomes (ILOs). Around 34% had identified video demonstrations as an important tool in imparting skills training to achieve the course ILOs. Over 70% rated it as highly useful when students’ opinion is taken in consideration in improving knowledge on the course content.

Sixty-four percent (64%) felt that that e-learning material should be used as supplementary materials for in-class learning within the skills domain. The e-learning materials considered appropriate were video demonstrations, procedural steps described in text documents, YouTube links and case discussions. Majority of the courses in the first semester (Anatomy, Dental Anatomy and Physiology related), third semester (Tooth morphology and occlusion, Human Diseases, Dental Biomaterials), fifth semester (Operative Dentistry, Population Oral Health, Clinical and Diagnostic Oral Sciences [CDOS1] and Child and Adolescent Oral Health [CAOH1]) and seventh semester (Adult Oral Health, CDOS2 and CAOH2) were rated as suitable for e-learning activities.

C. Opinion on Assessment via E-Learning Platforms

The Multiple Choice Questions (MCQ) and Short Answer Questions (SAQ) were the more common forms of assessments provided to the participants. However, some students (9%) had experience with essays too. These assessments were formative in nature whereby the questions were posted after each learning session in order to assess the effectiveness of the learning process. These questions were marked by the teachers or self-marked by the students. Sixty-nine percent (69%) felt that conducting assessments online is fair.

D. Opinion on Barriers Identified in E-Learning

Though the majority of first semester students had identified inadequate opportunities to work with other batch mates as a stumbling block, the majority of the seventh semester had identified technical difficulties in accessing the e-learning resources as the major barrier in e-learning. However, there was no significant difference in the responses between the genders and the semester of study of the student.

E. Suggestions to Improve E-Learning

When the students were requested to suggest ways to use the e-learning to improve the required skills, approximately half (52%) of the respondents preferred video demonstrations on clinical and lab procedures. Furthermore, multiple choice questions, use of charts to explain presentations, discussion forums, quizzes, assignments, web links and supplementary reading material were other ways of improving the learning experience as suggested by the participants. However, 3% of the students had clearly mentioned that e-learning could not be used to improve the required skills in dentistry.

There were multiple suggestions by the majority to improve the overall effectiveness of their e-learning experience. Some of the suggestions were uploading of lectures coupled with assignments, video demonstrations especially for practical scenarios, lectures followed by discussions and lectures on Zoom followed by case discussions. However, the statistical significance could not be assessed between genders or semesters as the number of responses for each option was small.

F. Analysis of Results According to the Respondents’ Current Semester

When the results were assessed according to the current semester, a majority of the first, third and seventh semesters students preferred video demonstrations for e-learning sessions. However, a majority of the fifth semester students preferred a combination of video demonstrations and a text document describing procedural steps or video demonstrations combined with YouTube links and discussion forums. Respondents from first semester had the highest overall satisfaction on e-learning materials they received and the difference between the semesters was statistically significant. (p=0.002). Over two-thirds of the seventh semester students (being the students who were exposed to conventional classroom learning experience for more than three years) confirmed that their overall e-learning experiences were better than the traditional classroom learning opportunities they received at the university and the difference was statistically significant (p=0.000) (Table 2). Further, students’ rating of e-learning materials received from teachers (p=0.002) (Figure 1) and encouragement to work on course material compared to the learning sessions received at the university (p=0.015) (Figure 2) were statistically significant when the semester of study were considered.

Table 2 describes participants’ response to the questionnaire according to their semester of study.

Table 2. Variations of participants’ response according to their semester of study (in percentages)

Figure 1 shows students’ rating of e-learning materials received from teachers according to their semester of study.

Figure 1. Students’ rating of e-learning materials received from teachers according to their semester of study

Figure 2 shows students’ feeling of encouragement to work on course material compared to conventional learning sessions received at the university.

Figure 2. Students’ feeling of encouragement to work on course material compared to conventional learning sessions received at the university according to their semester of study

When the results were analysed according to theory based courses (Anatomy, Oral Biology, Human Diseases, Tooth morphology and Occlusion, Dental Biomaterials) against practical, lab based and clinical training courses (Adult Oral Health, Population Oral Health, Clinical and Diagnostic Oral Sciences, Child and Adolescent Oral Health), the participants’ overall e-learning experience in theory based courses was significantly higher than practical and clinical courses (p= 0.03).

All data are available at https://figshare.com/s/c6c7b8f1d5cfd0076808.

V. DISCUSSION

E-learning is a broad term which encompasses the use of software applications to support learning, whether online or offline (Piccoli et al., 2001). The efficacy of an e-learning experience is dependent on many factors such as availability of devices, access to internet, knowledge on IT and uninterrupted internet connectivity (Asiry, 2017; Linjawi & Alfadda, 2018).

In the present study, half of the sample experienced some interruption during the e-learning sessions. It has been demonstrated in previous studies that students generally have a positive outlook to e-learning in spite of technical problems and related stresses (Brumini et al., 2014). Other studies have also highlighted positive experiences in isolated dental specialties (Bains et al., 2011; Gonzalez & Gadbury-Amyot, 2016; Qi et al., 2013; Reissmann et al., 2015). Our results revealed that students had a better learning experience with e-learning in comparison to traditional methods which was compatible with the findings of similar studies (Turkyilmaz et al., 2019). A study in Germany involving undergraduate dental students stated that participation in online learning was higher compared to “face-to-face” courses which was similar to the findings of the present study (Schlenz et al., 2020). Reasons for popularity of e-learning material over face-to-face learning are that it not only provides flexibility in the learning process (p=0.003) but also saves time (p = 0.012) (Anwar et al., 2021).

When the students’ perception on e-learning resources were analysed, males showed better IT literacy in comparison to female students. Even though the female students were not as confident as male students, a majority of them expressed that the overall e-learning experience was better than the conventional learning. These findings endorse the observations of Linjawi and Alfadda (2018) where the students claimed that they had better skills and motivation for e-learning than conventional learning activities. The identification of social media platforms for e-learning opportunities by a very few students in our study corroborate the fact that formal modalities of delivering e-learning resources should be implemented rather than relying on generic platforms.

Participants’ overall e-learning experience in theory based courses were significantly higher than practical and clinical courses due to the need of hands on experience, simulator training and working with patients for the practical and clinical courses than listening, reading and writing practice. This fact should be carefully considered when developing and planning the modes of content delivery as the knowledge and skills domains should be separately considered. More theory could be delivered through e-learning modalities and this time saved could be utilised for the face to face delivery of practical and clinical procedural teaching in predominantly skills based courses such as the Bachelor of Dental Surgery. However, the findings contradict the previous belief of the faculty that e-learning should only be used as a supplementary tool. There is a possibility to incorporate classroom and e-learning as a blended learning experience when imparting theory components in the future to save time, improve efficient use of limited infrastructure and to focus more on much needed skill development in dentistry. Incorporation of e-learning facilities to the maximum possible level should also be considered in future planning of the state universities in the delivery of undergraduate education in countries such as in Sri Lanka to enhance the quality of learning using the minimal physical and human resources available. Reports from experience in other countries highlight that e-learning processes are also cost effective, due to the availability of low cost or free online tools and platforms which can be used by teachers with a sound background of pedagogical knowledge (Goh, 2018).

First semester had the highest overall satisfaction on e-learning. This group consisted of students who hardly had any noteworthy face-to-face learning experience in the Faculty of Dental Sciences due to the abrupt closure during pandemic situation. Therefore, it seems that they could not effectively compare the two learning methods. Though less than first semester, more than 50% of the seventh semester students had a positive attitude towards e-learning experience. Our finding is in agreement with the findings of a previous study where it was shown that the perceived impact of e-learning and readiness for e-learning became less acceptable as students became mature (Linjawi & Alfadda, 2018).

Positive feedback regarding e-learning experience showed statistically significant differences between students of different semesters in relation to overall satisfaction on the e-learning materials received; encouragement to work on course materials; feeling that the teachers were friendly during the e-learning sessions; satisfaction on the student-teacher interaction during e-learning sessions. These findings should be considered when modes of learning for different components are planned by the Faculty of Dental Sciences during future revisions to the curriculum. Similarly, a recent report on undergraduate dental education during the COVID-19 pandemic has described that e-learning has been appreciated not only by students and teachers, but also in relation to the teacher-student interaction (Bennardo et al., 2020).

A majority of the students felt that the best way to receive the theory component was through PowerPoint presentation with voice narrations. This was statistically significant when compared among different semesters. This is in contrast with the preferred e-learning method among the Saudi Arabian dental students whereby online flash lectures were the most preferred method (Asiry, 2017).

Similar to our findings, a study on health care students belonging to 11 countries among the developed and developing nations also identified that 60% agreed that clinical and practical skills are best learned in clinics and laboratories (Abbasi et al., 2020). Another study involving over 3000 medical students of all years from over 13 schools in Libya has revealed only 21% agreed that e-learning could be used for clinical aspects, as compared with 55% who disagreed with this statement and 24% who were neutral (Alsoufi et al., 2020). The students ‘most preferred mode to learn skills as prescribed in the ILOs was through the use of procedural videos. A previous study carried out in the same institute to investigate the efficacy of procedural video versus live demonstrations revealed that that there was no appreciable difference in the development of skills in dental laboratory technology procedures (Thilakumara et al., 2018). This outcome could be applied to our findings that e-learning sessions, if followed by discussion forums with the teachers, as suggested by the participants would dramatically improve the e-learning experience.

