Published online: 7 January, TAPS 2020, 5(1), 76-78
DOI: https://doi.org/10.29060/TAPS.2020-5-1/PV1083

C. Rajasoorya

Department of General Medicine, Sengkang General Hospital, SingHealth, Singapore

I. INTRODUCTION

II. BAPTISM INTO CLINICAL TEACHING

I embarked on teaching medical students because I did not want them to encounter the same struggles I had with learning voluminous medical facts and lists. Moving into clinical years and with more experience, I understood the importance and applicability of basic sciences with greater clarity. As a way of guiding juniors and preparing for my own higher examinations, I got interested in teaching clinical medicine. Repeatedly ringing in me is what a clinical-skills foundation teacher profoundly reminded us that teaching is a way to expose our knowledge gaps and help us remember better. Being fortunate to have been taught by some of the doyens of medicine as well as having a high clinical load, it surprises me on how much I learnt from both my students and patients.

III. REJUVENATION AND EVOLUTION

Once, I had wrongly succumbed to the idea “the new generation is different and is less interested in learning”. Disillusioned, I almost contemplated giving up teaching. Fortunately, I closely worked with a few brilliant, enthusiastic and hardworking interns who rekindled my interest in teaching and awakened in me the need to customise teaching to the generation we are dealing with (not vice versa). A teacher must accept that his experience in the early years will not mirror those of his students, rather than reminisce the past. The new generation is learning and practising in a different era where patient expectations are different, knowledge has been democratised and voluminous knowledge can be easily accessed via the internet and smartphones. Clinical teachers may take benefit to emphasise on clinical application and reasoning rather than factual content.

When I had a family of my own, the similarities between teacher-student and parent-child stirred in me the importance of ownership, responsibility, and avoidance of the remark “no time to teach”. It also dawned on me the extent of pressure we inflict on our students and how it contributes to vanishment of the joy of learning. I learnt that learning can be intuitive, varied and supplanted by metaphors of daily activities of life and knowledge application.

For a long time in my career, I used to go on an ordered line of questioning whenever I dealt with clinical groups. There was predictability who was going to be asked next. I learnt subsequently such an order of questioning stops the thinking process in all except the one in the “hot seat”; the rest passively “switched-off”. I have now adopted a routine (albeit, struggled) to get to know my students by name and ask questions in a random order which allows everyone to think; besides making them feel appreciated being called by their name.

I have found it useful to open difficult questions to the entire group – letting the student know it is a difficult question and providing a challenge to the brilliant to attempt it. At times I have openly admitted that I did not know the answer to that question at their age (or even later!). This resonates very well with students who feel teachers understand their difficulties. The dictum that no question is ever a stupid question cannot be overemphasised.

An experienced teacher can sense which student is struggling and distract attention quickly to another party so that the embarrassment to the individual struggling student is removed. It is important to recognise a student with the knowledge but hesitant to answer; cajoling the answer out of him is an art that comes with experience. Where a wrong answer is provided, it would be useful to ask for the reasoning rather than brush it aside with an emphatic “no”. A couple of years ago, I asked one of my rather always quiet students why she volunteered to be in the “hot seat” for a short clinical case – her answer of not being intimidated by me and having confidence that I would not embarrass her was a powerful lesson on how fear kills enthusiasm. I was fascinated to hear in later times that she had expressed a desire to be a clinical teacher!

Experienced teachers will be bold enough to admit they do not know. Admittedly, this was never easy for me during the growing years, until recent times. An occasional bright spark student may know the answer and he or she should be given credit for educating the teacher. Mutual respect promotes learning for all involved. Time and again, I had experienced and learnt from my colleagues (particularly from my overseas stints) of how protecting ego and hiding ignorance serves only to retard the process of learning. Eating humble pie may seem daunting and embarrassing, but I now accept it as fulfilling and enriching. Teaching and learning are intertwined and run in both directions – one must break the cultural barrier that the teacher has all the knowledge and the student some or none. It took a young medical officer to unravel a misconception I had for more than 20 years that chronic malaria and tropical splenomegaly syndrome were different entities.

We often do clinical teaching on cases we already know accompanied by its inherent biases. Teaching on cases we are blinded to is a mind-boggling experience. In the last few years, I have experimented and adventured with teaching on cases where I am blinded to the findings or diagnosis. Both the student and the teacher can learn a lot and we get better as we express our thoughts and disrobe our thinking processes openly. This to me is akin to practising clinical reasoning live.

Most of my initial clinical teachings concentrated on artificial situations where we selected “good cases” — this, unfortunately creates an artificial divide of what we see as clinicians and how patients present to us. I am even more convinced, over the years, that every case is a good case to teach; choosing the slant and emphasis in every situation is critical.

We tend to cram information to students, as much as I did in the past. Now, I ask myself before a tutorial or lecture on what is the primary target of my teaching. Teaching must be customised to the audience. I used to joke with my students in the early years whenever an examiner asks you for causes of a certain abnormality – a second-year student gives two, third-year student three and final year student gives five, as a rough rule. This joke highlights the need to avoid unintentionally submerging our students in a factual journey and overloading them, forgetting how we acquired skills in a graduated manner.

Leonardo da Vinci is attributed to suggesting that simplicity is the ultimate sophistication. Great teachers have a way of simplifying complex concepts. Nobel laureates Michael Brown and Joseph Goldstein likened lipoprotein traffic to navigating the maze in the London underground system while explaining lipoprotein metabolism. Prober and Heath (2012) remind us of the importance of making lessons “stickier” by making it comprehensible and memorable. Efforts to make things “simple is often harder than complex”, as profoundly highlighted by Steven Jobs (as cited in Reinhardt, 1998).

IV. PRINCIPLES AND PHILOSOPHIES

Over the decades, I have gradually moulded myself into believing in some philosophical concepts on clinical teaching shared below:

1. Clinical teaching can be likened to planting a seed in a soil (student in the health care environment). We need to ensure the presence of sunshine, rain (stimulus) and fertile soil (conducive environment); as in nurturing, the wind (pressure and currents) cannot be too strong. A clinical teacher must look after the student welfare in preventing burnout, disillusionment or wilting away.
2. For busy clinicians, giving committed time and effort to teaching can be challenging. It is worthwhile reminding us that to be a “doctor” means “to teach”. With ownership, we never generally say we lack time or rewards to teach and guide. Sharing our experiences and difficulties make students feel they are in good company.
3. Teachers must learn to squeeze the best out of their students rather than looking negatively at their lack of knowledge. Beneath every “F-student” is an “A student” waiting in line and time to pop-out! A teacher must take part-responsibility and embarrassment for students’ failures, as much as we take pride and pleasure in their successes.
4. Teachers should take extra effort to simplify concepts and to remind themselves that if they face difficulty in understanding certain concepts, it is unreasonable to expect their students to grasp these same concepts easily.
5. Teaching should not concentrate on voluminous facts that are so easily accessible. It must be customised to deal with diversity in the audience as well as cater to the level of expertise of the student. Clinical teaching should focus on clinical reasoning.
6. We must be bold enough to try teaching methods to reflect the plasticity we have within ourselves to adapt, grow and regenerate our knowledge and its transmission.

V. CONCLUSION

Medical education has changed over the few decades that I have practised in. The fundamentals have remained – to train our doctors as future physicians and specialists. The core values must be preserved while stimulating progress incorporating new ways of practice. Experience and reflections are excellent tools in our armamentarium of methodologies. I have never regretted my adventure into clinical teaching.

Notes on Contributors

Professor Rajasoorya is a senior consultant, endocrinologist, Campus Education Director at Sengkang General Hospital; clinical professor at NUS School of Medicine; and adjunct professor of Duke-NUS Medical School. He has undertaken various leadership, administrative/advisory positions in medical education, curriculum development and is the recipient of numerous education and teaching awards.

Acknowledgements

I gratefully acknowledge the inspiration, experience, and knowledge of my students, my patients and my teachers that has moulded my philosophy in teaching.

Funding

No funding was obtained in the preparation and production of the paper.

Declaration of Interest

The author declares no conflict of interest, including financial, consultant, institutional and other relationships that might lead to bias or a conflict of interest.

References

Reinhardt, A. (1998, May 25). Steve Jobs: ‘There’s sanity returning’. Bloomberg Businessweek. Retrieved from https://www.bloomberg.com/businessweek

Prober, C. G., & Heath, C. (2012). Lecture halls without lectures – A proposal for medical education. The New England Journal of Medicine, 366(18), 1657-1659.

*C. Rajasoorya
Department of General Medicine,
Sengkang General Hospital,
110 Sengkang East Way,
Singapore 544886
Tel: +65 6930 2221
Email: c.rajasoorya@singhealth.com.sg

Published online: 7 January, TAPS 2020, 5(1), 70-75
DOI: https://doi.org/10.29060/TAPS.2020-5-1/SC2065

Carmel Tepper, Jo Bishop & Kirsty Forrest

Faculty of Health Sciences and Medicine, Bond University, Australia

Abstract

I. INTRODUCTION

The medical education community is rapidly embracing workplace based assessment (WBA) as a more authentic form of assessment of medical students’ clinical competence. These clinical interactions are complex, with integrated competencies observed in real-life settings. For the safety of patients, however, it is essential that medical schools have evidence that their graduates have attained sufficient standards in core skills and activities as indicated by their relevant accrediting institutions’ graduating doctor competency frameworks. This includes evidence not only of sufficient maintenance of compliance documentation, attendance in clinical settings and teaching sessions, but also the ability of the student to interact competently with a variety of patients.

Student clinical placements within medical schools are often undertaken in multiple locations with a variety of clinical supervisors. At Bond University, Australia this process involves over 150 locations with up to 800 clinical supervisors observing, assessing and providing feedback on student performance. Previous manual, paper-based processes were inefficient, time-consuming, prone to error, and limited the opportunity for real-time feedback to students. Difficulty aggregating information resulted in difficulty making pass-fail decisions on student performance on rotation and delayed intervention for students requiring remediation for either compliance, attendance or clinical performance.

Whilst clear and validated documentation of proficiency required of a “work-ready” graduate is often challenging to obtain, this aggregation of multiple data points to build a more complete picture of student competence is central to the concept of programmatic assessment (van der Vleuten, 2016). A portfolio of evidence with timely feedback on performance is seen as essential for demonstrating the growing development of student clinical skills.

An electronic, or ePortfolio, represents the technological evolution from paper-based to electronic clinical assessments (Garrett, McPhee, & Jackson, 2013). There are multiple ePortfolios and learning management systems available which can be used in the workplace and electronically collect in-progress assessments and accomplishments (Kinash, Wood, & McLean, 2012). Some ePortfolios also allow students to manage continuing professional development. Bond Medical Program, however, sought to develop an ePortfolio specifically designed for undergraduate medical students that could aggregate not only attendance and compliance but also competency assessment data in a meaningful way to build an accurate picture of student competency in the hospital setting.

The aim of this short communication is to describe why and how a new version of a bespoke electronic portfolio was designed and implemented.

II. METHODS

Bond University partnered with a software company, which had healthcare experience, in the development of a digital student Clinical ePortfolio. The business requirement specification was for a fully mobile-enabled, secure, digital platform available on any device from any location that would allow a range of clinically relevant WBAs to be captured by clinicians “at the bedside” with the ability to provide immediate feedback to students. In addition, the software was to contain a process for students to provide evidence of compliance documentation and attendance at compulsory teaching sessions and on rostered placement shifts. The initial plan was to replicate all paper-based processes onto an electronic platform. The development of the software was iterative to the needs of the university using a road cycle improvement process. An app-based product was developed to house the clinical portfolio.

Table 1. Bond eportfolio features

In August 2017, the compliance portion of the portfolio was piloted with a single clinical year cohort of medical students and supervisors. In 2018, attendance and WBAs were conducted at the bedside of patients across all clinical years.

Delivering the project across many sites required the support of all supervisors, along with timely stakeholder engagement, and change management considerations. The needs of busy clinicians were surveyed, and a low-key launch by way of an online training video was preferred by the majority, with face-to-face on-site training available upon request. There are several barriers to timely feedback in the busy clinical environment with ‘opportunistic assessment’, multiple demands on clinician time and multiple students and/or trainees under supervision at any one time (Algiraigri, 2014). Feedback using the ePortfolio can be provided in the moment, recorded as either typing or voice recording and reviewed by students within their own time. Feedback from clinicians described it as “easy to complete on the go” and “easy to assess then and there (at the bedside)”. Table 1 describes the features and benefits of the Bond ePortfolio.

An example of the compliance dashboard, and the assessment portfolio front page is shown in the Appendix.

III. RESULTS

The new platform successfully delivered the required features through the Bond Student Clinical Portfolio. The Portfolio is accessible to both student and supervising clinicians using mobile phones or office desktop computers. Students indicate their attendance using a GPS geolocating attendance application. Compliance documents, clerked cases, reflections and other assessment components including the final in-training assessment are uploaded for supervisor assessment, whilst Mini-Clinical Evaluation Exercises are now completed by supervisors using a mobile phone at the patient bedside. All assessments are housed in one cloud-based portal, accessible to the decision-making committees.

An added advantage of this system is improving student digital literacy and self-directed learning, assisting them to become familiar with the process of self-documenting evidence of competence and skills obtained a valuable and highly sought-after skill for a graduated doctor.

A. Workplace Based Assessment

Evaluation of the 2018 pilot demonstrated significant efficiencies in documentation collection of WBA. Previously, professional staff would have collated 2,350 components of high-stakes assessment per year to be reviewed and presented to the Board of Examiners (BoE). Faculty can now track student progress during clinical rotation, with a process in place to identify students who require additional support to succeed. Faculty receive automatic notifications for review of submitted assessment items. During meetings of decision-making committees such as the BoE, student assessment items can be viewed by the committee to verify students who are borderline or those who receive commendations.

B. Attendance

Key members of the medical programme have a ‘dashboard’ on their homepage with ‘live’ attendance data. The Professional Staff Team can run reports when required but the platform will monitor students who meet the nominated ‘concern’ percentage of missed sessions which notifies the team that a support email may be required. In our experience, concerns around student well-being often present with non-attendance patterns. Supervisors in the clinical setting can now electronically track the progress of students allocated to their teams during rotations. In addition, they can identify students who require additional support in a timelier manner, helping to provide the best education experience possible.

C. Feedback

The clinicians’ ability to utilise their preferred method of feedback delivery allows flexibility and improved engagement in the process. For instance, the ability to voice record was introduced, enabling students to immediately access assessor feedback. This has resulted in increased communication between students and their assessors and a very positive response from the student body.