E-learning with its virtual learning environment also requires different skills and a positive attitude from instructors. The positive attitude of the instructors towards technology, the interactive teaching style, and control over the technology were found to have an important influence on students’ reactions to the learning environment (Piccoli et al., 2001). This highlights the importance of professional development in two main aspects; technical and e-pedagogical areas (Conole & Oliver, 2002). The significance of institutional support should be highlighted. Therefore, the need of training for the teachers in the use of efficient methods for e-learning is emphasised. Furthermore, the faculty needs to have a long-term plan to encourage learning facilities through the use of different platforms, use of web links and production of supplementary video for demonstrations in order to encourage students towards a lifelong learning experience. Investment in more user-friendly and versatile software and resources to improve e-learning activities should be prioritised in order to make this endeavour more effective, interactive and receptive to the end users.

A. Limitations of the Study

Our study was performed in a single country and in a single institution as the country has only one dental school. Therefore, the results may not be generalised to other countries and to the region. The results must be validated through further multi-centre studies in order to obtain an overall opinion. Multi-national studies would provide a better understanding on how e-learning could replace the bulk of conventional dental undergraduate clinical learning and provide cost effective solutions for the developing countries with limited physical and human resources to avoid disruption of clinical training during difficult times such as the present COVID-19 pandemic. Another limitation is the cross-sectional nature of the study design, which limited our ability to identify causal associations.

VI. CONCLUSION

A positive learning experience was achieved through the e-learning modalities by the undergraduate dental students in comparison to traditional face-to-face learning. In terms of skills training, e-learning should only be considered as a supplementary tool. These findings will be useful when designing the study courses as a major part of theory component via e-learning mode and skill component with combined e-learning and conventional modes in the future.

We recommend adapting interactive e-learning platforms by using highly sophisticated technologies along with virtual clinical experience with combined clinical scenarios and assessments based on discussions of patient cases. Cost-effective solutions are needed to reduce disruption of undergraduate dental education especially in developing countries in the region like Sri Lanka and there should be new collective effort by the countries in the South Asian region in planning and sharing less expensive e-learning solutions in order to overcome financial issues. Such measures may vary from learning theory and virtual clinical and lab-based experience, followed by limited hands-on experience on live patients in a safe environment during difficult times of this nature.

Notes on Contributors

Principal and corresponding author (Rasika Jayasinghe) conceptualised the research and edited the initial draft and wrote the results after analysis. She also did the final approval of the version to be published and agreed to be accountable for all aspects of the work.

Manjula Attygalla edited the initial draft of the manuscript and supported in modification of the questionnaire. He also did the final approval of the version to be published and agreed to be accountable for all aspects of the work.

Manil Fonseka supported planning of the study, edited the research proposal and manuscript. He also did final editing and approval of the version to be published and agreed to be accountable for all aspects of the work.

Dhanushka Leuke Bandara supported planning of the study, designed the Google form, carried out the survey and entered the data in addition to editing of the manuscript. She also did final approval of the version to be published and agreed to be accountable for all aspects of the work.

Gishan Edirisinghe carried out the literature survey and did the final approval of the version to be published and agreed to be accountable for all aspects of the work.

Ruwan Jayasinghe supported planning of the study, prepared the initial draft of the research proposal and edited the final draft of the manuscript. He did the final approval of the version to be published and agreed to be accountable for all aspects of the work.

Indika Thilakumara supported planning of the study, edited the first draft and wrote the discussion. She did the final approval of the version to be published and agreed to be accountable for all aspects of the work.

Ethical Approval

Ethical clearance has been granted by Ethics Review Committee, Faculty of Dental Sciences, University of Peradeniya. (ERC/FDS/UOP/I/2020/21).

Data Availability

All data are available at https://figshare.com/s/c6c7b8f1d5cfd0076808 and can be accessed on request and approval from the corresponding author.

Funding

No funding sources are associated with this study.

Declaration of Interest

Authors declare that they do not have possible conflicts of interest, including financial, consultant, institutional and other relationships that might lead to bias or a conflict of interest.

References

Abbasi, M. S., Ahmed, N., Sajjad, B., Alshahrani, A., Saeed, S., Sarfaraz, S.,   Alhamdan, R. S.,  Vohra, F., & Abduljabbar, T. E. (2020). E-Learning perception and satisfaction among health sciences students amid the COVID-19 pandemic. Work, 67(3), 549-556. https://doi.org/10.3233/WOR-203308

Alsoufi, A.,  Alsuyihili, A.,  Msherghi, A.,   Elhadi, A., Atiyah, H.,  Ashini, A.,  Ashwieb, A.,  Ghula, M.,   Hasan, H. B., Abudabuos, S.,  Alameen, H.,  Abokhdhir, T.,  Anaiba, M.,  Nagib, T.,   Shuwayyah, A.,  Benothman, R., Arrefae, G.,   Alkhwayildi, A.,  Alhadi, A., … Elhadi, M. (2020). Impact of the COVID-19 pandemic on medical education: Medical students’ knowledge, attitudes, and practices regarding electronic learning. PLOS ONE, 15(11), e0242905. https://doi.org/10.1371/journal.pone.0242905

Anwar, A.,   Mansoor, H., Faisal, D., & Khan, H. S. (2021). E-learning amid the COVID-19 lockdown: Standpoint of medical and dental undergraduates. Pakistani Journal of Medical Sciences, 37 (1), 217-222. https://doi.org/10.12669/pjms.37.1.3124

Asiry, M. A. (2017). Dental students’ perceptions of an online learning. The Saudi Dental Journal, 29(4), 167–170. https://doi.org/10.1016/j.sdentj.2017.03.005

Bains, M., Reynolds, P. A., McDonald, F., & Sherriff, M. (2011). Effectiveness and acceptability of face-to-face, blended and e-learning: A randomised trial of orthodontic undergraduates. European Journal of Dental Education, 15(2), 110–117. https://doi.org/10.1111/j.1600-0579.2010.00651.x

Bennardo, F., Buffone, C., Fortunato, L., & Giudice, A. (2020). COVID-19 is a challenge for dental education—A commentary. European Journal of Dental Education, 24(4), 822-824. https://doi.org/10.1111/eje.12555 

Brumini, G., Špalj, S., Mavrinac, M., Biočina-Lukenda, D., Strujić, M., & Brumini, M. (2014). Attitudes towards e-learning amongst dental students at the universities in Croatia. European Journal of Dental Education, 18(1), 15-23. https://doi.org/10.1111/eje.12068

Chonkar, S. P., Qi, H. L. C., Ha, T. C., Lim, M., Ng, M. J., & Tan, K. H. (2019). Can digital media affect the learning approach of medical students? The Asia Pacific Scholar, 4(1), 13- 23. https://doi.org/10.29060/TAPS.2019-4-1/OA1058

Conole, G. C., & Oliver, M. (2002). Embedding theory into learning technology practice with toolkits. Journal of Interactive Media in Education (8), 2- 3. https://doi.org/10.5334/2002-8

Goh, P. S. (2018). eLearning in medical education – Costs and value add. The Asia Pacific Scholar, 3(2), 58- 60. https://doi.org/10.29060/TAPS.2018-3-2/PV1073

Gonzalez, S. M., & Gadbury-Amyot, C. C. (2016). Using Twitter for teaching and learning in an oral and maxillofacial radiology course. Journal Dental Education, 80(2), 149–155. https://doi.org/10.1002/j.0022-0337.2016.80.2.tb06070.x

Gunawardane, S., & Wijekoon, P. (2017). Changes in perceived computer use and knowledge in Sri Lankan dental students in the last ten years. Scholars Journal of Dental Sciences, 4(5), 216-219.

Hillenburg, K. L., Cederberg, R. A., Gray, S. A., Hurst, C. L., Johnson, G. K., & Potter, B. J. (2006). E-learning and the future of dental education: Opinions of administrators and information technology specialists. European Journal of Dental Education, 10, 169–177. https://doi.org/10.1111/j.1600-0579.2006.00413.x

Li, C., & Lalani, F. (2020). The COVID-19 pandemic has changed education forever. This is how. World Economic Forum. https://www.weforum.org/agenda/2020/04/coronavirus-education-global-covid19-online-digital-learning

Linjawi, A. I., & Alfadda, L. S. (2018). Students’ perception, attitudes, and readiness toward online learning in dental education in Saudi Arabia: A cohort study. Advances in Medical Education and Practice, 9, 855–863. https://doi.org/10.2147/AMEP.S175395

Piccoli, G., Ahmed, R., & Ives, B. (2001). Web-based virtual learning environments: A research framework and a preliminary assessment of effectiveness in basic IT skills training. MIS Quarterly, 25(4), 401-426. https://doi.org/10.2307/3250989

Qi, S., Yan, Y., Li, R., & Hu, J. (2013). The impact of active versus passive use of 3D technology: A study of dental students at Wuhan University, China. Journal of Dental Education, 77(11), 1536–1542.

Reissmann, D. R., Sierwald, I., Berger, F., & Heydecke, G. (2015). A model of blended learning in a preclinical course in prosthetic dentistry. Journal of Dental Education, 79(2), 157–165. https://doi.org/10.1002/j.0022-0337.2015.79.2.tb05870.x

Schlenz, M. A., Michel, K., Wegner, K., Schmidt, A., Rehmann, P., & Wöstmann, B. (2020). Undergraduate dental students’ perspective on the implementation of digital dentistry in the preclinical curriculum: A questionnaire survey. BMC Oral Health, 20, 78. https://doi.org/10.1186/s12903-020-01071-0

Thilakumara, I. P., Jayasinghe, R. M., Rasnayaka, S. K., Jayasinghe, V. P., & Abeysundara, S. (2018). Effectiveness of procedural video verses live demonstrations in teaching laboratory techniques to dental students. Journal of Dental Education; 82(8), 898-904. https://doi.org/ 10.21815/JDE.018.086

Turkyilmaz, I., Hariri, N. H., & Jahangiri, L. (2019). Student’s perception of the impact of e-learning on dental education. Journal of Contemporary Dental Practice, 20(5), 616-621.

Venkatesh, S., Rao, Y. K., Nagaraja, H., Woolley, T., Alele, F. O., Bunmi, S., & Malau-Aduli, B. S. (2019). Factors influencing medical students’ experiences and satisfaction with blended integrated e-learning. Medical Principles and Practice, 29, 296-402. https://doi.org/10.1159/000505210

Wong, M. L., Lee, T. W. O., Allen, P. F., & Foong, K. W. C. (2020). Dental education in Singapore: A journey of 90 years and beyond. The Asia Pacific Scholar, 5(1), 3- 7. https://doi.org/10.29060/TAPS.2020-5-1/GP1086

*RM Jayasinghe
Department of Prosthetic Dentistry,
Faculty of Dental Sciences,
University of Peradeniya
Tel: +94777806314
Email: manorija@pdn.ac.lk/ manoripathiraja@yahoo.com

Submitted: 18 December 2020
Accepted: 12 April 2021
Published online: 5 October, TAPS 2021, 6(4), 1-6
https://doi.org/10.29060/TAPS.2021-6-4/GP2451

Dora J. Stadler^1,2, Halah Ibrahim^3,4, Joseph Cofrancesco Jr⁴ & Sophia Archuleta^5,6

¹Department of Medicine, Weill Cornell Medical College, Doha, Qatar; ²Walter Reed National Military Medical Center in Bethesda, United States of America; ³Department of Medicine, Sheikh Khalifa Medical City, Abu Dhabi, United Arab Emirates; ⁴Department of Medicine, Johns Hopkins University School of Medicine, Baltimore, United States of America; ⁵Division of Infectious Diseases, Department of Medicine, National University Hospital, Singapore; ⁶Department of Medicine, Yong Loo Lin School of Medicine, National University of Singapore, National University Health System, Singapore

Abstract

Introduction: Gender equity in academic medicine is a global concern. Women physicians lag behind men in salary, research productivity, and reaching top academic rank and leadership positions.

Methods: In this Global Perspective, we provide suggestions for overcoming gender bias, drawn from a multidisciplinary literature and personal experiences working as clinician educators in the international academic arena. These suggestions are not exhaustive but inform a tool kit for institutions and individuals to support the advancement of women in academic medicine.

Results: Barriers include limited access to same gender role models and mentors, fewer networking opportunities, fewer nominations for awards and speakership opportunities, as well as implicit gender bias. Institutional interventions can address disparities along the career continuum focusing on scholarship, promotion and leadership opportunities. Women faculty can also seek out professional development programmes and mentorship to support their own advancement. Informal and formal networking opportunities, using a variety of platforms, including social media, can help build relationships to enhance career development and success, and provide social, emotional and professional support to women at all stages of their career. The National University Health System’s Women in Science and Healthcare project is an example of a successful group formed to empower women and foster personal and professional development.

Conclusion: Successful incentives and policies need to consider local institutional and cultural contexts, as well as approaches to mitigate implicit bias. Achieving gender parity in academic medicine will promote a personally and professionally fulfilled global healthcare workforce to improve patient care and clinical outcomes worldwide.

Practice Highlights

• The gender gap in academic medicine persists worldwide, especially at higher academic rank & leadership positions.
• Institutions should develop strategies to address gender equity in faculty recruitment, retention & advancement.
• Female faculty can help to advance themselves and each other through seeking self-development, mentorship and networking opportunities, utilising local as well as global resources available through a variety of channels, including social media.
• Women faculty groups can facilitate networking opportunities and create a critical mass of individuals, who can provide effective personal and professional support.

I. THE STATE OF GENDER EQUITY IN INTERNATIONAL ACADEMIC MEDICINE

Gender inequity in academic medicine has been a global concern for several decades. Although the enrolment of women in medical schools has reached or exceeded parity in many parts of the world, disparities remain in academic rank, career advancement, and leadership positions internationally (Stadler et al., 2017). Women faculty lag behind their male colleagues in several domains, including salaries, research productivity, and resource allocation. Various terminologies have been used to describe this phenomenon, including the leaky pipeline, sticky floor, broken rungs, and glass ceiling. Regardless of the phrasing, the outcome remains the same – the gender gap persists, particularly at the highest academic ranks and in medical leadership positions. As recent studies have linked physician female gender to improved patient clinical outcomes, hospitals and academic institutions now have additional incentives to train and retain a diverse workforce.

Though much of the literature on gender disparity in academic medicine is Western-based, global studies also document ongoing inequity. For example, a comparative study in Scandinavian countries found significantly fewer women in higher income specialties and in leadership positions, despite policies and cultural attitudes that support and promote work-life balance. Even in countries, such as Russia, where the majority of the physician workforce is comprised of women, the authors found significantly fewer women in prestigious specialties, tertiary care and academic medicine. In a multinational study of newly accredited postgraduate training programs in Singapore, Qatar and the United Arab Emirates, women comprised 25% of the clinician educator workforce and only 18% of hospital CEO/ CMOs, and were significantly less likely to hold an academic appointment (Stadler et al., 2017).

There are multiple barriers to female physician advancement, including limited access to same gender role models and mentors, fewer networking opportunities, lower salaries, less funding and resources (administrative staff, laboratory space), and fewer nominations for awards and conference speakership opportunities (Ibrahim et al., 2019a). These disadvantages start early in a female physician’s career and continue throughout her education, training and employment and, ultimately, impact her career trajectory. The cause is multifactorial, but there is a large body of literature that suggests that implicit gender biases play a significant negative role in the recruitment, retention and promotion of female physicians. Gender stereotype threat, which goes beyond how women are perceived and evaluated, and affects how they actually perform, could further augment disparity. There is currently a dearth of literature on successful initiatives to improve gender equity in the international arena and further research is needed to identify effective interventions in local contexts. Given the complexity of the underlying causes of gender inequity, initiatives to advance women in academic medicine should be comprehensive and multi-pronged, and include both institutional and individual interventions.

 II. INSTITUTIONAL INITIATIVES

International academic institutions can vary considerably in faculty gender composition, resources available, and institutional culture. International medical education is evolving, and now is the time for healthcare institutions to assess the diversity of their faculty and review policies and protocols for any evidence of systemic bias, as well as formally assess organisational climate. The leaky pipeline model offers a framework to address these issues along the continuum of a female physician’s career. First, explicit policies to recruit, hire and retain more female academic faculty are necessary. Institutions need to analyse their current status and set goals for improvement (Ibrahim et al., 2019b), and need to ensure equity in advancement, with a focus on success in scholarship, promotion and leadership. Contributors to the leaky pipeline and a summary of possible approaches to resolve issues are described in Figures 1 and 2, respectively.

Figure 1. Barriers to recruitment, retention, and advancement

Figure 2. Institutional strategies to support female faculty recruitment, retention and promotion

Implicit or unconscious bias affects all aspect of this process; therefore, continued training to recognise and mitigate its effects is vital to success. Effective institutional policies for recruitment of a diverse faculty have included bias training for members of search and promotion committees, ensuring committee diversity (representative of gender, minorities and clinical tracks), as well as accountability through tracking of female faculty applicants and hires. Successful initiatives for retention of faculty have focused on development of policies that facilitate work-life balance and integration, such as part-time work, job sharing, and on-site childcare. The facilitation of an institutional culture that makes these options accessible without fear of stigma or penalty is crucial for these programs to succeed. Transparency in policies and salaries, systematic review and adjustment of pay structure, as well as offering negotiation workshops for female faculty, have all been shown to be successful in equalising the salary gap. Formal institutional support in terms of funding, space, time allotment, and interdepartmental activities to foster collaboration can boost research productivity and decrease isolation reported by female academic faculty. Structured professional development for faculty at all career levels, with a family friendly schedule, can be a positive factor in women physicians’ career satisfaction and retention.

Institutional review and focus on parity in advancement can help to identify and fix the ‘broken rungs’ on the ladder to promotion and leadership positions for women. Adjusted promotion and tenure guidelines to account for childcare and part-time work are also integral to advancement. While many of these recommendations are based on literature from Western academic institutions, the overall framework and guiding principles can be adapted globally. Further, gender-based research in international academic institutions is needed to better address inequity and barriers in local contexts.

III. INDIVIDUAL INITIATIVES

Institutional change is a long-term process and transforming institutional culture can take time. Despite the systemic gender bias, women physicians can take proactive steps to advancement.  Women physicians face a set of internal challenges such as their own implicit bias, susceptibility to gender stereotype threat that can affect performance, and higher rates of imposter syndrome. Individual faculty members can seek out and request to participate in faculty development programs that support addressing these topics, as well those that support career advancement. Women can seek mentors and sponsors at their own or other institutions through local, regional and national networks. In addition to structured faculty development and formal mentorship processes, networking, a less formal relationship, can be utilised to support female faculty. Networking, a process used to build, maintain and use relationships to enhance career development and success, can provide social, emotional and professional support to women at all stages of their career. It can also combat professional and personal isolation often experienced by female faculty. In today’s globally dispersed and pandemic affected medical communities, the power of social media cannot be undervalued. Social media platforms can be used to form communities to share knowledge, address isolation, facilitate networking, and provide mentoring (Ibrahim et al., 2020). These platforms also serve as effective venues to broadcast and celebrate accomplishments. Networking can occur through individual channels and through grassroots efforts to build a community of women with shared goals and interests. A useful guide to building an international women’s group to facilitate and support female physician networking is illustrated in Figure 3 and exemplified through the following project.