Feedback on students’ experience of this platform has been sought through ongoing discussion with the initial pilot group, and regular updates on their learning management system, and representative year specific feedback through staff-student liaison committees. The attendance monitoring has had mixed reviews from students who “appreciate not having to sign in on paper” but have been impacted by technical issues around non-syncing with certain mobile devices.

IV. DISCUSSION

Our belief is that assessment within hospitals will encourage learning within hospitals. Our intention is to remove Objective Structured Clinical Examinations (OSCEs) from the final year assessment to be replaced with authentic WBAs that are reliable and valid. OSCEs will continue to be used in the earlier years of the medical programme. There may be limitations as the very nature of the hospital environment is opportunistic. Students will have multiple patient (data) interactions to support their developing portfolio with evidence of competencies achieved. Students can personalise their studies and identify areas of focus for skill development during placement, to ultimately build confidence in their work readiness as a day one doctor. Ultimately, assessment information “should tell a story about the learner” (van der Vleuten, 2016, p. 888).

This platform offers many advantages over other platforms. The selection of the software partner was a competitive process. A full needs analysis and tender process was performed which for brevity has not been presented here. The advantages over other platforms identified at procurement were the opportunity to customise and the ability to have all the processes (compliance, attendance, placement and assessment) on one platform. Subsequent advantages made clear after implementation, and not delivered by other platforms included; the ability for students to take the portfolio into the workforce, a dashboard for attendance, and working with a partner based in health care who understood all stakeholder requirements, with an emphasis on safe patient care.

The next step will be to utilise the platform for training, progression and maintenance of competency of procedural skills before graduation. Specific procedural skills, required by accrediting bodies and relevant to the year of learning, will be assigned to the student for completion during a rotation. The student, in addition to the routine clinical practice of for example intravenous cannulation, will observe an interactive learning module about that skill, complete a short assessment to test their understanding of the module, and the system will then generate an assessment assigned to a clinical supervisor. The student will then perform the skill on the patient and the supervisor will submit the completed assessment on a ‘trust level’ scale of competency (ten Cate, 2013). If the student is not yet able to perform the skill sufficiently independently, there are opportunities to practice and repeat the assessment until competency is obtained.

V. CONCLUSION

Digitising the processes for monitoring attendance, conducting and collating compliance documentation, clinical assessment and delivering feedback at sites of clinical exposure has created significant efficiencies in the delivery of our programme. Preliminary feedback indicates that this leads to a vastly improved student experience with real-time, enhanced feedback on assessment performance and timely student remediation to assist students in becoming safe and competent ‘work-ready’ doctors. Live updates that notify of absenteeism allow for more timely support and personalised care. The aggregation of data into one personalised student clinical ePortfolio will allow decision-making bodies to make intelligent and safe pass-fail decisions based on evidence of student clinical performance.

Notes on Contributors

Carmel Tepper is the Academic Assessment Lead at Bond University. She has a special interest in exam blueprinting, item analysis and assessment technologies.

Jo Bishop is the Academic Curriculum Lead and Associate Dean, Student Affairs and Service Quality at Bond University. Jo is an expert on curriculum planning and development and has a passion for enhancing the student experience.

Kirsty Forrest is the Dean of Medicine at Bond University. She has been involved in medical educational research for 15 years and is co-author and editor of several best-selling medical textbooks including ‘Medical Education at a Glance’ and ‘Understanding Medical Education: Evidence Theory and Practice’.

Ethical Approval

Ethical approval was not required.

Acknowledgements

An e-poster presentation on some of this work was presented at 15th anniversary APMEC and awarded a merit.

Funding

There is no funding involved for this paper.

Declaration of Interest

Other institutional uptake of the new designed Student Clinical Portfolio may financially benefit Bond University.

References

Algiraigri, A. H. (2014). Ten tips for receiving feedback effectively in clinical practice. Medical Education Online, 19(1), 25141. https://doi.org/10.3402/meo.v19.25141

Garrett, B. M., MacPhee, M., & Jackson, C. (2013). Evaluation of an eportfolio for the assessment of clinical competence in a baccalaureate nursing program. Nurse Education Today, 33(10), 1207-1213. https://doi.org/10.1016/j.nedt.2012.06.015

Kinash, S., Wood, K., & McLean, M. (2013, April 22). The whys and why nots of ePortfolios [Education technology publication]. Retrieved from https://educationtechnologysolutions.com/2013-/04/the-whys-and-why-nots-of-eportfolios/

ten Cate, O. (2013). Nuts and bolts of entrustable professional activities. Journal of Graduate Medical Education, 5(1), 157-158. https://doi.org/10.4300/JGME-D-12-00380.1

van der Vleuten, C. P. M. (2016). Revisiting ‘Assessing professional competence: From methods to programmes’. Medical Education, 50(9), 885-888. https://doi.org/10.1111/medu.12632

*Carmel Tepper
Faculty of Health Sciences,
Bond University,
14 University Drive, Robina QLD,
4226 Australia
E-mail: ctepper@bond.edu.au

Published online: 7 January, TAPS 2020, 5(1), 61-69
DOI: https://doi.org/10.29060/TAPS.2020-5-1/OA2152

Yoshitaka Maeda¹, Yoshikazu Asada², Yoshihiko Suzuki¹ & Hiroshi Kawahira¹

¹Medical Simulation Centre, Jichi Medical University, Japan; ²Center for Information, Jichi Medical University, Japan

Abstract

Practice Highlights

• This method helps inexperienced students brainstorm various scenarios needed for risk prediction.
• It was possible for students to practice risk assessment using What-If Kiken-Yochi Training (W-KY).
• Students could predict a wide variety of risks regarding patients and medical personnel using W-KY.
• It was difficult to predict management, clinical rules, and stakeholders’ risks even with W-KY.

I. INTRODUCTION

A. Issues on Patient Safety Education for Medical Students in Japan

In Japan, students enrol at medical schools immediately after graduating from high school. Safety education is often provided only at higher levels (4^th or 5^th year) in over 60% of medical schools in Japan, when clinical practice begins (Ishikawa, Hirao, & Maezawa, 2008). The following are the reasons: (1) educational practical methods for clinically inexperienced students are not specifically referred to in any guidelines or papers for students in the early years; (2) the educational effect on such students is unclear; (3) higher grade students have sufficient medical knowledge and can immediately apply their patient safety knowledge in clinical practice; and (4) there are few teachers specialising in medical safety, thus making it easier to determine the theme of education for higher grade students. On the contrary, 70% of medical schools only teach the minimum medical safety knowledge through lectures to students who have not yet practiced safety in clinical practice. The main contents of the lectures are analysis tools to prevent the recurrence of incidents, such as Root Cause Analysis and Failure Mode and Effects Analysis, legal responsibility knowledge, ethics, and infection (Mayer, Klamen, Gunderson, & Barach, 2009). However, as there are certain things that can be included immediately in clinical practice, it is difficult to keep students motivated.

The Telluride Interdisciplinary Roundtable (Mayer et al., 2009) and Lucian Leape Institute (2010) indicated that patient safety education should be conducted through a longitudinal curricular approach (including patient safety education in the curriculum of all grades), and it is important to educate lower grade students who have no clinical experience. This would enable students to learn the necessity and importance of patient safety knowledge, and to consider patient safety as implementation science while continuously practicing patient safety skills (Nakajima, 2012). Ishikawa et al. (2008) also emphasised the importance of continuous patient safety education, starting with beginner students so they can acquire good safety habits.

The Telluride Interdisciplinary Roundtable (Mayer et al., 2009) and Lucian Leape Institute (2010) outlined the patient safety competencies that students should acquire. In particular, students lack education on “non-technical skills” (Nakajima, 2012). Some of the necessary non-technical skills students need when they start working after graduation are risk assessment (situational awareness) skills to prevent accidents. This involves advance awareness of safety weaknesses and threats (risks) in the workplace or operations and the ability to avoid these risks (Doi, Kawamoto, & Yamaguchi, 2012; Takahashi, 2010). The World Health Organization’s (WHO’s) Patient Safety Curriculum Guide shows in Topic 6 (Understanding & Managing Clinical Risk) that students have to take correct action when they see an unsafe situation or environment (Walton et al., 2010). For example, when they see wet steps, they should predict the possibility of patients falling. WHO’s guide outlines the four-step process to manage clinical risks: (1) identify the risk, (2) assess the frequency and severity of the risk, (3) reduce or eliminate the risk, and (4) assess the costs saved by reducing the risk versus the costs of not managing the risk. However, this guide does not explain the teaching methods to enable students to identify or predict risks.

B. Educational Method Issues for Risk Assessment in Japan

Kiken-Yochi Training (KYT), a type of risk prediction training, was created by Sumitomo Metal Industries Co., LTD in 1974 (Chen & Mao, 2011), and helps workers understand risks in many kinds of industries, including the medical field (Doi et al., 2012; Hirokane, Shiraki, & Ohdo, 2010). KYT originated in Japan (Ito, Taguchi, & Fujinami, 2014) and has become a common safety management method (Ji, 2014). It increases workers’ awareness of risks and motivation to practice in a team and improves their problem-solving skills (Chen & Jin, 2012). KYT also enables workers to easily conduct on-site risk assessment. In a metal auto parts factory, the accident rate fell by six percent one year after the implementation of KYT (Poosanthanasarn, Sriboorapa, Fungladda, & Lohachit, 2005). In recent years, KYT use has also begun to spread in the medical field in countries other than Japan (Noor, Irniza, Emilia, Anita, & Suriani, 2016). In standard KYT (S-KY), the facilitator presents the learner with illustrations or photographs depicting the work site and guides them through four steps: (1) extracting items and risks considered to be dangerous in the illustration, (2) rating each item’s risk, (3) planning solutions, and (4) selecting urgent solutions (Japan Industrial Safety & Health Association, 2008). In particular, an important skill for medical staff at clinical sites is the ability to predict a myriad of risks from a broad perspective using the illustration in Step 1. More effective KYT has recently been designed, such as KYT using video instead of illustrations and KYT applications for tablets that enable students to easily take risk assessment training alone, such as during breaks, and KYT combining medical simulations of real clinic situations (Kadoyanagi, 2016; Nagamatsu, Miyazaki, & Harada, 2011; Takahashi et al., 2017; Yoneda et al., 2017).

However, in S-KY, the ability of experts to predict risks is higher than that of novices because novices do not have enough knowledge of important areas in the illustrations (Murata, Hayami, & Moriwaka, 2009). Hirokane et al. (2010) pointed out that experts are able to predict risks specifically in order to consider effective solutions to prevent accidents. Therefore, KYT is usually conducted for clinically experienced students, and is rarely implemented for inexperienced students. The reasons are as follows: (1) in S-KY, risk prediction in the illustrations is limited to “specific circumstances”; (2) if medical students practice risk prediction using only these illustrations, they cannot accurately identify risks at clinical sites when they encounter a situation different from the “specific circumstances” in the illustration in the future; and (3) if teachers use illustrations of scenes from non-medical sites to avoid the inability to predict risks in clinically inexperienced students who do not have enough medical knowledge, it is difficult for students to link the risk prediction content with actual clinical sites, to become motivated to learn, and to obtain educational effects from the training.

C. Hypothesis: What-If KYT (W-KY) Applicability

What-If analysis is used as a brainstorming method. It is widely used in the field of service design and brainstorms what kind of things will occur if a particular situation changes (Stickdorn & Schneider, 2012). Based on this method, Mochizuki and Komatsubara (2016) propose a step 0 prior to the existing risk assessment in KYT that is aimed at traffic safety, letting the participants identify various alternate situations: “If the situation of the illustration were different”. Next, the participants perform a risk assessment for each situation developed in Step 0. For example, the facilitator shows participants illustrations depicting sunny daytime “driving scenes on a straight road”. Participants conduct what-if brainstorming and consider various situations, such as “if the weather is different from the illustration”, “if it was night-time”, or “if it is a mountain pass”. They then conduct a risk assessment for each situation. This modification is called the W-KY. The subsequent steps are the same as the S-KY (Steps 1 to 4). By adding Step 0, participants are then better able to predict various risks from the illustrations, and their risk sensitivity increases.

Based on these articles related to S-KY and W-KY, S-KY might be more feasible for clinically experienced students than inexperienced students. Therefore, W-KY might be feasible for clinically inexperienced students, because the What-If analysis (Step 0) might help students’ brainstorming. It also might increase motivation to practice and improve students’ problem-solving capabilities. The central question of this paper is whether the W-KY is effective and feasible for clinically inexperienced students. Existing studies have not adopted the W-KY to medical treatment, and the effect on clinically inexperienced students is unclear.

D. Purpose of This Study

In this study, based on the W-KY, we propose and implement a training method to help clinically inexperienced students predict risks. We also clarify differences in the risk assessment tendencies of students in W-KY versus the S-KY.

II. METHODS

A. Methods in W-KY

We conducted the S-KY and W-KY for 120 medical students half a year after admission in 70-minute compulsory classes. The purpose of these classes was to teach diversity of thinking and thinking of others through discussions in small groups of seven to eight people. The S-KY and W-KY were conducted over two classes (140 minutes). Specifically, the students conducted group work in the following order using three kinds of illustrations (Figure 1) depicting clinical sites. In our class, after individual students brainstormed ideas, they shared ideas with others and learned about the diversity of ideas.

Figure 1. Illustrations used in S-KY and W-KY (Courtesy of Japan Industrial Safety & Health Association [n.d.])

Step 1 (S-KY Step): Individual students predicted what risks exist in the three illustrations, then they used posters to share their prediction results with the group.

Step 2 (W-KY Step): Individual students brainstormed “situations that differed from the illustration” for each of the three illustrations. For example, in Illustration 1, one student thought of “a situation in which only one person was guiding the gurney”.

Step 3 (W-KY Step): Individual students predicted what risks exist in the situations they brainstormed in Step 2, then shared the results in their groups using posters.

Step 4 (S-KY and W-KY Steps): Each student considered solutions to mitigate the risks that they had predicted and submitted a report on them at the end of the class. Specifically, each student selected one risk considered to be the biggest risk in each illustration, and considered three solutions to prevent the risk.