Figure 3. Framework for building a women’s group

IV. AN EXAMPLE OF SUCCESS IN THE LOCAL ARENA: THE WISH PROJECT

Solutions to achieve meaningful change require multidimensional and comprehensive strategies. However, there is limited information in the medical literature about developing or running an academic women’s group, especially in the international arena where policies and support systems for gender parity may be lacking. Often, a “bottom-up” approach, by women for women, is needed. Therefore, in 2017, to help the advancement of women at our institution, we formed the National University Health System Women in Science and Healthcare (NUHS WISH), dedicated to empowering and supporting women in healthcare and science fields in the NUHS ecosystem (Yoong et al., 2019). We viewed this group as more than a social opportunity, but rather as a vehicle for women’s empowerment. Borrowing from a multidisciplinary literature on group formation and change management, we structured our initiative according to John Kotter’s 8-step process of transformational change, as seen in Figure 3. First, we assembled a small team of passionate and dedicated women who served as transformation leaders. With the simple mission of supporting the personal and professional advancement of women in healthcare, the team communicated their vision through word of mouth and social media. Next, the transformation leaders worked with institution leadership to highlight and address barriers to female advancement in healthcare. We shared short-term wins, and planned for the future. Viewing the women’s group as an opportunity for culture change, rather than a single initiative, encourages sustainability and innovation. We deliberately alternated informal social gatherings and formal structured events. Workshops were planned for women at all career stages, with specific focus on the development of skills essential for success in healthcare, including leadership and mentorship. Given the varied professions and career stages of the members, we provided early career professionals the opportunity to network with experienced women, who offered career-related and other advice. Senior members benefitted from interacting with individuals in key leadership positions. WISH is now in partnership with senior leadership, and has grown to be a strong group of empowered female health professionals. We believe this network of developmental relationships is critical for the retention and success of women in academic medicine.

In conclusion, ensuring gender equity should be an important goal for academic medicine institutions worldwide. Our recommendations are based on personal experiences, as well as a review of best practices. The suggestions are not exhaustive and we are cognisant that no single model fits all institutions; culture and context must always be considered. Nonetheless, we believe that multilevel, institution-wide approaches to support the advancement of female faculty will benefit the institution as a whole, and help to foster inclusivity and equality in the international medical workforce. Women can also create structures to help support their advancement. By supporting all healthcare professionals to reach their full potential, we can strive for a personally and professionally fulfilled global healthcare workforce to improve patient care and clinical outcomes worldwide.

Notes on Contributors

Dora J. Stadler conceived the manuscript design, reviewed the literature and drafted the manuscript. Halah Ibrahim reviewed the literature and drafted the manuscript, Joseph Cofrancesco Jr. advised the manuscript design and gave critical feedback to the manuscript. Sophia Archuleta conceived the manuscript design, reviewed the literature and gave critical feedback to the manuscript. All authors have read and approved the final manuscript.

Acknowledgement

The authors wish to thank Siok Ching Chia, BS, National University Hospital for her assistance in preparing the manuscript for submission.

Funding Statement

There were no funding sources for this study.

Declaration of Interest

The authors declare no conflicts of interest.

References

Ibrahim, H., Abdel-Razig, S., Stadler, D. J., Cofrancesco, J., Jr., & Archuleta, S. (2019a). Assessment of gender equity among invited speakers and award recipients at US annual medical education conferences. JAMA Network Open, 2(11), e1916222. https://doi.org/10.1001/jamanetworkopen.2019.16222

Ibrahim, H., Stadler, D. J., Archuleta, S., Anglade, P., & Cofrancesco, J., Jr. (2019b). Twelve tips for developing and running a successful women’s group in international academic medicine. Medical Teacher, 41(11), 1239-1244. https://doi.org/10.1080/0142159X.2018.1521954

Ibrahim, H., Anglade, P., & Abdel-Razig, S. (2020). The use of social media by female physicians in an international setting: A mixed methods study of a group WhatsApp chat. Women’s Health Reports, 1(1), 60-64. https://doi.org/10.1089/whr.2019.0015

Stadler, D. J., Archuleta, S., Ibrahim, H., Shah, N. G., Al-Mohammed, A. A., & Cofrancesco J., Jr. (2017). Gender and international clinician educators. Postgraduate Medical Journal, 93(1106), 719-724. http://doi.org/10.1136/postgradmedj-2016-134599

Yoong, J., Alonso, S., Chan, C. W., Clement, M.-V., Lim, L. H. K., & Archuleta, S. (2019). Investing in gender equity in health and biomedical research: A Singapore perspective. The Lancet, 393(10171), e21-e22. https://doi.org/10.1016/S0140-6736(18)32096-8

*Sophia Archuleta
1E Kent Ridge Road
NUHS Tower Block, Level 10
Singapore 119228
Tel: +65 6772 6188
Email: sophia@nus.edu.sg

 

Submitted: 31 August 2020
Accepted: 17 February 2021
Published online: 13 July, TAPS 2021, 6(3), 91-94
https://doi.org/10.29060/TAPS.2021-6-3/SC2353

Melissa Su Yi Yong, Xing Tong Yong, Olga Hillary Li Chew & Kuan Chen Zenne T’ng

Speech Therapy Department, Tan Tock Seng Hospital, Singapore

Abstract

Introduction: During the COVID-19 epidemic in Singapore, there was an urgent demand to train more nurses within a short timeframe to perform the Water Swallow Test (WST). The previous training model involved training with actual patients and was time-consuming. Hence, the model was revamped and standardised patients (SPs) were engaged for nurses’ training. This study further investigated nurses’ feedback about the new training model and compared the efficiency and learner-reported outcomes of the previous and new models.

Methods: Nurses who completed WST training from January 2018 to July 2020 were enrolled. Training records were accessed to determine the number of nurses trained under the previous and new models. Nurses were invited to complete post-training evaluation forms and their responses were analysed. Descriptive statistics and the Mann-Whitney U test were used for data analysis. 

Results: Under the previous model, 52 nurses were trained over 2 years, whereas under the new model, 112 nurses were trained over two months. From the evaluation form responses, the majority of nurses trained under the new model agreed that they achieved the learning objectives and were confident in performing the WST. There was also no significant difference (p>0.05) found between learner-reported outcomes for both training models. 

Conclusion: Our findings demonstrated that the new model that engaged SPs was more efficient in training more nurses. Nurses were also satisfied with the new training model, which achieved similar learner-reported outcomes as the previous model.

Keywords:            Water Swallow Test, Standardised Patients, Train-the-Trainer, Dysphagia Screening

With the new training model implemented, the following research questions were posed:

1) Is the new training model more efficient in training providers to perform the WST compared to the previous model? 

2) Are providers trained under the new model confident that they have achieved the learning objectives of the training and in performing the WST? 

3) Is the new training model able to achieve similar learner-reported outcomes for providers as compared to the previous model?

It was hypothesised that:

1) The new training model is more efficient in training providers than the previous model.

2) Majority of providers trained under the new model will feel confident that they achieved the training learning objectives and in performing the WST. 

3) The new training model will achieve similar learner-reported outcomes for providers when compared to the previous model. 

II. METHODS

Nurses who completed WST training as providers from January 2018 – July 2020 were enrolled. Nurses were trained using the previous training model from January 2018 – April 2020. The new training model was implemented from May 2020. 

In order to evaluate the efficiency in training providers under both models, nursing training records were accessed retrospectively to obtain the numbers and dates of providers who completed their training from January 2018 – July 2020. Total training hours under the previous model were computed based on the number of providers who completed training (three hours per provider). Under the new model, total training hours were calculated based on the number of training sessions (three hours per session) conducted from May – July 2020.

In order to evaluate the providers’ confidence in achieving the training’s learning objectives and in performing the WST, providers trained under both models were invited to complete an anonymous course evaluation form generated by the authors and select their responses on a 5-point Likert scale (i.e., strongly agree, agree, neutral, disagree, strongly disagree). The evaluation form was updated along with the new training model, however, these three statements remain unchanged in both versions and were used to analyse learner-reported outcomes:

1. I have a clear understanding of the contraindications of performing the WST.

2. I am confident of accurately identifying all the signs of dysphagia during the WST.

3. I am confident of performing the WST independently.

For data analysis, ‘strongly agree’ and ‘agree’ responses were collapsed into a single category and assigned a score of 1, ‘neutral’ response was assigned a score of 2, and ‘disagree’ and ‘strongly disagree’ responses were collapsed into a single category and assigned a score of 3. Statistical analysis was performed using SPSS statistics version 27.0. Descriptive statistics and the Mann-Whitney U test were used to analyse the evaluation form responses.

Implied consent was obtained from providers who voluntarily completed the form. This study was exempted from a formal NHG Domain Specific Review Board review.

III. RESULTS

A. Number of Providers Trained and Duration Required

Under the previous training model, 52 providers were trained over 24 months (January 2018 – December 2019). The total number of training hours was 156 hours (i.e., 52 providers x three hours). Under the new model, 112 providers were trained in 15 training sessions over two months (end May – mid-July 2020). The total training hours were 45 hours (i.e., 15 sessions x three hours). 

Hence, one provider was trained every three-hourly training session and an average of 2.17 providers were trained per month under the previous model. Contrastingly, an average of 7.57 providers were trained every three-hourly training session and an average of 56 providers were trained per month under the new model.

B. Evaluation Form Responses

13 evaluation form responses (N_previous = 13) were received under the previous model, and 111 responses (N_new = 111) were received under the new model. The mean scores obtained for the three selected statements were: 

1. I have a clear understanding of the contraindications of performing the WST (Previous model: M = 1.08, SD = 0.277; New model: M = 1.22, SD = 0.624).

2. I am confident of accurately identifying all the signs of dysphagia during the WST (Previous model: M = 1.08, SD = 0.277; New model: M = 1.23, SD = 0.567). 

3. I am confident of performing the WST independently (Previous model: M = 1.15, SD = 0.555; New model: M = 1.22, SD = 0.563).

C. Comparison of Learner-Reported Outcomes

Scores from the new evaluation form (mean ranks = 62.76, 63.03, 62.90) were higher than scores from the previous form (mean ranks = 60.31, 57.96, 59.08) for all three statements. A Mann-Whitney U test indicated that the differences in scores between the previous and new model for all three statements were not statistically different, U_Statement1 (N_new = 111, N_previous = 13) = 693.00, z = -0.438, p = 0.661; U_Statement2 (N_new = 111, N_previous =13) = 662.50, z = -0.786, p = 0.432; U_Statement3 (N_new = 111, N_previous = 13) = 677.00, z = -0.608, p = 0.543. 

The above data set and analysis is available online (Yong et al., 2020).

IV. DISCUSSION

A. Efficiency of New Training Model

The new training model was more efficient than the previous model. Comparing the average number of providers trained per month, the new model was 25 times more efficient. Engagement of SPs allowed more staff to be trained in a single session by seven-fold, versus training with actual patients. Several factors made the new model more efficient: i) greater control over scheduling, ii) saving time from identifying suitable patients for training, and iii) reduced motion waste from accessing actual patients. Hence, more nurses could be trained to meet the needs of outbreak wards.

B. Feedback on Training

The mean rating scores for the three statements in the new evaluation form indicated that providers were satisfied with their training, as they mostly agreed or strongly agreed to achieving the training learning objectives and were confident in performing the WST.

C. Comparison of Learner-reported Outcomes under Both Models

No significant differences were found between responses in the previous and new evaluation forms. Thus, regardless of whether providers trained with actual patients or SPs, most perceived they fulfilled their learning objectives and felt confident to perform the WST independently. These findings indicated that providers did not perceive their training quality to be compromised with the use of SPs and shorter training duration.

D. Limitations

A limitation was that only 25% of providers completed the optional evaluation form under the previous model. The staff who responded likely had a positive training experience and this could lead to potential selection bias. We also acknowledge that the three statements from the evaluation form require further validity and reliability testing to analyse providers’ confidence levels and can be explored in future studies.

V. CONCLUSION

Our study demonstrated that having standardised patients as part of the training method translated to a significant increase in the efficiency of WST training. Potential scale-up of this WST training method can ensure that there is a steady pool of providers and trainers in the workforce to cope during peacetime and crises. Adopting the WST as part of routine dysphagia screening ultimately ensures safer feeding management and early access to Speech Therapy intervention. Further directions include investigating the effectiveness and validity of the new WST training model in various healthcare settings, such as acute and community hospitals and nursing homes, to improve training standards for dysphagia screening in the region, especially in light of the ongoing COVID-19 pandemic.

Notes on Contributors

Yong Su Yi Melissa and Yong Xing Tong evaluated the training model, conducted the training and wrote the manuscript. Olga Hillary Chew Li conducted the training and performed data collection. Zenne T’ng Kuan Chen initiated the design of the training model and gave critical feedback to the writing of the manuscript. All authors read and approved the final manuscript.

Ethical Approval

This study has been reviewed by NHG Domain Specific Review Board (DSRB) for determination of ethics requirement and does not require formal review (NHG DSRB Ref: 2020/00953).

Acknowledgements

We would like to acknowledge:

Senior Nurse Educator Kylie Tang and Nurse Educator Zhao Yue for their feedback in the design of the training model, accessing training records for data collection and collaboration in facilitating WST training for the Nursing Services department.

Senior Speech Therapist Ei Leen Fong for vetting the final manuscript

Principal Speech Therapist Kwong Seh Ling for her guidance in the data analysis and feedback on the manuscript.

Funding

There is no funding involved for this study.

Data Availability

All available data can be accessed publicly via https://doi.org/10.6084/m9.figshare.13110617.

Declaration of Interest

The authors declare there are no conflicts of interest.

References

Betihavas, V., Bridgman, H., Kornhaber, R., & Cross, M. (2016). The evidence for ‘flipping out’: A systematic review of the flipped classroom in nursing education. Nurse Education Today, 38, 15-21. https://doi.org/10.1016/j.nedt.2015.12.010  

Kowitlawakul, Y., Chow, Y. L., Salam, Z. H., & Ignacio, J. (2015). Exploring the use of standardized patients for simulation-based learning in preparing advanced practice nurses. Nurse Education Today, 35(7), 894–899. https://doi.org/10.1016/j.nedt.2015.03.004

Pearce, J., Mann, M. K., Jones, C., van Buschbach, S., Olff, M., & Bisson, J. I. (2012). The most effective way of delivering a train-the-trainers program: A systematic review. The Journal of Continuing Education in the Health Professions, 32(3), 215–226. https://doi.org/10.1002/chp.21148

Suiter, D. M., & Leder, S. B. (2008). Clinical utility of the 3-ounce water swallow test. Dysphagia, 23(3), 244–250. https://doi.org/10.1007/s00455-007-9127-y

Yong, M., Yong, X. T., Chew, O., & Tng, Z. K. C. (2020). Training nurses to perform water swallow test with use of standardised patients (raw data & analysis) [Data set]. Figshare. https://doi.org/10.6084/m9.figshare.13435310.v2

*Yong Su Yi Melissa
Tan Tock Seng Hospital,
11 Jalan Tan Tock Seng,
Singapore 308433
Tel: +65 8522 8013
Email: melissa_sy_yong@ttsh.com.sg

Submitted: 31 August 2020
Accepted: 9 December 2020
Published online: 13 July, TAPS 2021, 6(3), 87-90
https://doi.org/10.29060/TAPS.2021-6-3/SC2394

Juanita S. M. Kong^1*, Boon See Teo^2*, Yueh Jia Lee¹, Anu Bharath Pabba¹, Edmund J.D. Lee¹ & Judy C. G. Sng¹

¹Department of Pharmacology, Yong Loo Lin School of Medicine, National University of Singapore, Singapore; ²Department of Family Medicine, Yong Loo Lin School of Medicine, National University of Singapore, Singapore

^*Equal contribution; first co-authors are in alphabetical order

Abstract

Introduction: With the COVID-19 pandemic, Singapore underwent a national lockdown in which most organisations, including schools were closed. Halting face-to-face tutorials resulting in decreased clinical contact for medical students. Prior to the pandemic, we had developed the Virtual Integrated Patient (VIP). Equipped with conversational technology, it provides students online practice in various clinical skills such as history-taking, physical examination and investigations. The aim of this paper is to describe the supplementary use of VIP in the second-year class, in which a pilot study was conducted.

Methods: The VIP platform was introduced to the cohort and used to supplement the teaching of history-taking in the “Communication with Patients” (CWP) module for second-year students. Traditionally, CWP tutorials involve face-to-face history-taking from standardised patients (SPs). Students, who consented to participating in the trial, had an additional 3 weeks’ access to VIP to practice their history-taking skills. They completed a survey on their user experience and satisfaction at the end of the 3 weeks.

Results: Out of the 106 participants, 87% strongly agreed or agreed that using VIP helped in remembering the content while 69% of them felt that VIP increased their confidence and competence in history-taking.

Conclusion: VIP was well-received by students and showed promise as a tool to supplement history-taking tutorials, prior to students’ encounter with SPs and real patients. Hence, this trend showed its potential as an alternative when clinical rotations were delayed or cancelled. Further research can be done to evaluate its effectiveness in this context.

Keywords:            Medical Education Tool, Virtual Patients, Communication, Skill Acquisition, Chatbot, Conversational

I. INTRODUCTION

Clinical skills that are commonly practised face-to-face were a challenge for students to practise during the onset of the Novel Coronavirus (COVID-19) in Singapore. Singapore underwent a 2-month lockdown during which time most non-essential organisations, including medical schools were closed nationwide. In our institution, lectures and tutorials were moved online and face-to-face clinical teaching on campus and in hospitals were cancelled. This move necessitated the use of virtual tools, such as remote meeting through Zoom and the use of virtual patient simulators that do not require the students to be physically on campus.

Virtual patient simulators have been used in a wide range of medical education settings, ranging from the teaching of clinical reasoning, procedural skills, communication skills, and integrated performance to critical thinking (Kononowicz et al., 2019). In recent years, there has been increasing use of virtual patients in the healthcare sector and technology improvements will continue to grow. The Virtual Integrated Patient (VIP) is a virtual patient simulator that was created by our team prior to the pandemic. It leverages on artificial intelligence (AI) technology advancements in the area of naturalistic conversational technology. Prior to VIP, existing technology platforms were focused on the linear, semi-linear and menu-driven (with drop-down option boxes) simulators and there were very few developed in free-text conversations (Kononowicz et al., 2015). The VIP has a natural language processor that is flexible to adapt and adjust to conduct a realistic conversation that can enhance specific skill acquisition (Cendan & Lok, 2012; Kononowicz et al., 2019).

The next unique feature of the VIP is the random patient generator (Figure 1a and b). Every time a student logs in, a new patient is generated. They can revisit the past patients if they have not completed the case and restart where they have left off. The random patient generator provides a realistic situation for users that no two doctors will see the same patient at the same time increasing in variability of patients and potentially, diagnoses. Users can also probe into their virtual patients’ history in their unique ways. Integration of natural language processing using conversational technology has allowed users to chat with the virtual patient as though they are chatting with a real person (Figure 1c). The virtual patient is trained with data sets and is AI-learning enabled. Wi-fi connectivity allows VIP to be accessed anywhere and at any time. It is a safe environment where students are able to make mistakes without any penalty and learn from it. VIP has interfaces for history-taking through a chatbot, physical examination, and laboratory investigations as seen in Figure 1c to d.

The aim of this short communication is to describe how VIP has been employed in a history-taking module for second-year medical students. VIP may play a role in providing a platform for users to consistently practise their skills during a global pandemic where face-to-face tutorials are limited.

Figure 1. a to d. Screenshots of the Virtual Integrated Patient (VIP) interface; b. An example of a random patient generator with no same patient; c. In the history-taking screen, the user can chat with a randomly generated virtual patient, who generates answers using the pre-loaded content and the natural language processor; d. Left: The physical examination screen. d. Right: The laboratory investigations screen which provides realistic case information given explicit buttons throughout interface for easy navigation. Bottom Panel: e to f: Skill Retention Confidence survey results.