B. Clarification of Differences in Risk Assessment Tendency of Students Between W-KY and S-KY

We compared the prediction results of S-KY in Step 1 and W-KY in Step 3 using the P-mSHELL model (Kawano, 2002). This model shows that factors of medical incidents are patient, management, software, hardware, environment, and liveware (individuals/ teams). P-mSHELL represents the initials of these factors. To evaluate the effectiveness of safety education, it is necessary to ensure that risks related to Human Factors can be predicted from a broad viewpoint. There are several models that explain the cause of Human Factors issues: Lewin’s equation model (human behaviour is determined by factors related to the person and their environment; Lewin, 1936), the 4M model (factors related to Man, Machine, Media, and Management), and Reason’s categories (factors related to patient and provider; task, technology, and tool; and team, environment, and organisation; Reason, 1997). All models consider both human and environmental factors as the background of Human Factors issues. Among these models, P-mSHELL is a highly detailed model that explains human and environmental factors in medicine, thus making it easy to evaluate the effectiveness of safety education. The P-mSHELL model is based on the SHEL model that has been used in analysis of Human Factors issues in aviation. Molloy and O’Boyle (2005) pointed out this model is useful in examining errors in clinical site, and may have some potential in training medical staff about Human Factors. Therefore, the P-mSHELL model is frequently referenced to understand human error in medical care. It is expected that the target students of this research will be able to predict the safety weaknesses (risks) in the clinical site from the point of view of P-mSHELL and to take preventative solutions. For this reason, this study verifies the educational effect by comparing the danger predicted by S-KY and W-KY using this model. We also summarise student brainstorming results in Step 2 “regarding situations that differ from the illustration” and examine its effect on student risk assessment. Then, we classify the solutions described in the report by students from the point of view of P-mSHELL.

C. Ethical Considerations in This Research

Regarding the ethical use of the results of S-KY and W-KY conducted in the class for research, we emphasised and explained to students that cooperation in this study was voluntary and that declining to cooperate would have no influence on their grades. We explained that students’ grades are scored based on the rubric described in the syllabus and that consent to cooperate in the research could be withdrawn at any time. It was explained that the results of this study may be published after processing, but the student’s personal information would not be revealed in the publication. The students entered their consent to use the results of S-KY and W-KY for this research in the e-learning system, Moodle, and 120 out of 123 students agreed to participate. In this research, we analysed data from students who agreed to participate. This study was considered exempt by the Jichi Medical University Review Board (protocol number 18-014).

III. RESULTS

A. Results of Predicted Risk by S-KY and W-KY

Figure 2 (left) shows the total number of risks predicted by students for each illustration. In addition, Figure 2 (right) shows the average number of predicted risks for each student group. We clarified the difference between S-KY and W-KY using the students’ t-test.

First, students were able to predict a variety of risks regardless of whether S-KY or W-KY was used. With the exception of liveware (team) in Illustration 3, the risks for all elements of P-mSHELL were predicted. In addition, the risks varied widely in the ease of prediction by the illustration (Figure 2, left). In Illustration 1, patient, environment, and liveware (individual) risks were predicted in S-KY and W-KY. In Illustration 2 predicted risks were liveware (person), and in Illustration 3, patient. Risks related to management, software, and liveware (team) were very few in both S-KY and W-KY, and for some illustrations, student groups predicted no risks in some categories.

Despite W-KY being implemented after S-KY, patient and environment risks had approximately the same number in S-KY and the W-KY. The number of liveware (individual) and hardware risks predicted in W-KY was less than in S-KY—liveware (individual): t(16) = 3.47, p < .05; Hardware: t(16) = 3.44, p < .05. In W-KY, many were predicted in Illustrations 1 and 2.

For example, in scenario 1, risks such as, “staff transferred patient to the wrong room” and “the patient would be injured if the stretcher breaks” were predicted in S-KY. In W-KY, risks such as, “If the corridor is dark, staff are not able to notice changes in the patient’s condition”, “If the corridor gets wet, the stretcher may slip and fall”, “If the patient is elderly, the patient will fracture a bone due to impact”, “If the patient has dementia, he forgets about treatment when he wakes up and removes the infusion tube himself”, and “If the staff is busy, he forgets to change the drip, emptying the drip and harming the patient” were predicted.

 Figure 2. Result of predicted risk by S-KY and W-KY (Based on the classification of P-mSHELL)

B. Results of Brainstorming Situations That Differed from the Illustration in Step 2

Table 1 shows how the students brainstormed situations that differed from each illustration in Step 2 as mentioned in the Methods section (refer to A. Methods in W-KY). In Table 1, the situations brainstormed by the students are organised based on each element of P-mSHELL.

First, the situations brainstormed by the students were remarkably diverse regarding patient, liveware (individual), hardware, and environmental factors. Although the number of liveware (individual) and hardware risks predicted in W-KY were less than in S-KY, the liveware (individual) risks predicted in W-KY were diverse.

On the other hand, the situation about management, software and liveware (team) were small in number (Table 1). This is also reflected in the low number of risks predicted for these factors (Figure 2).

Table 1. Results of brainstorming in Step 2 about “situation different from illustration”

C. Solutions Proposed by Students to Mitigate the Risks

In Figure 3, the solutions proposed by the students to mitigate the risks were classified by P-mSHELL. In addition, Table 2 shows a concrete example of solutions for each element. In this paper, it has not been possible to analyse what kind of solutions were considered for each risk in S-KY and W-KY because students considered solutions in a post-class report.

In both S-KY and W-KY, students were able to consider a wide variety of solutions for almost all P-mSHELL factors. Although predicted risks related to management, software, and liveware (team) were very few, students were able to propose a lot of solutions related to them. There were many solutions, especially for software and hardware. For example, for software, double-checking, pointing and calling (occupational safety method), and creating a checklist were suggestion; in hardware, changing the shapes and names of the medicine in order to make it difficult to make mistakes was proposed.

Table 2. Examples of solutions considered by students

 Figure 3. Result of solutions of predicted risks (based on the classification of P-mSHELL)

IV. DISCUSSION

A. Similarity and Difference Between S-KY and W-KY

Students should be able to predict risks in all elements of P-mSHELL as they can minimally experience the risks of each element in a clinical site. The results show that the elements of risk in P-mSHELL in both S-KY and W-KY are similar. Students could predict many patient and environment risks. These elements were drawn in advance in each illustration as shown in Figure 1. In other words, it was possible for students to brainstorm risks regarding stakeholders and medical devices drawn in illustrations in S-KY and W-KY. One of the possible reasons students could predict several patient and environment risks is that even a clinically inexperienced medical student has experience as a patient or has experienced the same situation (e.g., fatigue, immorality, lack of knowledge, etc.) as liveware (individual). Kazaoka, and Otsuka (2003) indicate that nursing students tend to recognise risks that they can imagine as their own and consider important, such as liveware (individual). On the other hand, management, software, and liveware (team) risks were very few in both S-KY and W-KY. The number of patient, environment, management, software, and liveware (team) risks had approximately the same number in S-KY and W-KY. The number of liveware (individual) and hardware risks in W-KY was less than in S-KY. In other words, it is considered that W-KY may cover the risks that can be predicted with S-KY.

Next, we discuss the strengths of W-KY. The risk description by students in W-KY included the risks and information related to various situations. Particularly in W-KY, students were able to brainstorm a wide variety of situations regarding patient, liveware (individual), hardware, and environmental risks (Table 1). This tendency is the same as the risk prediction tendency of S-KY and W-KY, and the reason for this tendency is considered to be the same. In W-KY, for example, regarding the transporting of stretchers, inexperienced students could consider various dynamic situations that can cause accidents, such as wet corridors, crowded corridors, violent or acutely ill patients, and lack of human resources. These situations that students brainstormed, listed in Table 1, are paraphrased as medical accident risks. In other words, in S-KY, students predict only medical accidents related to illustrations (results of accidents), whereas in W-KY, students were able to predict many high-risk situations that can cause medical accidents, and medical accidents (possible cause and results of accidents).

Through W-KY, students may have learned what a high-risk situation is and that clinical tasks can change into various dynamic situations that differ from illustrations. As a result, they may have learned the necessity of risk prediction in clinical practice and the significance of learning patient safety. These points will be explored in future research. In addition, Hirokane et al. (2010) pointed out that it is very important to predict risks specifically to prevent accidents. Therefore, it is possible that even inexperienced students can do this by using W-KY.

B. Limitations of W-KY

Only few students could predict risks management, software, and liveware (team) in S-KY and W-KY. However, students were able to consider solutions for almost all P-mSHELL factors (Figure 3). Contrary to the results of predicting risks in W-KY and S-KY, students were able to propose many solutions related to the aforementioned elements. This means that students can brainstorm these elements. In particular, regarding the software, students can mention the establishment and thoroughness of rules and manuals when planning solutions, and can think sufficiently from that viewpoint. Therefore, improving the format of discussion in W-KY may allow students to predict risks from a wider range of perspectives.

V. CONCLUSION

In this research, we proposed and implemented a training method to help clinically inexperienced students predict various risks. W-KY (brainstorming situations in illustrations and predicting risks based on them), as implemented in this research, allowed clinically inexperienced students to predict risks. We found that the elements of risk in P-mSHELL in both S-KY and W-KY are similar. Students could predict many patient and environment risks. However, with regard to management, software, and liveware (team) factors, S-KY and W-KY appeared to be difficult.

In addition, W-KY enables the prediction of high-risk situations that can cause medical accidents. This is important for predicting risks—including possible causes of accidents—specifically to prevent accidents.

In summary, W-KY can cover the risks that can be predicted by S-KY, and also allows students to consider various dynamic high-risk situations that can cause accidents. This suggests that W-KY can be used instead of S-KY.

In this study, it was not possible to analyse what kind of solutions to prevent risks were considered for each risk in S-KY and W-KY, as students considered solutions in a post-class report. Because this study was conducted as part of the class, we could not obtain data of student perspectives on learning outcomes or transferring learning to practice. The first-year medical school students in this research have the opportunity to receive medical safety education again when they are in the fourth year. At that time, we have plans to provide opportunities for practicing skills by applying W-KY in clinical practice, which will be explored in a future research. In addition, comparisons between students with clinical experience and inexperienced students and between W-KY/S-KY and other educational programs on accident prevention are also future topics of this research.

Notes on Contributors

Yoshitaka Maeda, PhD, is a research associate at the Medical Simulation Center at Jichi Medical University, Japan. He conducted the research supervision, class implementation, and data analysis.

Yoshikazu Asada, PhD, is an assistant professor at the Center for Information at Jichi Medical University, Japan. He contributed to the data compilation regarding the effect of this education.

Yoshihiko Suzuki, MD, is an assistant professor at the Medical Simulation Center at Jichi Medical University, Japan. He contributed to the design and planning of this class.

Hiroshi Kawahira, MD, is a professor at the Medical Simulation Center at Jichi Medical University, Japan. He gave advice on writing this paper and on data aggregation.

Ethical Approval

This study was approved by the Jichi Medical University Institutional Review Board (Protocol number 18-014).

Funding

There is no funding involved for this paper.

Declaration of Interest

The authors report no conflict of interest. The authors alone are responsible for the content and writing of this article.

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*Yoshitaka Maeda
Medical Simulation Center,
Jichi Medical University,
3311-1, Yakushiji,
Shimotsuke-shi, Tochigi, Japan
Tel: +81 285 58 7455
Email: y-maeda@jichi.ac.jp

Published online: 7 January, TAPS 2020, 5(1), 54-60
DOI: https://doi.org/10.29060/TAPS.2020-5-1/OA2095

Min Jia Chua¹, Gen Lin Foo² & Ernest Beng Kee Kwek²

¹National Healthcare Group, Ministry of Health Holdings, Singapore; ²Department of Orthopaedic Surgery, Woodlands Health Campus, Singapore

Abstract

Practice Highlights

• Study to evaluate value of mentoring by faculty and near-peer mentoring to orthopaedic surgery resident.
• Residents viewed mentoring by faculty and near-peer mentoring programmes as being beneficial and crucial.
• Ideal mentoring programme should be tiered and allow choice of mentors.
• Near-peer mentoring should be a requirement but not necessarily monitored.

I. INTRODUCTION

Mentoring has long been a crucial element of effective resident medical education (Sambunjak, Straus, & Marusic, 2006), with many programmes adopting mentoring by faculty as an integral component of their residency programme. Various models of mentoring and types of mentoring activities have been described including didactic sessions, regular mentor-mentee meetings and group projects (Kashiwagi, Varkey, & Cook, 2013). The benefits of mentoring have also been shown in various studies, by aiding personal and professional development during residency, helping with

career preparation (Ramanan, Taylor, Davis, & Phillips, 2006), improving professional and social skills (increased self-confidence, improved communication skills; Buddeberg-Fischer, & Herta, 2006).

There is however, little data looking at how Orthopaedic residents view mentorship programmes (Flint, Jahangir, Browner, & Mehta, 2009). Furthermore, most studies look at mentoring by faculty with little emphasis on near-peer mentoring. In fact, a literature review has shown that no studies have looked at and compared the two entities in orthopaedic residency programmes.

In our residency programme, a tiered mentorship framework, where both mentoring by faculty and near-peer mentoring are practised, has been in place since 2014. In the former, a mentor of associate consultant grade and above who is in post-fellowship training will mentor a resident while in the latter, a senior resident mentor will mentor a junior resident two residency years below him or her.

The objective of having a near-peer mentorship framework in our programme was to bridge some of the gaps in traditional mentorship. In mentorship by faculty models, there will inevitably be hierarchical distance between mentors and mentees and residents may not feel as at ease approaching their mentors for certain issues. Furthermore, there may be a shortage of faculty members who are also strapped for time and may not be able to devote enough time for holistic mentorship of residents. These mentors are also further away from their residency training years and may not be able to understand some of the issues their mentees face in the current residency climate. It was envisaged that senior residents who are near-peers on the ground will be able to address some of the abovementioned shortcomings in the traditional mentorship model.

Currently, mentorship by faculty is formally monitored by the programme and mandates at least bi-annual meetings with a mentoring form to be filled in while near-peer mentorship is a self-directed initiative by the residents which is more informal with no stipulated frequency of meetings and no compulsory documentation under the residency programme requirements.

Residents were either assigned mentors or chose mentors at the start of the second year of their residency but due to various factors including efflux of faculty mentors or other administrative reasons, some residents do not have either senior resident or faculty mentors or both.

The objectives of this study were to 1) evaluate the orthopaedic surgery residents’ perception of mentoring by faculty and near-peer mentoring and 2) establish factors perceived as being important in mentors and a successful mentoring environment.

II. METHODS

An anonymised online survey with voluntary participation was administered to all orthopaedic surgery residents, from residency years 2 to 5 (R2 to R5), in our orthopaedic surgery residency programme. No identifiers were collected to ensure protection of the privacy of survey respondents. The choice of survey as the tool was to maximise response rates without compromising on data collection through comprehensive survey questions. There were two sets of questions evaluating the residents’ perception of mentoring by faculty and near-peer mentoring. The near-peer mentoring questions differed depending on whether the resident was a senior or junior resident and whether the resident possessed a mentee or mentor respectively. The mentoring by faculty questions varied depending on the presence of a mentor. The survey questions presented to the respondent were modified real-time based on their initial answers to the previous questions, hence eliminating questions which were not relevant.