II. METHODS

This study’s information sheet, study plan, instruction slides, and survey forms were submitted to the National University of Singapore’s (NUS) institutional review board (IRB) for assessment. It was approved with the study approval code of S-19-263.  

VIP was introduced to Phase II “Communications with Patients” (CWP) module in Academic Year (AY) 2019/2020. In this module, students usually clerk a total of three to six standardised patients (SPs) for three sessions over a course of 3 weeks. VIP was introduced to supplement the CWP curriculum. On top of clerking three to six SPs in 3 weeks, participants were given access to VIP during the same 3 weeks. VIP was loaded with cases that complemented and reinforced the contents taught during tutorials, with the aim to deepen students’ understanding of the tutorial content and train them to use the history-taking framework taught during the module.

The VIP team introduced the VIP computer programme and how to use it during the first lecture of the CWP module. Recruitment was done and informed consent was taken from the willing participants for the study. All Phase II students enrolled in the course (n=296) were divided into two groups: the first group received access at the first tutorial (intervention group) and the other group with no access (control group). Eventually, all students from both groups (intervention and control) had received access to the VIP by the end of first week and they could practise over the remaining 2 weeks of the study. Participants were asked to complete a survey at the end of 3 weeks. This is to provide an insight on their confidence levels in executing the history taking exercise and key takeaways with VIP usage at the end of the study.  

Students who declined to participate in the study would still have received access to the VIP, but only after the study period of 3 weeks. This ensured fairness for all second-year medical students to have 6 months to practice on the VIP system before their OSCE (Objective Structured Clinical Examination) at the end of the semester.

Following the 3 weeks of tutorials, students were encouraged to continue practising using the VIP prior to the OSCE which was scheduled to be at the end of the academic year. The original study protocol included collection of participants’ history-taking scores at the OSCE, but this was not possible as the OSCE was cancelled due to the COVID-19 situation in Singapore.

III. RESULTS

We obtained quantitative survey responses (n=106 respondents out of 298; 35% response rate). They indicated positively to VIP with 87% of students feeling that using VIP helped in remembering the content. And 69% of the students strongly agreeing or agreed that VIP increased their confidence in taking history (Figure 1f and g).

Students also provided qualitative responses of the key takeaways with the supplementary usage of VIP with their curriculum. First, they indicated that they were able to execute the history-taking procedures more efficiently with additional practice on the VIP. Second, students indicated that they could better remember the methodological content taught in class after repeated usage, thus reinforcing the procedural history-taking skills. Last but not least, survey respondents also reported enhanced understanding of the multiple facets of presenting cases. Where they learnt more about each diagnosis from the summary page after each case completion. 

IV. DISCUSSION

VIP was well-received by students in CWP. Users’ survey responses reiterated that more practice aided their skill acquisition, helping them to score in their examinations. By keeping the simulation realistic, they could transfer the skills back into their clinical attachments in future. Also, adding VIP supplementary to the planned curriculum, students were provided additional practice that past years students have requested for in course feedback.

Traditionally, CWP students could only clerk three to six SPs during the whole course of module over a span of 3 weeks. Thereafter, they would not have any chance to practice their history-taking skills through the clerking of SPs until their OSCE which would happen half a year later. Over the years, students provided feedback that they did not receive adequate practice prior to the OSCE and practising on their friends was not feasible due to the hectic nature of their curricular commitments. However, this barrier could not be overcome due to the constraints of the packed timetable of the Phase II students. Therefore, current phase II students who reported that VIP enhances their efficiency and has provided them with adequate practice suggest that VIP is a promising supplement for the course.

One key objective of the VIP is to focus on the processes of getting to a diagnosis rather than just the right diagnosis itself. Medical students’ focus usually stems from the diagnoses to symptom as they are taught in that framework. The enhanced understanding of case definition through the case summaries were welcomed due to the realistic nature of their experiences and how it can be related in the actual clinics. This therefore enhances the students’ enthusiasm toward the usage of the platform. Furthermore, the intention of this was to ease the performance anxiety faced by the students by preparing them in a low-stakes environment, helping them to boost their confidence, in facing SPs or real patients. The study results resonated with this purpose as the students reported greater confidence and efficiency in taking family history after using VIP.

Moreover, the availability of VIP appealed to the students. Due to their curricular commitments, students are more often than not, on the go. While travelling or waiting for a class, where there is available Wi-Fi connectivity, they can log on and practise clerking patients on the simulator. Some students who were not able to attend tutorials were slightly disadvantaged as they would lose one or two SP clerking from the 3 weeks.

V. CONCLUSION

With greater confidence and better utilisation of CWP framework among the students who utilised VIP, VIP is promising as a tool to supplement face-to-face history-taking tutorials. It may have potential use in a pandemic situation where medical students have reduced access to in-person clinical teaching. However, further research is needed to establish its effectiveness as an alternative to in-person clinical teaching.  

Notes on Contributors

Author 1, Juanita Kong, was involved in the data collection, analysis, writing, reading, and the final submission of this manuscript. Author 2, Teo Boon See was involved in the planning and execution of this study, writing, reading, and the submission of this manuscript. Both Authors 1 and 2 have equal contribution to the manuscript. Author 3, Lee Yueh Jia, was involved in the data collection, analysis and the reading of this manuscript. Author 4, Anu Bharath Pabba, was involved in the data collection and programming of the tool. Author 5, Edmund Lee was involved in the conceptualisation of the study, data collection, analysis, reading and the final approval of this manuscript. Judy Sng, was involved in the conceptualisation of the study, data collection, analysis, reading and the final approval of this manuscript.

Acknowledgements

We would like to thank the students who participated and provided us with additional feedback when we requested for it. Additionally, we would like to thank all the people who has helped us along the way. Last but not the least, we are grateful for the people who believed in this project.

Funding

The development of the VIP was initially funded by the MOE Tertiary Research Funding (2018 to 2020). It is currently supported by the Yong Loo Lin School of Medicine, under the Innovation Project. 

Declaration of Interest

There are no conflicts of interests in this study.

References

Cendan, J., & Lok, B. (2012). The use of virtual patients in medical school curricula. Advances in Physiology Education, 36(1), 48–53. https://doi.org/10.1152/advan.00054.2011

Kononowicz, A. A., Zary, N., Edelbring, S., Corral, J., & Hege, I. (2015). Virtual patients – What are we talking about? A framework to classify the meanings of the term in healthcare education. BMC Medical Education, 15(1), 1–7. https://doi.org/10.1186/s12909-015-0296-3

Kononowicz, A. A., Woodham, L. A., Edelbring, S., Stathakarou, N., Davies, D., Saxena, N., Tudor Car, L., Carlstedt-Duke, J., Car, J., & Zary, N. (2019). Virtual patient simulations in health professions education: Systematic review and meta-analysis by the digital health education collaboration. Journal of Medical Internet Research, 21(7), e14676. https://doi.org/10.2196/14676

*Judy C. G. Sng
Department of Pharmacology,
Yong Loo Lin School of Medicine,
National University of Singapore
MD3, 16 Medical Drive #04-01
Singapore 117600
Tel: +65-65163676
Email: phcsngj@nus.edu.sg

Submitted: 30 August 2020
Accepted: 12 November 2020
Published online: 13 July, TAPS 2021, 6(3), 83-86
https://doi.org/10.29060/TAPS.2021-6-3/SC2390

Rahman Habeebul

Department of Psychiatry, Tan Tock Seng Hospital, Singapore

Abstract

Introduction: Archetypes in psychology are complete models of behaviours, thoughts and feelings, representative of universal experiences. From Plato’s description of Forms to Jung’s analytical introduction to archetypes in psychology, to common use of Moore’s masculine archetypes in popular culture, we use such “complete representations” to enable change.

Methods: In examining psychologically driven responses to the recent and ongoing pandemic crisis, the use of a graphic representation of interacting archetypes is proposed—the ‘archetypogram’.

Results: Drawing on concepts from psychodynamic therapy practise, including Transactional Analysis and Jungian theory, four main archetypes are proposed for their interdependence—the prisoner, the soldier, the sage and the jester/trickster, and a model describing their interactions is presented with the intention of enabling helpful behaviours in response to crisis. The model further proposes positive and negative positions within each archetype, labelled as ‘creating’ and ‘consuming’ behaviours respectively. The ‘archetypogram’ thus is a visual representation of three main components – the four archetypes, creating vs consuming behaviours, and movement between the various positions. Use of the ‘archetypogram’ is aimed at enabling individuals in crisis to move from consuming to creating behaviours.

Conclusion: The ‘archetypogram’ is a model of change which may be applied to persons distressed in crisis, and is able to move behaviours towards positive and creating self-states.

Keywords:            Archetypes, Psychology, Crisis, Distress

I. INTRODUCTION

This was a crisis borne on the wings of travellers, leaving in its wake the term ‘a new norm’. In reflecting on observed and experienced emotional responses to the crisis, a structure emerged that identified three main themes—1) feelings of helplessness 2) seemingly never-ending activity and 3) a wish to be able to rise above billowing waves of information and misinformation.  Hence the archetypes of a prisoner, a soldier and a sage seemed appropriate.

It was expected that psychological reactions of anxiety, worry, grief and helplessness would run their course in this new crisis, but behavioural responses were unpredictable, from hoarding of toilet roll to disregard of rules and breaking of lockdown laws, to apathy. Why was there a difference between a leader of a nation (Luce, 2020) and a 9-year-old girl (Harris, 2020); one denying the problem at its outset, and the other, deciding to sew personal protective equipment (PPE) gowns to help her local doctors? What enables one person to do what needs to be done in crisis, and yet paralyses another into inaction? Many concepts have been put forth, with names such as grit, resilience, and growth mindset, but are there quick descriptors we can apply, that can help us move out of unhelpful states into more effective, useful ways of being?