These survey questions were adapted from a census survey conducted by the American Academy of Orthopaedic Surgeons (Flint et al., 2009) on residents with regard to their experience in, and opinion of mentorship programmes and the prevalence of such programmes.

The questions administered were largely multiple-choice questions and scaled-response questions with a few open-ended questions. The multiple-choice and scaled-response questions covered the characteristics and perception of the mentoring environment (including how beneficial and crucial they found the mentoring programme, their satisfaction with the programme, their ideal mentorship framework, etc.), the perception of the value of mentoring (for instance to what extent they felt it supported their educational experience, aided with networking and making career decisions) and the characteristics of an ideal mentor. For the scaled response questions, respondents were asked to rate the importance of and their satisfaction with the different facets of their mentoring experience or environment on a scale ranging from 1 to 5.

The open-ended section of the survey allowed residents to air what they had achieved or hoped to achieve through the mentorship programme as well as general comments about the programme and suggestions for improvement.

Standard institutional review board procedures were followed and ethics board approval was obtained. Data analysis was performed using SPSS.

III. RESULTS

The survey was administered to a total of 33 residents across the residency batches from R2 to R5 in the residency year, with a response rate of 100%. Of the respondents, 19 were junior residents (8 R2 and 11 R3) and 14 were senior residents (6 R4 and 8 R5).

Of the junior residents, 68.4% (13/19) of them had senior residents while 78.6% (11/14) of the surveyed senior residents had junior resident mentees, with two of the senior residents having two junior resident mentees. 84.8% (28/33) of surveyed residents had faculty mentors (further details in Table 1).

Table 1. Breakdown of residents with faculty and senior resident (SR) mentors/mentees

Of the junior residents with a senior resident mentor, 53.8% (7/13) of them chose their own mentors while the rest had their mentors assigned. Of the residents with a faculty mentor, 60.7% (17/28) of them chose their own mentors. 69.2% (9/13) of junior residents met up with their senior resident mentors at least twice a year while 82.1% (23/28) of residents met up with their faculty mentors at least half-yearly or more frequently.

It was found that junior residents viewed senior resident mentors as being moderately beneficial and crucial to their training, with average scores of 3.92 on a scale of 1 to 5 (Figure 1). Of note, it was found that residents with senior resident mentors viewed near-peer mentorship as being more crucial and beneficial compared to their counterparts without senior resident mentors. Similar results were also echoed by the residents regarding their faculty mentors, with average scores of 3.89 and 4.14 for how crucial and beneficial faculty mentors were to residents with mentors and average scores of 3.6 and 4.0 for residents without mentors.

Figure 1. Chart showing how crucial and beneficial residents viewed senior resident and faculty mentors

In terms of satisfaction levels with the mentoring programme, residents with mentors (senior resident and faculty mentors) were also more satisfied with the mentoring programme than their peers without mentors, with average scores of 4.31 and 4.33 for residents with senior and faculty mentors respectively compared to average scores of 3.75 and 4.00 for residents without senior and faculty mentors.

A further subgroup analysis yielded that respondents with a self-selected mentor from both the senior resident and faculty mentor groups had higher scores for satisfaction levels (4.28 and 4.41 respectively) compared to those who had assigned mentors (4.16 and 4.20). Those with self-selected mentors in the faculty mentor group also felt that their mentor aided them more in supporting their educational experience and in making career decisions.

84.6% (11/13) of junior residents who had a senior resident mentor felt that their senior resident mentor was able to provide them with advice about career, employment, or difficult cases in the future while 89.3% (25/28) of residents with faculty mentors felt the same about their faculty mentors.

In terms of desired characteristics in a senior resident mentor, approachability, willingness to share and experience were the top three most desired characteristics (Figure 2A). Similar results were echoed in the results for faculty mentors, with ability to give feedback also highly valued (Figure 2B).

66.7% (22/33) of all residents felt that near-peer senior resident mentoring should be required in the resident programme but only 30.3% (10/33) thought that it should be formalised. Some of those who felt that near-peer mentoring should not be required expressed that they would like it to be up to the individual resident and that residents who are in need would approach senior residents directly of their own accord. 78.7% (26/33) of residents surveyed were of the opinion that faculty mentorship by faculty was required. Those who felt that faculty mentorship should not be required offered reasons including the hectic schedule of consultants and the unpredictable flow of faculty members into the private practice which would make it difficult for residents to maintain the same mentor throughout residency training.

Figure 2A. Chart depicting the desired characteristics scores in senior resident faculty mentors, ranked from most to least desired

Figure 2B. Chart depicting the desired characteristics scores in faculty mentors, ranked from most to least desired

IV. DISCUSSION

Traditionally, the art of medicine and especially surgery has been passed down through an apprenticeship model (Gofton & Regehr, 2006). Multiple studies have shown that various aspects such as career paths, research output as well as personal development can be influenced greatly by mentorship (Calligaro, Dougherty, Sidawy, & Cronenwett, 2004; Gedde, Budenz, Haft, Lee, & Quigley, 2007). In fact, close to 80% of paediatric residents polled in a survey gave feedback that having a mentor was either very useful or crucial to survival during their residency years (Curtis, Adam, & Shelov, 1995). Over 20 years later, it appears that little has changed, with similar results being echoed in our study, with high scores reported for how crucial and beneficial faculty and senior resident mentorship was viewed as being by residents.

There are myriad challenges which one will face when mentoring orthopaedic residents. In comparison to teaching medical students, teaching an orthopaedic resident is often longer, more intense and calls for greater responsibility for teaching while compared to fellowship training (post-residency for subspecialty training); the mentor is teaching a much less knowledgeable and skilled protégé (Levine, Braman, Gelberman, & Black, 2013). There is hence an enhanced requirement for timely provision of feedback and assessment, and for nurturing the resident through his or her years of training. As Hill and Boone (2002) mentioned in their paper, mentoring aims “to provide a young aspiring professional with a tangible and immediate role model”. (p. 73)

For successful mentoring to occur, it requires reciprocity and has to be a “collaborative learning relationship” (Bland, Taylor, Shollen, Weber-Main, & Mulcahy, 2009). Levine et al. (2013) proposed certain obligations for a mentee to fulfil to maintain the mentor-mentee relationship and enhance the likelihood of success, including demanding and accepting feedback, seeking opportunities for self-improvement, following through, being prepared, requiring accountability, and more.

For the mentors, some traits which have been viewed as being important by surgical trainees include enthusiasm for the practice of surgery, commitment to excellence, good surgical technique, good leadership qualities, integrity and professionalism (Healy, Glynn, Malone, Cantillon, & Kerin, 2012). Certain more desirable traits of mentors which we have noted in our study include approachability, willingness to share and impart knowledge, experience as well as ability to give feedback. A mentor who has these traits will be better equipped to pass on his knowledge and skills to his mentee and hence provide a more well-rounded learning environment for the resident.

Nevertheless, we understand that mentoring is no mean feat and hence, it is recommended that both faculty members and senior residents take it upon themselves to train specific skill sets and develop desirable traits for mentoring which will enable them to successfully take on this mantle of responsibility. Mentoring workshops have been shown to improve mentoring competency and thereby improve outcomes for optimally mentored mentees (Lau et al., 2016; Gandhi & Johnson, 2016).

Our study also found that residents with self-selected mentors had higher satisfaction with the mentoring programme and felt that these mentors were able to support them more in their educational experience and making career decisions, a finding echoed in other studies (Yamada, Slanetz, & Boiselle, 2014). We postulate that this is because residents who selected their own mentors would be able to choose mentors who had desirable traits and whom they saw as ideal role models or were like-minded in their approach. Mentees have been shown to select role models—partners with whom they enjoy working and often report a mutual attraction or chemistry that sparks the development of the relationship (Kram, 1983).

As previously alluded to, mentoring by faculty is practised in many institutions and residency programmes but near-peer mentoring is often overlooked. The original intent of having a tiered mentorship framework in our programme was to ensure a holistic approach to mentoring of residents. It was envisioned that the senior resident mentor would be able to help ease the junior resident into the training programme and deal with immediate junior-level issues as well as assist in intermediate examination preparation while the senior faculty mentors would be able to provide a more overarching view as well as guidance and career advice. In the literature, it was found that mentees were generally less intimidated by near-peer mentors, felt they could relate better to them, and the near-peers understood them better as they had recently gone through situations they (the mentees) were now facing (Akinla, Hagan, & Atiomo, 2018). It was also shown that near-peer mentoring was a way of promoting professional and personal development, aid transition and maintain well-being of mentees (Akinla et al., 2018).

Residents in our programme were generally of the opinion that tiered mentorship was necessary but that near-peer mentoring should be informal, without any stipulated frequency of meetings, documentation of meetings and forms to fill up unlike mentoring by faculty. This is likely because senior residents are usually just a few years senior to the junior resident and both the mentors and mentees prefer a more informal environment and style of mentoring. This also enables junior residents to be more at ease to freely discuss any issues with the senior resident mentor. Furthermore, both the senior and junior residents have far more opportunities for interaction compared to the faculty mentor and the resident.

In the survey administered, aside from the previously mentioned results, we have also found that near-peer mentoring has positive effects on both the mentor as well as the mentee, with mentees commenting that senior resident mentors could provide pertinent directions as they started junior residency. Similarly, senior resident mentors felt that senior resident mentorship gave them an avenue to provide guidance and encouragement to their juniors, to allow them to benefit from past mistakes and to learn more efficiently. Furthermore, a tiered mentoring system contributes to a positive learning environment, creating a culture of camaraderie amongst seniors and juniors, resulting in a more closely-knit professional community.

Our residency programme encompasses both senior resident and faculty mentoring with the details on its implementation in our programme covered above. Moreover, it is the first to look at tiered mentoring and its impact on residents in orthopaedic surgery, with a 100% response rate among residents in our programme.

However, we acknowledge that this study does have some limitations. The first is that of the small sample size, which contributed to many of the variables being studied not having a statistically significant difference. Though we are limited by the small sample size due to the number of residents in the programme, we were able to achieve a high response rate as well as sub-divide the residents based on other variables including presence of a mentor and method of selection of mentor to allow for comparison between different groups. Other limitations include the fact that this study was only carried out in one institution which practised said model of mentorship. In addition, the mentorship programme had only been in place for two years when the survey was administered and its effects may not have been that far-reaching and apparent given the relatively short period of implementation, though this could form the basis for a longitudinal study in the future at further time points.

Future studies should be undertaken in the future to explore this field further. Studies involving various institutions which practice this model could be considered. Another area of study could be to look at objective measures like the Orthopaedic In-Training Examination and clinical rotation scores, exit examination success percentages and more. This would allow us to find out the tangible measurable effects that mentoring has on residents.

V. CONCLUSION

In conclusion, our study has found that mentoring by faculty and near-peer mentoring programmes are generally viewed as being beneficial and crucial to residency training and we believe that programmes should consider instituting tiered mentorship to reap the benefits.

We propose that an ideal mentoring environment should be 1) one that is tiered (encompassing both mentoring by faculty and near-peer mentoring), 2) a system that allows residents to choose their mentors, and 3) have near-peer mentoring as a required part of residency but on a more informal basis.

Notes on Contributors

Dr Chua Min Jia is a senior resident in orthopaedic surgery at the National Healthcare Group. He was involved in devising of the survey questionnaire, data collection and analysis and was the primary author of this manuscript.

Dr Foo Gen Lin is an associate consultant in the Department of Orthopaedic Surgery at the Woodlands Health Campus in Singapore. He was involved in devising of the survey questionnaire and editing of the manuscript.

Dr Ernest Kwek Beng Kee is a senior consultant and Chief of the Department of Orthopaedic Surgery at the Woodlands Health Campus in Singapore. He was involved in devising of the survey questionnaire, editing and approval of the final manuscript as well as overall supervision of the project.

Ethical Approval

This study was exempted by the National Healthcare Group Domain Specific Review Boards (DSRB).

Acknowledgement

The authors wish to thank all the orthopaedic surgery residents in our programme who participated in this study.

Funding

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

Declaration of Interest

There is no conflict of interest to declare.

References

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*Chua Min Jia
Ministry of Health Holdings,
1 Maritime Square, Singapore 099253
Tel: +65 6357 7713
E-mail: minjia.chua@mohh.com.sg

Published online: 7 January, TAPS 2020, 5(1), 46-53
DOI: https://doi.org/10.29060/TAPS.2020-5-1/OA2080

Jaime L. Pacifico¹, Julie Anne S. Villanueva¹, Sylvia Heeneman² & Cees van der Vleuten²

¹Internal Medicine, De La Salle Medical and Health Sciences Institute, Philippines; ²Maastricht University, The Netherlands

Abstract

Practice Highlights

• Any form of assessment activity serves as a stimulus and provokes an educational response.
• Assessment in residency motivated the trainees to study and fostered an active learning attitude.
• Perceptions of credibility, fairness and commitment of assessors to trainees’ welfare matter.
• Patients, engagement with consultants and a supportive environment contributed to motivation.

I. INTRODUCTION

Any form of assessment activity will result in an educational response, however, the unpredictability of this response requires careful monitoring to realise the desired educational outcomes and to recognise the unwanted effects (van der Vleuten, 1996). Assessment can influence how a student learns through the content, design and scheduling and regulatory structure of the assessment program (Schuwirth & van der Vleuten, 2010). When does assessment itself become a barrier to learning and when does the response to assessment promote learning? Holmboe, Durning and Hawkins (2018) assert that the responsibility lies on the program administrator of any assessment program to conduct a systematic review on the potential consequences of any assessment exercise, whether positive or negative, regardless whether the examination is conducted in the classroom or at a national level. Through the years, decisions about method of assessment are primarily based on consideration of its validity and reliability (Norcini & McKinley, 2007). But is this indeed the only attribute of an assessment procedure that is of importance? An in-depth and systematic review of any assessment program on the potential consequences compels that the perceptions of the trainees are included.

When non-medical higher education students were asked about assessment, they talked about fairness instead of validity. It was clear that fairness as alluded to by students, is a representation of how the educationalist defines validity (Sambell, McDowell, & Brown, 1997). In a review involving non-medical higher education students, it was shown that approaches to learning are strongly influenced by the students’ perceptions of the assessment methods (Segers, Nijhuis, & Gijselaers, 2006; Struyven, Dochy, & Janssens, 2005). The same relationship between assessment and approach to learning is echoed in studies involving nursing students in clinical and classroom settings (Leung, Mok, & Wong, 2008; Tiwari et al., 2005). Among medical students, it has also been shown that students would adapt their learning strategies to the perceived requirements of the evaluation (Newble & Jaeger, 1983). These studies substantiate the well quoted maxim that assessment drives learning, although as McLachlan (2006) argues the oft-repeated axiom ‘assessment drives learning’ is misleading and is more complicated, for example, different students are motivated by different reasons and assessment does not influence learning in all contexts.

In postgraduate medical education, whether assessment is a driver of learning and how it directs learning is less established. The continuing challenge for the program directors and clinical faculty is to understand the relationship between assessment and learning and to be able to promote learning as intended (van der Vleuten, Schuwirth, Scheele, Driessen, & Hodges, 2010). In postgraduate medical settings, it is of paramount importance to evaluate the educational effects of assessment, because of the high stakes and risks involved. Although such is also expected in undergraduate medical education, according to Holmboe, Hawkins and Huot (2004), “residency is the last structured experience to ensure that young physicians have sufficient clinical skills” (p. 874) thus the urgent and serious need to influence learning through assessment methods done in clinical training.

The remaining intriguing question in postgraduate medical training is, how do the trainees perceive their current assessment practices and how do these facilitate their learning? Given this research question, we conducted this study to: 1) look into the perceptions of postgraduate trainees undergoing residency training as to how assessment practices influence their motivation to accumulate knowledge and attain the competence levels expected of a specialist, and 2) to determine if there are identifiable conditions or factors associated with assessment practices that can facilitate or deter learning.

II. METHODS

A. Setting

The study was done among residents of the internal medicine (IM) and paediatrics departments at De La Salle University Medical Center (DLSUMC) in the Philippines. DLSUMC serves as the academic institution of De La Salle University College of Medicine. Undergraduate medical education in the Philippines requires a bachelor’s degree and postgraduate medical education such as residency is done after passing the national licensure examination. The duration of residency in IM and paediatrics is three years and is a prerequisite to further training such as adult or paediatric cardiology. Evaluation of the residents included assessment of their knowledge and skills which were done through summative written examinations, mostly multiple choice questions, and Objective Structured Clinical Examinations (OSCEs), attitudes were assessed through a Likert-scale questionnaire. The OSCEs consisted of 12 stations. The scope of the written examinations and the OSCEs include the presentation, diagnosis, and management of the major and more common IM diseases. These assessment methods are done at least twice a year, throughout the three years of training. The examiners are the consultants belonging to the department of IM. During the time this study was done, there was no assessment that involved direct observation of the trainees other than through OSCEs.

B. Data Collection

A convenient sampling was done of second- and third-year residents in both departments since we needed trainees who have already experienced at least one year of training and have experienced several assessment processes. Twenty residents were interviewed for this study, ten males and ten females. Fourteen residents were from the department of IM and 6 were from the department of paediatrics. Seven were third-year residents and 13 were second-year residents during the time of the study. The interviews were conducted by a single person, who was not connected to the current training program of any of the departments. The interviews were done in both English and Filipino and the interviews were later transcribed in English. The interviews lasted from 45 minutes to 1 hour per subject. The residents were notified the interview was voluntary. A semi-structured interview was done using a published guide initially (Dijksterhuis, Schuwirth, Braat, Teunissen, & Scheele, 2013). However, consistent with the iterative nature of grounded theory and utilising constant comparison the interview questions were modified as initial results became available, which informed the succeeding interview guide.

C. Data Analysis

A grounded theory was used to explore how postgraduate trainees in IM and paediatrics perceived assessment of their knowledge and skills during training, and the contributions of these assessments to their learning and their clinical performance (Charmaz, 2014; Glaser & Strauss, 1967; Watling & Lingard, 2012). Grounded theory is an inductive method which allows theories to emerge from the data gathered. Simultaneous data collection and analysis were done which is characteristic of grounded theory. All the interviews were transcribed and during the early data analysis, some of the concepts that emerged from the early transcripts were utilised to guide in the ensuing interviews. Constant comparative method was employed throughout the data analysis. Codings were subsequently organised into concepts and elevated to categories. There was consultation and comparison between JLP and JAS with regard to the codes and analysis of the collected data. During the coding process, memos were written that elaborated on the different codes. Data collection was stopped when saturation was attained, by saturation we mean the data were leading to recurring themes and there was adequate data to support a theory that is comprehensive and credible. In addition, for saturation, our emphasis was on the quality of data rather than its frequency (Morse, 1995). Cognizant of the effects of the researchers in the data collection and analysis and subsequent creation of concepts and knowledge, the background of the different authors are as follows: JLP is a practising internist and cardiologist, and has been a faculty in the college of medicine for many years. He was former chair of the department of IM. JSV is a recent graduate of IM training. SH is a biologist with an educational background. CvdV has training in psychology and psychometrics with many years of engagement in medical education and medical education research. This is the second study together of JLP, SH and CvdV.

III. RESULTS

There was a general positive acceptance among the trainees regarding the role of assessment in their training, as discussed under ‘assessment and its impact’, below. There are two important categories that came out from our data, we called these categories: the mediating factors and stronger motivators. We define mediating factors as prerequisites for learning, these preconditions were necessary for assessment to be meaningful to the trainees. The second category we termed the ‘stronger motivators’. These were situations/conditions which we discovered to contribute to the motivation of the trainees to learn, they were equally as important as the actual assessment in influencing the trainees positively and driving them to strive to be better clinicians. Table 1 summarises the results.

Table 1. Summary of results

A. Assessment and Its Overall Impact

The trainees agreed that assessment had a positive influence on both their clinical education and performance.

“Assessment improves knowledge of a case, lack of knowledge of a case motivates me to read more in the same way that poor performance prompts us, residents, to exert efforts to improve.”

(IM-1)

One perceived effect of assessment was that trainees were more conscious of their actions especially at the bedside and this improved clinical performance. The residents agreed that assessment positively influenced their learning because:

“I was forced to study and ask questions, learned to prioritise and manage cases, and even one’s personality tended to improve.”

(IM-4)

Assessments improved clinical performance as residents were inclined to study more, facilitating that when they would encounter these cases in the future, they would be more prepared to manage such cases. The OSCE had a positive effect on clinical performance by testing the confidence of the residents.

“You are face to face with the consultant during the OSCE, so it will test your confidence. You may know it theoretically but anxiety can get in the way… at least here they practice in practicals how to explain well even when you are with consultants or seniors.”

(P-1)

For some residents, assessment had a constructive impact on their day to day duty by being aware of what mistakes to avoid and by knowing which patients to give more attention to. Many of these beneficial effects followed on the awareness and what was learned through mistakes in the past, which were facilitated through the assessment practices.

B. Mediating Factors

Although there was a general agreement among the participants in the study that an assessment program had beneficial educational and clinical performance effects, there were certain minimum conditions that were perceived as necessary so that the assessment would be meaningful and would have an impact. These mediating factors that facilitated learning and had an impact on the clinical performance are credibility, fairness, interpersonal relations (between the trainees and supervisors), and commitment.

As for credibility, if the assessment was not perceived as valid, it had no influence on resident learning and performance. The educational role of assessment was readily lost if there was uncertainty regarding the validity of the evaluation.

“If I do not agree with the evaluation it will not have an effect on my performance.”

(P-2)

There was also a perception among the trainees that receiving an unfair assessment would demotivate a trainee, wherein the trainee stopped to try hard since his/her efforts were not properly judged.

“If you receive a wrong assessment… you lose the motivation to pursue to learn, the work becomes very tedious and a lot of your energy is spent being anxious.”

(IM-4)

The evaluator had to have more than superficial knowledge of the residents they were evaluating. Several trainees expressed that they doubted the ability of their consultants to evaluate them effectively in the absence of sufficient interaction between the consultants and the trainees. Another perception was that the consultants did not really see them at work, at the emergency room for example, yet were asked by the department to evaluate them, which obviously caused concerns on the validity of their evaluation.

The last mediating factor was the perceived commitment of consultants towards their role as evaluators. Some expressed doubt about the commitment of the consultants who were evaluating them because of the perception that they were spending limited time in performing their role as evaluators. Such perception tended to undermine the positive effects of their presence and participation in the training of the residents.

“Our consultants who evaluate us who are perceived to be sincerely concerned with us as trainees, have more impact in clinical performance.”

(IM-2)

C. Stronger Motivators to Study and Perform Optimally

Although many trainees thought that assessment had an impact on their learning and performance, we identified some peripheral factors inherent in the training program which served as a catalyst, increasing the motivation of the residents, these effects were either independent of the assessment process or in conjunction with it. These factors or conditions that promoted a stronger incentive for the residents were: interesting and/or new cases, concern for patient’s welfare and/or outcomes, engagement with consultants and a supportive environment.

D. Interesting and/or New Cases

This was the strongest motivation as expressed by the trainees, both as a reason to study or to improve their clinical performance. Exposure to new cases motivated more than examinations or grades to study. New cases refer to diseases or conditions they have not seen before or rarely see such that encountering these motivates them more, giving them the needed confidence to handle such cases better in the future.

“I am more driven by the cases I see and I am happy when faced with something I do not know.”

(IM-4)

E. Patient’s Welfare or Outcome

Many residents found a strong incentive to study harder during their rotation in a particular ward out of a sincere desire to contribute significantly in the recovery and successful management of the patients they handled or encountered. This consideration for a good outcome of their patients created a strong desire to learn more about the case. A trainee expressed that his/her goals had significantly changed from pleasing their consultants as a first year resident to pleasing their patients as a third year resident.

“But on day-to-day duties my motivation already shifted since I am more confident now. During my shift, my goal is on how I can help the patient get better, rather than how I can please the consultants.”

(IM-4)

F. Engagement with the Consultants

It was a prevailing view of many of the trainees that interactions with consultants increased motivation to study or to perform better.

“Interaction with consultant is the best reinforcement to learning and has impact on daily duties.”

(IM-3)

The intermittent moments of one-on-one interaction between the trainee and the consultant was a much valued teaching-learning opportunity for the residents, was something residents awaited and had the impact of creating a strong incentive for them to study. These interactions were a critical affirmation for the trainees and had a crucial influence on facilitating the development of competence they need as future clinicians.

G. Supportive Environment

A learning environment that encouraged the trainees to try to excel was crucial so that the trainees would be uplifting each other in terms of continuously improving their knowledge and skills. The trainees acknowledged that the absence of such a kind of environment would not foster learning. As one trainee said:

“…in the presence of such an environment I will try to do good not because I have been reprimanded but because I am inspired by my co-trainees.”

(IM-2)

The residents conveyed that their departments must make an effort to create an atmosphere that promotes excellence and maintain an unmistakable uplifting standard which would push the residents to aspire to work hard. Also, an environment where residents feel there is ‘respect for everyone’ fosters motivation among the trainees to study more and perform well.

IV. DISCUSSION

This study explored, through the experiences of resident trainees, how assessment influenced their motivation to accumulate knowledge and skills and attain the competence levels expected of a specialist. We limited our study to the general perception of the residents with regard assessment and how it impacted their learning and not into the specific aspects of their clinical performance. Our results showed that assessment in general positively affected the residents as they were conscious of their actions, and they were inclined to study more.

Our results also revealed there are factors we considered as the catalyst, indirectly related to the assessment process that influenced their desire to learn and improve clinical performance.

There are two messages from this study. Firstly, it was clear there is no single assessment factor that promoted learning. An interplay of several elements within an assessment process ultimately promoted learning – these were patients the residents encounter and concern for their welfare, engagement with the consultants and a supportive environment. The subtleties among these factors and how they interacted with the residents are critical in promoting learning of the residents. Secondly, it is noteworthy to mention that our findings suggest of a considerable degree of self-directed learning (SDL) among the residents who participated in our study, even in the absence of a formal structure on SDL within the departments. Although used interchangeably SDL and self-regulated learning (SRL) are different. SDL refers to the general approach a learner adopts for his own learning whereas SRL is focused on the important learning processes (Gandomkar & Sandars, 2018). In our study, a trainee’s desire to be a good specialist is a reason that was a predominant motivation, which was a key driver of SDL. In the process through SRL, the trainees utilise several cognitive and metacognitive processes to guarantee that the intended learning is met (Gandomkar & Sandars, 2018). The phrase “the self is a bigger motivation to study” from one of the participants, typified the aspiration of the residents to reach another level in their medical education.

Several studies have cited patient care and implicitly patient’s outcome as a vital influence on how residents learn. Nothnagle, Anandarajah, Goldman and Reis (2011) in a study reported that residents acknowledged patient care as the strongest incentive for SDL, adding that residents’ engagement to learn was stronger when it was clinically driven. Similarly, the large role patient’s outcome played as a motivator among the residents in this study has been reported elsewhere (Sagasser, Kramer, & van der Vleuten, 2012; Watling, Driessen, van der Vleuten, & Lingard, 2012). Berkhout et al. (2015) emphasised that the clinical environment is characterised by unique features that influence opportunities to self-regulate which include the patients and the interactions with patients. Matsuyama, Nakaya, Okazaki, Leppink and van der Vleuten (2018) reported that rural physicians in Japan were motivated to initiate learning strategies in a self-regulated manner because of the knowledge that they could upgrade health care in a particular community. The above studies are in congruence with our finding that patients create a powerful drive among residents to strive to become a competent physician.

From the perspective of the residents, the consultants were very instrumental in supporting learning and in giving feedback that was acceptable to the trainees, even if it was negative. The residents felt very strongly that sufficient and meaningful interactions with consultants were valuable in fostering learning because of the perceived increased knowledge and experiences of the consultants. Wong (2011) in a study comparing Canadian and Thai residency programs, reported that knowledge and scholarship were given more premium at the Thai program compared to the Canadian program. It can be surmised that it is reflective of a shared cultural value regarding education among Southeast Asian cultures. Additionally, the residents were more inclined to accept a negative assessment to improve themselves from a consultant who was perceived to be committed to the department and the training of the residents than from a consultant who is perceived to have less commitment. This resonated with the conclusion of Watling et al. (2008) where they investigated the perceptions and experiences of residents toward in-training evaluation process, that such a process became meaningful to the residents only when there is engagement between the evaluator and the residents. Holmboe, Ginsburg and Bernabeo (2011) commenting on the short and frequent rotation among clinical faculty in the USA, stress that such a situation makes it hard for trainees to establish a meaningful relationship with the clinical faculty which predisposes to superficial assessment. Steven, Wenger, Boshuizen, Scherpbier and Dornan (2014) in their research involving clerks in clinical workplace, concluded that the willingness of clinical practitioners to interact with students is the main element that influenced their learning and their education can be enhanced further by involving learners more dynamically in what they referred to as the ‘communicative processes’ of the clinical communities. Nothnagle et al. (2011) in their study of residents’ views toward SDL revealed that residents expressed a need for coaching or guidance to maximise their learning. Sagasser et al. (2012) researching among postgraduate trainees conveyed that affirmation from supervisors and mentors were sought by trainees, as well as from their peers. Faculty must be aware they can influence each specific phase of a resident’s learning process especially since residents look up to them to validate the interpretation and construction of meaning based on what the residents experienced (Teunissen et al., 2007).