II. OBSERVATIONAL PERSPECTIVE

We gravitate towards archetypes—“whole” descriptions of images that we identify with externally, and which we identify within ourselves internally. Jung’s description of archetypes has enabled a scaffold on which we can build our understanding of basic human reactions and behaviours in a Gestalt manner. In archetypes we unite both unconscious and conscious domains of being, and place intention second to observation.

The first evident experiences observed in the thick of the outbreak were feelings of being stuck, or being held hostage by the situation with feelings of helplessness that imprison the person. The prisoner was both angry and sad, and endured a mind filled with comparisons e.g. “Were there other prisoners being better treated? Was the suffering equal? Would someone else gain whilst we were denied of something possibly essential to our well-being, such as PPE?” Locus of control was felt externally (Rotter, 1954).

Amongst those who would put action to thought, a different set of behaviours was noted. There was a sense of constant effort, of having to negotiate endless tasks for a small ‘win’. Life was a blur of activity with anticipation of further problems, and resentment (signalling a slip back into prisoner state), but most times the effort of doing kept away negative emotions. This seemed to be the role of a tireless soldier, who would get wounded through unpreparedness.

There was yet a third group, who seemed untouched by the outbreak. They would go about their usual activities, or turn to alternatives effortlessly. This group I called the sage, and hypothesised that few of us would achieve the transcendental nature they exuded, in keeping with Maslow’s topmost hierarchy of being values (Maslow, 1998). 

However, referencing Transactional Analysis (Berne, 1961) where the ego-states of Parent, Adult and Child were further divided into negative and positive functional states depending on how stable they were, a further split within the three archetypes could be seen, with negative positions and positive positions. Hence, for the prisoner archetype, whilst inactivity was observed as a behaviour, the prisoner in a positive position was able to plan, or conserve parts of themselves for further action, to either rise as a soldier or guide as a sage.

The positive position of soldier archetype was decisive, enabling energy to effect change without burning themselves out, and able to make difficult decisions. Behaviour was internally motivated and pragmatically guided by agency. 

For the sage archetype, the positive position enabled them to nurture those around, lending stability to the system while being transcendental- as encompassed in the description by Maslow who placed this at the apex of the hierarchy of needs. Such a person is ‘care-ing’, not just caring of those around him or her, but also actively engaged in ‘care’ which is a constant state of being present.

III. INTERVENTIONAL PERSPECTIVE

Pathological emotions, thoughts and behaviours were proposed to arise from a primary prisoner state. Subsequently, as responses to helplessness and anger, three main behaviours were noted. 1) Continued inactivity (staying in the helpless prisoner state). 2) Busyness in ‘doing’, but where excessive activity was used to deflect uncomfortable feelings of helplessness (escape into soldiering) or 3) Non-responsiveness, where the uncomfortable feelings are avoided altogether (escape into sageing). These corresponded to efforts to defeat the source of conflict, but being ineffective, resulted in inaction (self-defeat), ineffective activity (other-defeat) or avoidance (reality-defeat).

Figure 1.  The Crisis Archetypogram

If we were to look to the negative positions, we see the behaviours as ‘consuming’, where either time, effort or emotional energy are consumed with poor outcomes, or no change in adapting to crisis.

If we were to look to the positive positions, we see the behaviours as ‘creating’ – ideas are born, work is done to engage parts of the system, there is nurturing of others and effort is concise, allowing adaptation and solving of problems.

In looking at ‘creating’ from the positive position, a further archetype emerges—that of the jester. This was the archetype who was flexible and not imprisoned, not always embattled nor always aloof and calm. This archetype would defuse tense situations with humour as a mature defence mechanism. The utility of the jester lies in the ability to bind people (and oneself) to a common cause; in the absence of hugs, laughter does a fair job of oxytocin production, and of fostering attachment. Pulled into negativity however, the jester’s negative position manifests as a trickster who would undermine with cunning the work done by the planning prisoner, the decisive soldier and the nurturing sage. The trickster at work was observed in the form of self-sabotage, or by disrupting efforts of the group with jokes belittling the efforts of others.

 A. Completing the Circle – The ‘Archetypogram’

The ‘Archetypogram’ in Figure 1 seeks to visually represent the interconnectedness of the various archetypes, in positive (creating) and negative (consuming) positions. How may we use such a crisis archetypogram to help ourselves and those around us?

The first step would be to identify where we are in the archetypogram—remembering that the position we are holding is temporary and a state (a current and temporary manner of being or interacting in domains of thoughts, feelings and behaviour), not a trait (longer term more durable repeated patterns of interactions).

The second regular step is to move to creating rather than consuming, and meeting the needs of the future instead of being mired in the past. In times of crisis, resources are limited. By moving to a creating state (which is often creative), we make better use of resources available, or contribute more if we agree to change. In a consuming state, time is a price to pay for opportunity lost when not moving forward, even if no other resources are used (anxiety paralysis).

B. Limitations in Change

Having applied the archetypogram in change management, limitations in effectiveness have been observed in situations where either there was a clinical disorder giving rise to anxiety and depression, or if there was resistance to the idea of change being possible within the archetypogram (similar to being in the pre-contemplative state of change). It is hoped that with development of the archetypogram, limited therapy sessions may be used to address clinical disorders. 

IV. CONCLUSION

Whilst it is ideal that we move in the general direction of actualization we need to be mindful of limitations in resources; flexibility in approach is paramount, as is being kind to ourselves no matter the approach we adopt.

In a crisis, the ‘work to do’ therefore is to:

1. Identify the state we are in – Prisoner/ Soldier/ Sage/ Jester-Trickster.

2. Identify the outcome of our behaviours – creating or consuming.

3. Identify how we can move ourselves from a consuming to a creating position, first by moving within our archetype (e.g. from angry/ helpless prisoner, to a conserving/ planning prisoner), then up archetypes (eg on to a decisive soldier, and eventually to a nurturing and care-ing sage). The movement can be internal via self-awareness (a practiced skill incorporating conservation of energy by mindfulness/ relaxation exercises and problem solving) or external via a coach, counsellor or therapist.

4. Be aware of the tendency to move upwards within the consuming rank states where avoidance and burnout from the sage and soldier states respectively can reinforce a primary angry / helpless prisoner’s distressed negative position.

5. Be mindful that the distressed position is often at the base of what one feels and thinks as ‘problems’. Emotional responses of grief, anxiety and anger arise from helplessness or loss, and these responses can be true of individuals as well as groups, but still amenable to working through with the aid of the archetypogram.

In conclusion, while the use of archetypes in verbal tradition is established, the visual archetypogram proposes an exciting model to move behaviours in crisis towards positive and creating self-states, in fields ranging from coaching, to counselling, to psychotherapy.

Note on Contributor

Dr Habeebul Rahman is solely responsible for all observations and ideas contained within this manuscript.

Ethical Approval

Ethics review (including informed consent) was not sought for this manuscript owing to the hypothetico-deductive nature of the paper.

Acknowledgement

The writer wishes to acknowledge TTSH Department of Psychiatry, Organisational Development and Operations for their contribution to the development of this work.

Funding

No funding was sought or obtained for this paper.

Declaration of Interest

No conflicts of interest.

References

Berne, E. (1961). Transactional analysis in psychotherapy: A systematic individual and social psychiatry. Grove Press.

Harris, E. (2020, May 11). For Malaysian schoolgirl, homework is sewing PPE gowns to help beat coronavirus. Reuters https://www.reuters.com/article/us-health-coronavirus-malaysia-protectiv-idUSKBN22N037

Luce, E. (2020, May 17). Inside Trump’s coronavirus meltdown. The Straits Times. https://www.straitstimes.com/world/united-states/inside-trumps-coronavirus-meltdown

Maslow, A. H. (1998). Toward a psychology of being. Wiley.

Rotter, J. B. (1954). Social learning and clinical psychology. Prentice-Hall.

*Rahman Habeebul
Tan Tock Seng Hospital,
11 Jalan Tan Tock Seng,
Singapore 308433
Email: habeebul_rahman@ttsh.com.sg

Submitted: 16 July 2020
Accepted: 16 September 2020
Published online: 13 July, TAPS 2021, 6(3), 95-98
https://doi.org/10.29060/TAPS.2021-6-3/SC2342

Shin Ying Thng, Bao Yu Geraldine Leong, Guat Keng Yvonne Goh, Ching Ching Elaine Tan, Jimmy Kock Keng Goh & Kaibin Kelvin Kuan

Emergency Department, Changi General Hospital, Singapore

Abstract

Introduction: Singapore was one of the earliest countries affected by the COVID-19 outbreak, requiring our emergency department to respond urgently to this surge. A designated Fever Area (FA) with a resuscitation room was rapidly set up to manage patients at risk of COVID-19. Our paper describes measures put into this new area to optimise safety outcomes of these patients.

Methods: Plan-Do-Study-Act (PDSA) cycles incorporating in-situ simulation in the FA resuscitation room were conducted. Using varied resuscitation scenarios and facilitated debriefing, we identified safety gaps and took immediate steps to rectify them in a collaborative manner involving various respective stakeholders.

Results: Following reflective debriefing and studying of work processes, latent safety threats were identified resulting in successful improvements and modifications to protocols, equipment, staffing and processes in the FA resuscitation area.

Conclusion: PDSA cycles involving in-situ simulation helped to identify safety threats and refine work processes in a newly set up FA facility. As a result, our healthcare team was more prepared to manage the complexities of COVID-19 patients in a high-risk environment.

Keywords:            Simulation, COVID-19, Medical Education

I. INTRODUCTION

Singapore was one of the first countries to be affected by the COVID-19 pandemic and has the highest number of Covid-19 cases in South East Asia to date. When the COVID-19 outbreak first reached Singapore, healthcare facilities had to prepare for a surge of patients with suspected or confirmed COVID-19. Our Emergency Department (ED) serves a 1006 bed hospital and sees an average of 400 patients daily pre-COVID-19. We were required to quickly reconfigure our space, equipment and staff. There was a need to segregate high risk or suspect COVID cases to be seen in a separate area in order to minimise cross-infection risks to our vulnerable patients. There was also a need to limit exposure of high-risk patients to a designated team of doctors and healthcare professionals in order to ensure continuity of services.