The learning environment is an important determinant of behaviour of students or trainees, for this reason many instruments have been designed to measure the learning climate in postgraduate settings (Genn, 2001). The departments must be aware they can promote learning or actually discourage it (Boor et al., 2008). Thus, there is a real need to be aware of how the residents perceive their learning environment within their departments or within the hospital. There is now recognition that it is imperative that hospitals include residents’ training as a part of organisational initiatives to enhance quality, safety and value in patient care, in so doing producing a high quality graduate medical training (Weiss, Bagian, & Nasca, 2013). With regard to SRL, there is definite interaction between the personal, behavioural and environmental aspects that govern self-regulation (Zimmerman, 1989). In a review of the published researches on SRL, van Houten-Schat et al. (2018) concluded that the use of SRL is not maximised in the clinical settings and recommends that a deliberate effort to design a learning environment that offers trainees the opportunity to apply their goal setting skills and helps improve their SRL confidence.

Our findings have shown that indeed any assessment method results in an educational response from postgraduate medical trainees. Our residents do complain, however, that consultants have limited interactions with them, yet these consultants are asked to evaluate them. Such complaints could be overcome by the introduction of direct observation of trainees through workplace based assessments (WBA). Being able to accurately observe resident-trainees performing clinical tasks such as history taking and physical examination and in the process deliver applicable feedback is one of the most important aspects of medical training (Norcini & Burch, 2007). Additionally, the opportunity for feedback which is inherent in these workplace assessment methods is equally important to their role in assessment (Norcini, 2010).

A. Strengths and Weaknesses of the Study

We chose IM and paediatrics because they are two departments without surgical skills and the expected competencies between the two are not very different in terms of knowledge and skills. Involving other residents from departments that train their residents to acquire the needed surgical skills may reveal different resident’ perspectives. Our study was done in a training institution with no WBA methods implemented yet, it would be interesting to study how WBA methods would change the perceptions of these residents toward assessment and the impact of the assessment program itself among the residents. Another limitation is that our study involves a single institution, and we are aware that some institutions may have situations which simulate a ‘hidden curriculum’ which changes the response of the trainees and their perceptions to the assessment practices.

V. CONCLUSION

In postgraduate medical education, trainees acknowledge that assessment positively influences their clinical training and performance. However, it is imperative that the following are considered before assessment can be assumed to contribute to the training and clinical performance of trainees, these are credibility, fairness, inter-personal relations between the trainee and the evaluator and commitment of the evaluator. Additionally, assessment drives learning through an interplay of different elements which include the patients and concern for their welfare, interactions with the consultants or supervisors and the learning environment. The residents, despite the absence of formal training or guidance from the clinical faculty, manifested a high degree of SDL to achieve their goals. The contributory effects of patients toward training of residents must be further researched to add more to the motivation of residents, and when better understood this can be applied even in undergraduate medical settings. Training institutions must make an effort to create an environment that stimulates learning and must be conscious of how the learning environment influences their trainees.

Notes on Contributors

Jaime L. Pacifico, MD, is a cardiologist and a faculty in the college of medicine at De La Salle University in the Philippines. He is a PhD student at Maastricht University. His studies are about perceptions of the learning environment in postgraduate medical education.

Julie Anne Villanueva, MD, is an internist in the Philippines.

Sylvia Heeneman, PhD, has a background in biomedical sciences and is currently an educational researcher and PhD supervisor in this field at Maastricht University.

Cees van der Vleuten, PhD, is the scientific director of the School of Health Professions of Maastricht University. He has published widely on medical education, particularly assessment. He supervises PhD students from the same university.

Ethical Approval

This study was approved by the ethical review board of the De La Salle Medical and Health Sciences Institute, Dasmarinas, Cavite, Philippines.

Acknowledgements

The authors wish to thank all the residents who voluntarily participated in this study.

Funding

This is an unfunded study.

Declaration of Interest

The authors declare that they have no competing interests.

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*Jaime L. Pacifico
De La Salle University College of Medicine,
De La Salle Medical and Health Sciences Institute,
Dasmarinas, Cavite, Philippines
Tel: +63 46 481 8000
E-mail: jlpacifico@dlshsi.edu.ph

Published online: 7 January, TAPS 2020, 5(1), 25-45
DOI: https://doi.org/10.29060/TAPS.2020-5-1/OA2073

Margaret Tan¹, Jonathan S. Herberg¹, Celestial Yap^2,3, Dujeepa D. Samarasekera⁴ & Zhi Xiong Chen^2,3,4,5,6

¹Institute of High Performance Computing, Agency for Science, Technology and Research (A*STAR), Singapore; ²Department of Physiology, Yong Loo Lin School of Medicine, National University of Singapore, Singapore; ³National University Cancer Institute, National University Health System, Singapore; ⁴Centre for Medical Education, Yong Loo Lin School of Medicine, National University of Singapore; ⁵KK Women’s and Children’s Hospital, Singapore; ⁶Office of Student Affairs, National University of Singapore

Abstract

Practice Highlights

• Research commitment and organisational support are predictors of perceived research performance.
• Research commitment and continuance commitment are predictors of anticipated research career length.
• Develop intellectually stimulating curriculum and work tasks to promote research motivation and innovations.
• Develop holistic curriculum to include knowledge management and domain expertise in graduate education.
• Encourage STEM employers to create more attractive careers and conducive workplace culture and conditions.

I. INTRODUCTION

Building a scientist’s expert domain knowledge is a long-term investment. Many years of education guidance and training are required to nurture each scientist to be competent in the field of expertise. Although the bachelor’s degree is often the stepping-stone in building a Science, Technology, Engineering and Mathematics (STEM) career, more advanced skills and specialised know-how developed during Masters and PhD programs are often required in order for a scientist to progress. Beyond PhD studies, a researcher aspiring to be independent requires further exposure to the scientific environment through postdoctoral fellowships. During this period, supervisors play an important role in the education and training of these young scientists, guiding, mentoring and nurturing them to be innovative in developing research that is of relevance to the world. In addition to research experience, the scientist needs pragmatic skills such as resource management. Yet, globally, young scientists including the best and the brightest, are leaving research careers for other non-research related careers independent of job competition, availability of funding and number of publications (Callaway, 2014; Roach & Sauermann, 2017).

In the early 2000s, when Singapore identified life sciences as the next pillar of economic growth, the government forged ahead to develop this sector, and one of the ways was for the university to become part of the ‘university-government-industry’ trinity to train and prepare the country’s limited human resource for this important sector. Considering that national policies and institutions are obliged to provide long-term and extensive investments to nurture these graduates in order for them to produce research innovations, attract investments, and stimulate economic and intellectual growth, there is an urgent need to understand why increasing number of promising STEM postgraduates opt to leave their scientific career paths to pursue non-research related careers that are not aligned to their prior education and training.

While the reasons for leaving STEM research careers could be due to changing job preferences because of self-perceived inability to do research, and misalignment in the expectation and reality of what research has to offer, the factors for this self-perceived research performance and misalignment in expectation and reality of research careers remain unknown. Therefore, this study aims to investigate and understand the factors that may influence the graduates’ perceived research performance and anticipated career longevity in scientific research paths. Identifying the factors that lead to the attrition of the STEM workforce will help educational institutions to refine or enhance graduate programs. The findings will also help educational leadership to understand the unmet needs and socio-psychological perceptions of the research scientists, and to address the intrinsic (personalised) and extrinsic (environmental/ organisational) factors which may motivate them to persevere towards successful careers in scientific research.

A. Conceptual Framework

Review of the literature suggests that a scientist’s research career performance and longevity may be rooted in specific motivational tendencies and can be driven by perspectives supported by the organisational culture and environment. It is in this context that the study investigates the factors that determine the scientist’s research career path longevity. We propose a conceptual framework as shown in Figure 1 that takes into account the individual traits such as the need-for-cognition, need-for-closure, and intrinsic motivation in identifying career performance. The two constructs, the need-for-cognition and need-for-closure, are integral to one’s knowledge-seeking motivation, and they are both linked to driving intrinsic motivation that has a direct effect on perceived research performance, which in turn affects the scientist’s choice to remain in the research career. However, we also propose that the commitment to remain in a research career over the long term is moderated by extrinsic factors such as perceived support in the work environment/organisation, supervisor’s support, and work autonomy. In other words, a graduate’s choice to remain in a research career path is influenced by perceived research performance with extrinsic factors in the work environment moderating the relationship.

Figure 1. The conceptual framework of cognitive and motivational constructs and their links to perceived research performance and anticipated research career length

Need-for-cognition refers to the extent one gains pleasure from effortful cognitive processing, such as figuring out solutions for difficult puzzles (Cacioppo & Petty, 1982). It has general utility and predictive power in social and educational psychology as a stable personality trait that shapes knowledge-seeking behavioural tendencies across a diverse range of situations (Fortier & Burkell, 2014; Szumowska & Kossowska, 2016, 2017). In our framework, the need-for-cognition is directly linked, as well as indirectly linked, through intrinsic motivation to career performance. As success in a research career path depends on a stable motivation to solve difficult and often long term problems, individuals who have a high need-for-cognition should exhibit better performance through their drive toward pursuing challenging questions out of curiosity. They tend to have a greater inclination to devote time and effort to difficult issues with deep analysis. Further, the need-for-cognition also opens one to new ideas, and facilitates willingness to engage in argument and having differing perspectives (Mussel, 2010). In fact, knowing that accumulating one’s knowledge is based on one’s prior research, the high need-for-cognition not only contribute to better performance but it should also influence long term career.

Need-for-closure refers to one’s need to obtain clear-cut answers to questions. Depending on situational factors, a higher need-for-closure can entail a greater motivation to seek information in carrying out cognitive tasks, or contrariwise a greater resistance to incorporating new information that challenges answers subjectively seem sufficient for getting tasks done (Roets, Kruglanski, Kossowska, Pierro, & Hong, 2015). For instance, if early cues suggest a feasible solution to a problem, a higher need-for-closure can result in a greater resistance to assimilating new information that may later challenge the earlier solution. On the other hand, a higher need-for-cognition can help spur an individual to seek new knowledge when significant uncertainties are made apparent. Thus, an individual’s need-for-cognition is a source for a variety of impacts on one’s motivation to seek and incorporate new knowledge; as such it is important to specify its roles in the context of determining a scientist’s research path and longevity.

The need-for-closure could be viewed as specifying a form of motivated cognition, leading to different goals depending on circumstances, rather than specifying a general lack of motivation for cognitive processing (Kruglanski et al., 2012; Kruglanski & Webster, 1996). In situations of high ambiguity and significant knowledge gaps, such as might be present at the start of a research endeavour, one’s need-for-closure can trigger significant devotions of cognitive effort toward obtaining clear answers. On the other hand, when seemingly satisfactory answers are obtained, a higher need-for-closure can entail goals to avoid acknowledging subsequent conflicting evidence and ambiguities requiring additional research. Hence, we propose that the link between need-for-closure and career performance may be moderated by need-for-cognition. This reflects the idea that different psychological motivations and capacities can interact to influence behavioural tendencies (Fortier & Burkell, 2014; Hill, Foster, Sofko, Elliot, & Shelton, 2016; Szumowska & Kossowska, 2016, 2017). For instance, if one’s need-for-cognition is low, a higher need-for-closure may only weakly improve, or even detract from perceived research performance, as one may have a tendency to crystalise knowledge too early in the research process, and be resistant to modifying knowledge based on follow-up research. Experimental evidence supports the notion that individuals with a higher need-for-closure have a higher tendency to “seize” early information cues in cognitive decision tasks, and to “freeze” the knowledge thereby acquired, being less prone to modify knowledge from subsequent information cues (Roets et al., 2015). It is possible that a high need-for-cognition can counteract the knowledge “freezing” tendency in high need-for-closure individuals, thereby sustaining their motivation for further knowledge-seeking behaviours following initial knowledge formation. This is consistent with the finding that individuals high in both needs tend to engage most predominately in information-seeking behaviours indicative of intellectual openness (Fortier & Burkell, 2014; Szumowska & Kossowska, 2016, 2017), which we propose as a key component for successful research careers.

Intrinsic motivation is an essential construct for understanding performance and choice to stay in the career. Motivation generally refers to an individual’s inclination to devote effort toward goals; however, intrinsic motivation arises from one’s desire for self-improvement and genuine interest, rather than from external pressures (Koestner & Losier, 2002). For intrinsic motivation to be maintained, one’s needs for autonomy (sense of self-control), competence (sense of capability) and relatedness (sense of social connectedness and purpose) have to be obtained while one engages in effortful activities toward achieving long-term goals (Ryan & Deci, 2000). Empirical research supports the notion that intrinsic motivation, as compared to more extrinsic forms of motivation, is critical for long-term academic performance (Taylor et al., 2014). In our model, intrinsic motivation has a direct link not only to performance, but also to long-term career choice, i.e. the likelihood of choosing to stay on a given research career path over an extended period of time, rather than changing careers. Thus, we propose the importance of intrinsic motivation in driving career performance and choice to remain in it.

Extrinsic factors include organisational culture and structure that support the work environment comprising such components as i) perceived support and value (conveyed by the organisation; Lambert, 2000); ii) interpersonal trust at work (Cook & Wall, 1980); iii) work autonomy, which includes approach to perform the tasks (or the degree of choice one has in determining the means and plans for completing the tasks), and scheduling autonomy (or how much flexibility one has in the timing of completion of tasks and goals; Breaugh, 1985, 1999) and iv) supervisor support. For research work, a mentor relationship is important to generate interpersonal trust and confidence. By mentor relationships, we refer to the degree of research guidance, coaching, and support that the scientist receives from his or her mentors. Better mentor relationships can lead to an increased motivation to maintain one’s career as a research scientist, in addition to sustaining increased performance. Further, extrinsic motivation also involves one’s continuance commitment referring to one’s inclination to remain in a given job for practical considerations; hence we propose that while better perceived research performance tends to increase anticipated research career length, the strength of this link is moderated by extrinsic factors.

II. METHODS

Ethical approval was obtained from the Institutional Review Board, National University of Singapore (NUS) to conduct the survey questionnaire investigation. Participants completed an online questionnaire (hosted on SurveyMonkey) that took about 45 minutes to complete. The online survey was conducted over a period of nine months.

A. Participants

The target respondents consisted of the STEM postgraduate students and PhD fellows. The administrative staff independent of the investigators sent out individual emails to each of the following departments and faculties to seek their approval to disseminate the survey – NUS Yong Loo Lin School of Medicine (12 Heads of Department, Vice-Dean [Research], Assistant Dean [Research] and Vice-Dean [Academic Medicine]), Faculty of Arts and Social Sciences (Vice-Dean, Research), Faculty of Engineering (Vice-Dean, Research), Faculty of Science (Vice-Dean) and NUS Graduate School (Executive Director). Once approval was obtained, their secretaries were requested to send an email invitation containing the survey link to each of their respective postgraduate students and PhD fellows to participate in the survey.

Participants were given three weeks to complete the questionnaire. Reminder emails were sent to the participants to complete the survey if they had not done so. 92 participants took part in the survey. Among the 63 participants who provided their demographic details, 32 were male and 31 were female. The ages ranged from 21 to 44 years old, with the majority between 25 to 34 years old. On average, they had about 2 to 6 years of research experience. Majority respondents came from Biomedical & Related Sciences (44), with the rest as follows: Engineering & Technology (6), Natural Sciences (excluding Biological Sciences; 4), Social Sciences (3), Agriculture & Food Sciences (2), Biological Sciences (2), Healthcare & Related Sciences (1) and Healthcare Services (1). We used responses from 64 participants for the regression and path analyses on anticipated research career length.

B. Questionnaire Design

We developed a survey instrument measuring various constructs of the model by adapting validated questionnaires established in the industrial organisation and cognitive psychology literature. The questionnaire consists of four parts as follows – i) 64 closed-ended questions on a 6-point Likert scale, ii) 10 closed-ended questions, iii) 2 ranking questions, and iv) a demographic section. For all scale questions, participants indicate their responses on a six-point Likert scale by indicating whether they “Strongly Disagree”, “Disagree”, “Slightly Disagree”, “Slightly Agree”, “Agree”, or “Strongly Agree”. For each construct, a participant’s agreement ratings across the construct’s items were averaged (with negatively framed items reverse-coded), to obtain an overall rating for the construct. The appendix shows the questions that we used for the various constructs.

To assess Need-for-Cognition, we utilised eight items from the Cacciopo et al. validated for the need-for-cognition scale (Cacioppo & Petty, 1982). Need-for-Closure was also assessed by eight validated items as well (Roets & Van Hiel, 2011). Organisational Commitment was measured directly through participants’ ratings of items from the established Cook & Wall scale (Cook & Wall, 1980), as well as items assessing their Affective Commitment (in relation to their organisation) and their Normative Commitment (to remain in their organisation; Allen & Meyer, 1990), as these latter sets of items pertain to their motivation to remain in their current education or work environment. As a distinct component of Intrinsic Motivation, we included five items measuring the participant’s Research Commitment. These items are likely to most directly reflect intrinsic motivation, as they were adapted from the validated Intrinsic Motivation Inventory (Ryan & Deci, 2000), and contextualised with the aim to assess directly participants’ intrinsic motivation for engaging in research tasks in relation to their work or education. Next, our main Extrinsic Factors component, Organisational Support was measured from the validated Lambert et al. scale (Lambert, 2000) which directly assesses the degree of support participants perceive to come from their organisational environment. In addition, we included other organisational-related subscales, which we propose to reflect extrinsic factors in relation to one’s research career. These consist of items assessing participant’s Supervisor Support, Interpersonal Trust at Work, and Work Autonomy granted by the organisation (Breaugh, 1999; Cook & Wall, 1980). Lastly, as an extrinsic factor distinct from organisational factors, we included items to measure participants’ Continuance Commitment, or the degree to which they are motivated to remain in their work environment for extrinsic rather than intrinsic reasons (Allen & Meyer, 1990).

To assess participants’ perceived research performance, we had five questions, which we intended to indicate how strongly they viewed their level of performance (and their co-workers’ view of their performance). In addition, participants indicated their expected research career length in terms of choosing one of five responses, ranging from “less than 2 years” to “more than 10 years”, which we coded on a five-point ordinal scale. In addition, we had questions designed to elicit direct feedback from participants regarding their motivations, expectations, and experiences in their work or education environment.

III. RESULTS

Through our 10 closed-ended questionnaires on the participants’ research and career aspiration, the descriptive statistics showed some 84.5% of the participants were motivated to pursue a STEM career as indicated by their early passion or participation in science and research (Question 5). In fact, some 95.3% started to think about attending graduate school even before or during their undergraduate years (Question 6). However, despite their early enthusiasm to pursue a science and research career, it is discouraging that 54.7% intended to continue research in an academic or research setting (Question 7), and worse only 25% see themselves working in research and development beyond 10 years after their PhD (Question 9). Thus, it is not surprising that 23.4% were unlikely/very unlikely to take up non-academia/non-research careers after PhD (Question 8) and for those who were likely/very likely to take up non-academia/non-research careers, they included careers in banking and finance, management and consulting, and corporate positions in biotech and pharmaceutical firms (Question 10). It appeared that remuneration is an important deciding factor (68.8% cited it) whether or not to stay in research (Question 11); indeed, they also want increases in their current salary (Question 13). The findings also showed that the top two factors influencing participants’ decision to stay or leave a research and development career are physical work environment (e.g. equipment, ergonomics, cleanliness – Question 15) and working conditions (e.g. organisation culture – Question 16). In terms of the descriptive statistics, it is a concern to note that participants see the unattractiveness to pursue a scientific research career despite early strong motivation, prior to graduate studies.

Furthering our investigations using the closed-ended questionnaires, we analysed the relationship between our scale-construct metrics and a) participants’ self-rated research career performance (as reflected in the mean of the five questions at the end of Part D of the survey; and b) participants’ expected research career length, as reflected in their responses (coded as 1 to 5) to the question “How long do you see yourself working in research and development after your PhD?” To address these latter questions, we applied multiple regression analyses and path analyses. Multiple regression analyses were applied for each of our two dependent variables (the metric of self-rated research performance, and of anticipated research career length). For each dependent variable, a stepwise regression was calculated with all the subscale scores initially entered as separate predictors, and with the Akaike Information Criteria (AIC) utilised to select which subscale predictors to keep in the final stepwise model. In addition, for predicting perceived research performance, which was a mean rating across several items, we applied linear multiple regression models, but for predicting anticipated research career length, comprising a single item rating for each participant, we applied ordinal logistic regressions, to avoid in the latter case the more questionable approximation of treating a single-item rating as though it were on an interval scale.

For a more direct test of the proposed links in our conceptual framework, we developed two path analysis models. First, to examine the loadings of the intrinsic motivation and the extrinsic factors constructs on their respective subscale scores, we conducted a confirmatory factor analysis. The indicators for the intrinsic motivation construct were taken as its subscale scores (affective commitment, normative commitment, organisational commitment, and research commitment). The manifest indicators for the extrinsic motivation construct were the scores on the subscales for organisational support, interpersonal trust at work, supervisor support, work autonomy, and continuance commitment. The fit statistics for this factor analysis was adequate: Confirmatory Fit Index (CFI) = 0.91; Root Mean Square Error of Approximation (RMSEA) = 0.08; c² = 36.60, df = 26, p = 0.08. However, the standardised loadings for affective commitment (.09) and for continuance commitment (.13) were not statistically significant. Therefore, in our initial structural equation model (SEM), we dropped these indicators. The endogenous variable of anticipated research career length was treated as ordinal, with weighted least square mean and variance adjusted estimation applied. This SEM however had poor model fit statistics: CFI = 0.56; RMSEA = 0.23; c² = 412, df = 95, p < 0.01. These fit statistics were improved when a link between Extrinsic Factors and perceived Research Performance was included (rather than, as with our original conceptual model, only having only the link between Extrinsic Factors and Anticipated Research Career Length included): CFI = 0.66; RMSEA = 0.20; c² = 333, df = 94, p < 0.01. However, as these statistics are still far from adequate overall model fit, we settled on a simplified, single-indicator path analysis approach. Intrinsic motivation was represented by the Research Commitment subscale score, as this subscale was most directly relevant in being based on the validated Intrinsic Motivation Inventory, and in the final stepwise model utilising the subscale scores as predictors for perceived Research Performance since Research Commitment and Organisational Support were the only significant subscale predictors. For the regression analysis predicting Anticipated Research Career Length, in the final stepwise model Research Commitment and Continuance Commitment were the only significant predictors. Based on these considerations, we implemented two single-indicator path analysis models. Both utilised Research Commitment as the indicator for Intrinsic Motivation. For the Extrinsic Factors indicator, our first path analysis model utilised Organisational Support, whereas our second one utilised Continuance Commitment. The fit statistics for our first path analysis are substantially improved over the more complicated SEMs: CFI = 0.91; RMSEA = 0.12; c² = 13.0, df = 7, p = 0.07. For our second path analysis, the fit statistics were very strong: CFI = 1.00; RMSEA = 0.00; c² = 5.01, df = 7, p = 0.66. Thus, for the purpose of exploring potentially important causal links among critical variables, our final path analysis models both include one link that was not in our conceptual framework, which is the link between “extrinsic factors” and perceived “research performance”. They also focus specifically on the research commitment component of intrinsic motivation, and (separately) on the organisational support and on the continuance commitment components of extrinsic factors.

Our results showed that the research commitment component of intrinsic motivation may be the driver in influencing perceived research performance (as it is significant in both the final model output; Table 1, Figures 2 and 3). Organisational support component of extrinsic factors, on the other hand, seems to impact perceived research performance, and is the only significant extrinsic factors subscale in the stepwise regression for predicting perceived research performance (Table 1 and Figure 2). Table 1 shows the final AIC stepwise model, for the intrinsic and extrinsic subscales that affect career performance.

Note: Standardised coefficients, t-statistics, and p-values for final model in AIC stepwise regression for predicting perceived research performance (with intrinsic motivation and extrinsic factors broken down into subscales).

Adjusted R² = .54, F(4,66) = 21.68, p < .01
*p < .05, **p < .01
Table 1. Stepwise regression results for perceived research performance with construct subscales

Focusing on the paths in Figure 2 that lead to perceived research performance (in the path analysis with organisational support as the extrinsic factor indicator), we found that the direct link from need-for-cognition is non-significant, whereas that from research commitment is significant. In addition, the indirect link between need-for-cognition and perceived research performance, through research commitment, is statistically significant (β = 0.17, p < .05). Also, the link between organisational support and perceived research performance is significant. Lastly, need-for-closure has no direct or indirect effect on perceived research performance, and there is no interaction effect of need-for-cognition on need-for-closure to influence perceived research performance. In addition, in our path analysis that includes continuance commitment as the extrinsic factor indicator, there is no effect of continuance commitment component on perceived research performance (Figure 3).

Note: The research commitment subscale represents intrinsic motivation, and the organisational support subscale represents extrinsic factors. Links are labelled with standardised coefficients. Coefficients in red are statistically significant.

Figure 2. Path analysis of the conceptual framework (research commitment and organisational support)

Note: The research commitment subscale of intrinsic motivation and the continuance commitment subscale of extrinsic factors are the only subscales with significant beta coefficients. Links are labelled with standardised coefficients. Coefficients in red are statistically significant.

Figure 3. Path analysis of the conceptual framework (research commitment and continuance commitment)

Thus, perceived research performance may be significantly predicted by research commitment, i.e. items assessing intrinsic motivation for research. Furthermore, need-for-cognition may indirectly affect perceived research performance, by influencing research commitment. Organisational support may, in addition, be an important predictor of perceived research performance. In other words, scientists with high need-for-cognition, high intrinsic motivation coupled with strong positive extrinsic factors may perform better in research, which we proposed might increase the likelihood of them staying on in research careers. However, satisfying their need-for-closure may not necessarily enhance their perceived research performance, or lead them to remain in STEM careers.

Note: Standardised coefficients, t-statistics, and p-values for final model in AIC stepwise ordered logistic regression for predicting anticipated research career length (with intrinsic motivation and extrinsic factors broken down into subscales).

*p < .05, **p < .01
Table 2. Stepwise regression results for anticipated research career length with construct subscales

Our stepwise ordinal logistic regression analysis for predicting anticipated research career length that included the individual subscales for intrinsic motivation and for the extrinsic factors scale suggests that research commitment (within intrinsic motivation) and continuance commitment (within extrinsic factors) may be important, as they are the only statistically significant predictors in the final stepwise model (Table 2).

From our path analysis of predictors that affect anticipated research career length, with organisational support as the extrinsic factors indicator, we found no effect from perceived research performance, from organisational support, or from the organisational support by perceived research performance interaction. The only direct link to anticipated career length comes from research commitment (Figure 2). However, the indirect effect of need-for-cognition, through research commitment, is in the marginal area of statistical significance (β = 0.21, p = .06). In our path analysis that includes continuance commitment as the extrinsic factors indicator, we found a statistically significant effect of continuance commitment on anticipated research career length (Figure 3).

IV. DISCUSSION

We believe that this is the first study in Singapore to investigate the factors to determine perceived research performance and anticipated career longevity of scientists in the STEM environment. We envisaged that graduates who are inclined towards and enjoy effortful cognitive activities are likely to do well in research activities. The findings of the study, however, suggest that future education as well as career policies concerning graduate students’ recruitment may need to focus on identifying individuals who demonstrate their psychological cognitive trait in pursuing investigative and creative research. In a similar context, academic chairs of graduate schools and institutions should be mindful of designing programs that are geared towards enhancing and sustaining the researchers’ cognitive and motivational aspirations.

It is not surprising to note that individuals, who are intrinsically motivated or having stronger commitment to do research are likely to perceive themselves to perform better, but only when organisational support and environment are favourable and conducive. In this context, it appears that programs for training and nurturing graduate students need to focus not only on providing domain knowledge competence but to also understand researchers’ aspirations and life purposes, and expressed by participants, they can be as diverse as the need to “provide for family”, to pursue “personal achievement” or be a “stepping stone in academia”. Given that organisational culture, supervisory support and their interdependency have been shown to be important in how employees perceive their value to the organisation and reciprocate in kind, our lack of significant correlations could be due to the limitation of the small sample size as our study only obtained about 10 to 20 percent response rate (92 out of estimated 500 to 1000 participants reached) and with only 64 completed usable responses compared to higher response rates and completed usable responses in other studies (Shoss, Eisenberger, Restubog, & Zagenczyk, 2013).

In terms of anticipated career longevity, there is no single factor that is able to predict an individual’s likelihood to choose and embark on a long-term research career trajectory. What is striking is that perceived research performance is unable to predict for anticipated career longevity. This suggests that even if an individual performs well in research, there is no certainty that he or she may continue to pursue research as a long-term career. Indeed, our finding confirms previous work showing that postgraduates may leave the research career path independent of publications and funding (Roach & Sauermann, 2017). However, there is evidence to suggest that individual elements of particular factors may be indicative for anticipated career longevity. Specifically, individuals who are committed to research and emotionally attached to the institution are more likely to stay on and be committed in research careers. This suggests that it may be beneficial for graduate mentoring programs to incorporate activities that are likely to enhance emotional bonding of students with their institutions, which in turn may increase their affinity towards research careers. It seems that the findings suggest that research commitment or a passion to do research is a key ingredient to perceived performance success and anticipated career longevity.