An area comprising the original admission transit area (with three isolation negative pressure rooms) and unused outpatient clinics next to the main ED underwent reconfiguration to become the new designated Fever Area (FA). This was to allow easy access to shared ED resources. The new FA had a combined capacity of 58 patients. Two FA resuscitation rooms were set up to cater for rapidly deteriorating patients that will require endotracheal intubation and resuscitation, both for COVID related complications as well as non-infectious related medical emergencies, such as an acute myocardial infarction or an acute surgical abdomen. Adequate resuscitation and stabilisation facilities in the FA were needed to minimise unnecessary movements of these infectious critically ill patients to the resuscitation area in the main ED, thus, decreasing the risk of cross-infection in other personnel.

The first few patient resuscitations conducted in the FA were challenging. There were many issues raised by the healthcare team concerning resuscitating and performing high-risk procedures in an unfamiliar environment. The FA team recognised an urgent need to improve system workflow competence in the FA resuscitation area. The healthcare team had to be shown that the improved FA resuscitation rooms were as well equipped as the main ED resuscitation area to handle critically ill patients and that such patients can be stabilized effectively there.

II. METHODS

In-situ simulation was the chosen modality as many of the difficulties encountered were systemic issues related to acute care in the unfamiliar FA resuscitation rooms and appropriate usage of Personal Protective Equipment (PPE) in such a scenario. In-situ simulation occurs where the case scenario is simulated in the actual clinical care area with real inter-professional teams instead of in an artificial setting in the simulation centre. By carrying out in-situ simulation, the team hoped to be able to recognise and remedy potential active failures and latent threats (Couto et al., 2018) present in the FA resuscitation rooms before any real-life adverse outcomes (Raemer et al., 2018) can occur.

Four emergency physicians and two nurse clinicians experienced in simulation design and debriefing conducted four in-situ simulation sessions with a high-fidelity mannequin in the FA (Dieckmann et al., 2020). Safety of all faculty, staff and patients were a priority and careful measures were taken to ensure participants and patients were not put at risk by simulating in-situ (Knight et al., 2018). Simulation sessions were conducted at the time of lowest patient load and all participants were outfitted in full PPE. They were also educated prior on potential safety hazards of in-situ simulation. Participant numbers for each simulation session were kept small at five to six with two facilitators.

The simulation scenarios, comprising of COVID-19 patients deteriorating from acute myocardial infarction, respiratory failure and cardiac arrest, were designed to challenge the complexities of adapting clinical management, manpower and equipment requirement and existing workflows to an infectious setting.

A multidisciplinary team comprising of eight nurses, six doctors and two radiographers involved in patient care at the FA participated in four simulation sessions held over two months. Verbal informed consent was taken from participants prior to simulation and confidentiality of participants was ensured. Centralised Institution Review Board (CIRB) review was submitted and waiver of consent was obtained. After each simulation scenario, formalised debriefing was carried out immediately, focusing on work process issues, communication failures and latent threats identified within the FA. Questions were crafted to guide participants to attain dialogical reflection and to move past a description of errors. They were encouraged to consider the implications of observations and come up with solutions for change using Fleck’s framework of reflection levels (Kihlgren et al., 2015).

The list of ideas generated was gathered and studied for common themes. A separate session was held where clinical, operational and administrative representatives brainstormed to find feasible and practical solutions to each problem identified. Immediate steps were taken to implement improvements and modifications to clinical protocols, equipment, staffing and workflows. Plan-Do-Study-Act (PDSA) quality improvement cycles were used to evaluate the improvements instituted after each simulation. This was carried out by a multidisciplinary team, comprising of medical, nursing and allied health staff.

III. RESULTS

The latent safety threats that surfaced were broadly categorised into five descriptive categories: Equipment, Organization, Staffing, Communication and Protocol (Refer to Table 1).

Table 1: Results

In-situ simulation uncovered the problems of insufficient Powered-Air Purifying Respirators (PAPR) and viral filters, as well as, missing defibrillator pads and bag valve masks from resuscitation trolleys. A checklist of essential equipment and medications was created with mandatory checks and re-stocking carried out by the FA nurses every morning. Medications vital for resuscitation were also found to be inadequate. A pharmacist was recruited to draw up and stock an essential list of drugs in the FA. Medications, which required refrigeration, were packed in a portable box so they could be easily brought to the FA resuscitation room from the fridge when required. Drug and resuscitation charts were put up as reminders and easy reference to improve patient safety.

Workspace organization issues that surfaced from in-situ simulation included the need to maintain patient privacy with mobile screens during resuscitation. Confusion over the head-foot orientation of the trolley bed resulted in suction and oxygen ports being too far for efficient use when it was placed in the wrong configuration. To correct this, the FA resuscitation room floor was labelled with tape indicating the proper orientation. The small FA resuscitation room area made manoeuvring equipment, trolleys and personnel difficult. Efforts were taken to re-site equipment to specific demarcated areas outside the FA resuscitation room, with the added benefit of reducing equipment contamination. A crisis phone was set up so that existing staff in FA could quickly call for additional staff deployment in event of a surge, thus improving communication and increasing situational awareness of the entire department to emergent needs at the FA.

Protocols were also adapted to the needs of the FA. During a resuscitation scenario, too many healthcare workers crowded into the room, raising a safety concern. It was protocolised that staff numbers should be minimized in the FA resuscitation room, especially during Aerosol Generating Procedures (AGP). PPE use was a barrier to communications, with “handovers” and “read back” being disrupted or unclear. The importance of adhering to these communication tools was reinforced. There was no fixed route identified for the transport of infectious patients to critical inpatient areas, thus, these were delineated so as to minimize confusion and decrease the infectious footprint, and risk of cross-infection to others. Staff protection during AGP was found to be inconsistent; hence PPE education was reinforced and educational resources provided to staff.

IV. CONCLUSION

Many issues were surfaced and lessons learnt via in-situ simulation, which allowed immediate risk mitigation to be carried out. Simple, immediate changes were made in FA with the available resources, resulting in improved patient and staff safety—which is especially important during surges due to the COVID-19 pandemic. We have successfully used in situ simulation with PDSA cycles to test and develop new facilities and protocols whilst managing the demands of a pandemic.  Similar outcomes had also been demonstrated in other in-situ simulation studies. Using this modality to test pre-existing protocols and equipment in the FA resuscitation rooms offered an opportunity for the identification of potential threats and service gaps that would otherwise not have been detected as efficiently via conventional reporting systems (Knight et al., 2018). This method of PDSA testing is useful in the rapidly evolving COVID-19 situation, and may be replicated in other hospitals and regions safely when required. It ensures the safety of healthcare workers and actively improves patient safety despite the limitations of the pandemic.

A follow-up study to look at the usage of the FA resuscitation area, number of critically ill patients in the FA being transferred into the main ED resuscitation room, and patient morbidity and mortality data would be necessary to further determine the success of our intervention at a higher Kirkpatrick level of behavioural change to improve patient outcomes in the FA.

Notes on Contributors

Dr Elaine Tan carried out the literature search and instituted the changes. Dr Geraldine Leong ran the simulation, wrote the manuscript and instituted the changes. Dr Jimmy Goh set up the fever area, advised regarding the manuscript and instituted the changes. Dr Kelvin Kuan ran the simulation, wrote the manuscript and instituted the changes. Dr Thng Shin Ying designed the simulation, ran the simulation, and wrote the manuscript. Dr Yvonne Goh designed the simulation, ran the simulation and wrote the manuscript.

Ethical Approval

This study was exempted from CIRB review- 2020/2640.

Acknowledgements

The authors would like to acknowledge the staff of Changi Simulation Institute for their technical help and assistance with this project. We would also like to thank Dr Syahid Hassan for providing his expertise in the methodology of this project.

Funding

No funding was required.

Declaration of Interest

The authors state no conflict of interest.

References

Couto, T. B., Barreto, J. K. S., Marcon, F. C., Mafra, A. C. C. N., & Accorsi, T. A. D. (2018). Detecting latent safety threats in an interprofessional training that combines in situ simulation with task training in an emergency department. Advances in Simulation, 3(1), 23. https://doi.org/10.1186/s41077-018-0083-4

Dieckmann, P., Torgeirsen, K., Qvindesland, S. A., Thomas, L., Bushell, V., & Langli Ersdal, H. (2020). The use of simulation to prepare and improve responses to infectious disease outbreaks like COVID-19: Practical tips and resources from Norway, Denmark, and the UK. Advances in Simulation, 5, 3. https://doi.org/10.1186/s41077-020-00121-5

Kihlgren, P., Spanager, L., & Dieckmann, P. (2015). Investigating novice doctors’ reflections in debriefings after simulation scenarios. Medical Teacher, 37(5), 437-443. https://doi.org/10.3109/0142159X.2014.956054

Knight, P., MacGloin, H., Lane, M., Lofton, L., Desai, A., Haxby, E., Macrae, D., Korb, C., Mortimer, P., & Burmester, M. (2018). Mitigating latent threats identified through an embedded in situ simulation program and their comparison to patient safety incidents: A retrospective review. Frontiers in Pediatrics, 5, 281. https://doi.org/10.3389/fped.2017.00281

Raemer, D., Hannenberg, A., & Mullen, A. (2018). Simulation safety first: An imperative. Simulation in Healthcare, 13, 373-375. https://doi.org/10.1097/SIH.0000000000000341

*Thng Shin Ying
Changi General Hospital
2 Simei Street 3
Singapore, 529889
Email: thng.shin.ying@singhealth.com.sg