Understanding the factors that influence commitments to perceived research performance and anticipated career longevity is important to guide the design of scholarship policies to mitigate declining scholarship and increasing attrition among graduate students pursuing the STEM career paths. Currently, training of graduate students mainly involves undertaking a suite of domain-related course modules and embarking on a research project over a specified period of usually 4 years, leading to a thesis. Students are encouraged to publish but often, this is not a mandatory requirement. These students are also required to support and perform teaching duties as one of the program requirements. For early career scientists, the training is less structured where trainees typically spend an undefined amount of time in a research setting working on various projects. Given that “research can be too mentally challenging and stressful” as cited by a participant, it is therefore crucial to have effective, supportive and readily approachable mentors. Supervisors of graduate students and early career scientists are typically universities’ faculty or research institutes’ principal investigators who may not have formal training in mentorship. Currently, in Singapore, there is no systematic training of supervisors on how to supervise and mentor students in a holistic manner. Perhaps, it may be useful to take guidance from best practices for doctoral training in Europe and North America, and contextualise these to local settings and conditions (Barnett, Harris, & Mulvany, 2017).

We would like to suggest that future education and training of graduate students and early career scientists should not only focus on developing programs that build depth and breadth of domain knowledge but they must instil the desire for intellectual contribution to society. Scholarships should enhance the researchers’ intrinsic motivation of their research commitment and help them to appreciate their contributions to their research endeavours. Guidelines should be in place to provide supervisors with the necessary guidance for effective and holistic mentorship, and to shift from an output-oriented mindset to a human development-centric mindset. Although we have no evidence from direct feedback to suggest a link between organisational support and continuance commitment, nevertheless, given that forms of organisational support such as physical work environment and working conditions are the top two factors influencing participants’ decision to stay or leave a scientific research career, this may suggest a potential link between organisational support and continuance commitment. In brief, we believe these changes would alter mentor-mentee behaviour and relationship, creating a conducive and trusting environment with strong organisational and supervisory support for fostering meaningful research that is aligned to each organisation’s goals and objectives.

V. LIMITATIONS

A limitation of this study is that the sample sizes are small, and as the study is a questionnaire survey, only perceived research performance and self-declared expected research career length were used. We acknowledged that research performance could be measured more objectively in terms of number of academic publications and citations, however, our definition of research performance also encompasses subjective aspects which are harder to evaluate such as having an inquisitive mind, taking initiatives to explore innovations, providing ethical scholarly behaviour that includes collaborations. We note that self-declared expected research career length may not reflect reality, and it would have been more realistic to evaluate actual periods that the scientists stayed on in their successful research careers versus those who did not. However, this is logistically challenging to carry out with potentially more confounding variables that are difficult to define.

VI. CONCLUSION

In conclusion, we hope that our findings will provide insights to implore domain curriculum developers and prospective research-oriented employers to incorporate intellectually stimulating learning or work components that will motivate and strengthen research commitment. Indeed, education policymakers should explore areas of support that are lacking in graduate education while policymakers of research institutes should provide making research careers and workplace conditions more conducive and attractive for retaining scientific talents. Indeed, the many issues surrounding STEM career deserve attention and especially in the context that many young scholars who aspire to do research at the onset eventually choose to leave their research careers (Kavallaris et al., 2008). For instance, participants cited that “career stability is very limited” as projects are based on research funding; consequently it has been touted as having weak career development prospects when funding runs out. Researchers also often cited that they are “underpaid in the research field” and “pay for them is very low, relative to other industries”. Hence, having adequate annual leave considering that they tend to work long hours to finish a project, better remuneration that is more comparable to other industries, and greater assurance towards a clearer career roadmap would ensure a more research continuance commitment.

We hope that other researchers would replicate this study to delve deeper into the importance of understanding the cognitive and psychological needs of the researchers, enhancing research commitment in the community and developing strong organisational ties in influencing research performance and commitments as well as longevity in research careers among graduate students and early career scientists.

Notes on Contributors

Dr Margaret Tan, PhD, was a senior scientist at A*STAR prior to setting up SmartWerkz, an AI-driven ontological system that delivers immersive extended reality skills coaching to facilitate effective application of knowledge assets. She was also an Associate Professor at NTU and NUS specialising in knowledge management and organisational behaviours.

Dr Jonathan Herberg, PhD, has worked over five years as a research scientist (cognitive psychologist) at A*STAR IHPC. He obtained his PhD in Psychology from Peabody’s Cognition and Cognitive Neuroscience Program at Vanderbilt University. His research includes experimental and educational psychology, collaborative learning, human-computer interaction, psychometrics and predictive analytics.

A/Prof Celestial Yap, MBBS, PhD, is the Education Director for Health Professions at the Department of Physiology and an Affiliate Associate Professor from the National University Cancer Institute. She is also the Integration Lead Educator in undergraduate medical curriculum. Her research interests include medical education and graduate research training.

Dr Dujeepa D. Samarasekera, MBBS, MHPE, FAMS, FAcadMEd, FAMEE, is the Director of Centre for Medical Education, National University of Singapore and the President of the Western Pacific Regional Association of Medical Education. He also consults for the Singapore Ministry of Health on medical education matters.

Dr Zhi Xiong Chen, PhD, is the Deputy Education Director from the Department of Physiology and the Assistant Dean of Students at NUS. He is also the Integration Lead Educator in undergraduate medical curriculum and a Joint Scientist at KKH. His research interests include health professions education.

Ethical Approval

This research received approval from the NUS-Institutional Review Board (NUS-IRB Ref No. B-15-256). Consent was obtained from participants for the research study.

Acknowledgements

The authors would like to thank Mr Yeo Su Ping for the administrative help rendered throughout the study.

Funding

No funding is involved in this paper.

Declaration of Interest

The authors report no conflict of interest. The authors alone are responsible for the content and writing of the article.

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*Zhi Xiong Chen
Department of Physiology,
Yong Loo Lin School of Medicine,
National University of Singapore,
2 Medical Drive, MD9, Singapore 117593
Tel: +65 6516 3231
E-mail: zhixiong_chen@nus.edu.sg

Published online: 7 January, TAPS 2020, 5(1), 8-15
DOI: https://doi.org/10.29060/TAPS.2020-5-1/RA2087

Justin Bilszta¹, Jayne Lysk¹, Ardi Findyartini² & Diantha Soemantri²

¹Department of Medical Education, Melbourne Medical School, University of Melbourne, Australia; ²Department of Medical Education, Faculty of Medicine, Universitas Indonesia, Indonesia

Abstract

Practice Highlights

• Successful transnational collaborative FDI requires genuine collaboration and partnership.
• Curriculum blueprinting with the awareness of cultural nuances is important for a collaborative FDI.
• Long-term sustainability needs to be considered and planned in light of the resource challenges.

I. INTRODUCTION

The opportunities to develop and foster collaborative partnerships across the globe in the field of higher education are growing. There are many forms of transnational collaboration in education; however, the majority of university collaborations are symbolised by ‘providers and buyers’, with buying countries being developing nations and provider countries based in developed ones (Nhan & Nguyen, 2018). This contrasts with non-economically driven forms of transnational collaboration which generally include partnerships looking to expand areas of research, knowledge or working on international curriculum (Carciun & Orosz, 2018), Regardless of the form, research into collaborative international partnerships reveal common challenges including issues of joint decision making, the different learning cultures and hierarchical structures, and sustainability of program outcomes (Allen, 2014; Caniglia et al., 2017; Kim, Lee, Park, & Shin, 2017; Sullivan, Forrester, & Al-Makhamreh, 2010; Yoon et al., 2016). This has implications for any new or emerging form of international collaboration and its continuing success.

One expanding area of non-economically driven transnational collaborations in higher education has been faculty development. These partnerships have been flourishing in many different disciplines and similar challenges concerning the establishment and long term sustainability have been identified. This paper contributes to the study of transnational collaborations in higher education by focusing specifically on faculty development in the field of medical education. It firstly reviews the challenges associated with international collaborations involved in faculty development. The authors then critically reflect on an example of an international collaboration between researchers from medical schools in Indonesia and Australia through the lens of the experiences of those involved.

Faculty development initiatives (FDIs) in medical schools are an inseparable part of the internationalisation of medical education (Harden, 2006). In this era of globalisation, medical faculty should be prepared to teach in a cross-cultural environment (Deardorff, 2009). International collaboration in FDIs aim to tackle challenges in resource and financial constraints as well as to increase the quality of programs by drawing on expertise and best evidence from different centres and countries (Burdick, Amaral, Campos, & Norcini, 2011; Burdick et al., 2010; Harden, 2006; Kim et al., 2015; Yoon et al., 2016). Despite the push to develop international collaborations in FDIs many countries, particularly those in developing nations, find this especially challenging (Kim et al., 2017; Sherman & Chappell, 2018) and there are several reasons for this. The first relates to the dominant model of foreign ownership and control. Whitehead et al. in their recent commentary on this issue highlighted the trend for educational collaborations to flow in one direction – Europe and North American to other parts of the world – with control of the curriculum and academic structures resting with the ‘foreign expert’ (Whitehead, Wondimagegn, Baheretibeb, & Brian, 2018). The second challenge centres around the limitations on the opportunities for faculty development because of heavy teaching loads, a lack of a well-trained faculty who can provide professional training, limited infrastructure and competing demands for research and clinical services (Alkan, 2000). The World Health Organization has recognised this critical problem for faculty development and its long term impact on creating a healthcare workforce fit for purpose in the 21st century (Buchan & Campbell, 2013). As clinical education changes health provider practice, it can have wide-ranging effects on the health of a population, especially in underdeveloped countries (Boulet, Bede, McKinley, & Norcini, 2007). Thus, FDIs must reflect the contexts and requirements of developing countries if they are to surmount these challenges.

Southeast Asia has its specific challenges that need to be recognised. Although in some countries it is heavily modelled on Western education systems, the medical education culture has innumerable adaptations and innovations with identified socio-economic, cultural and institutional barriers (Amin, 2004; Majumder, 2004). Cultural and community needs differ vastly and with one of the smallest number of medical schools per million population (Boulet et al., 2007), the lack of human and institutional capacity to satisfactorily address the healthcare needs of populations in this region is stark (Kanchanachitra et al., 2011). Although there are international FDIs provided by developed countries for academic institutions in Southeast Asia there is limited evidence as to their effectiveness and benefits to teaching practice gained by participants (Phuong, Duong, & McLean, 2015; Steinert et al., 2006). Other commonly cited challenges for FDI development include: a divide between the education contexts and expectations of Asian and Western countries (T. P. Lam & Y. Y. B. Lam, 2009); a lack of English ability which adversely impacts on establishing an effective international collaboration as well as in delivery of the FDI content to participants (Ferry et al., 2006); and where countries in Southeast Asia have tried to develop and implement their own FDIs (World Health Organization, 2013) insufficient resources and shortage of qualified educators result in significant limitations in achieving self-sufficiency.

II. CONTEXT

The Faculty of Medicine Universitas Indonesia (FMUI) and the Cipto Mangunkusumo Hospital, are committed to supporting the role of clinical teachers. An introductory FDI–Clinical Teacher Course (CTC)–has been available since 2008 to clinical teachers wanting to develop their teaching practice. The CTC is designed to support clinicians in the practical delivery of teaching and primarily focuses on the principles and techniques of teaching and supervising in clinical settings, the development of clinical reasoning skills, teaching procedural skills, and assessment practices in clinical settings. Training materials have been developed by the Department of Medical Education FMUI and the trainers are teaching staff from the Universitas Indonesia Academic Health System community. The CTC meets the provision of a minimum of 40 hours of training as regulated by the Directorate General of Higher Education, Ministry of Research and Higher Education and Universitas Indonesia.

In 2015, a formal collaboration (Partnerships in Clinical Education) between FMUI and the University of Melbourne (UoM) Medical School’s Excellence in Clinical Teaching (EXCITE) program was established. EXCITE is a series of linked award courses for clinical teachers from all health-related disciplines, that supports them in the practical delivery of teaching into the clinical workplace and provides a deeper understanding of the theories underpinning clinical education. A key aim of the FMUI–UoM collaboration was to develop an innovative and culturally relevant teaching program for clinical teachers from FMUI, that leveraged pedagogical strengths of the CTC and EXCITE programs and their teaching staff. The impetus for this collaboration was the long-standing professional relationships between academics from UoM and FMUI and was borne from FMUI recognising the need to develop, not just the practical delivery of teaching to their medical students, but opportunities for their clinical teachers to be exposed to cutting-edge clinical education practice. Importantly, any educational initiative needed to consider Indonesian academic and cultural traditions and be developed specifically for Indonesian clinical teachers, rather than simply transplanting or imposing an external (i.e. Western) teaching program ill-suited to the Indonesian context (Bleakley, Brice, & Bligh, 2008; Hodges, Maniate, Martimianakis, Alsuwaidan, & Segouin, 2009; Waterval, Frambach, Driessen, & Scherpbier, 2014).

III. AIMS AND OBJECTIVES

Much of the research into transnational collaborations have focused on the issue pertaining to quality assurance, regulation and accreditation of educational programs; translocation of curriculum and intercultural understanding; institutional and management strategic decision making; and student choice and academic mobility (Kosmützky & Putty, 2015). However, few studies have evaluated the critical factors for the success or failure of sustainable partnerships (Waterval, Driessen, Scherpbier, & Frambach, 2018; Waterval et al., 2014) particularly from the perspective of those who have negotiated the challenges of establishing such a transnational partnership. In this light, the focus of this paper is to provide the reader with insights on how to facilitate transnational collaboration viewed through the lens of the experiences of those involved. Its aim is not to provide a step-by-step process for the development of an FDI but critically reflect on the process by which the collaboration was established, and management of both the partnership and differences in context between medical schools in Indonesia and Australia. When read in conjunction with the companion paper published in the previous issue (Findyartini, Bilszta, Lysk, & Soemantri, 2019), we hope that the reader will gain an appreciation of better ways to foster transnational collaborations to drive educational reform.

IV. INSIGHTS

A. Insight 1 – Actively Foster Genuine Collaboration

Collaboration is a process of working together, which involves not only cooperation and communication, but also trust, respect and understanding, in order to establish an interdependent relationship that will augment the contributions of each party involved (Pike et al., 1993). As outlined, a key focus of the FMUI–UoM collaboration was to consider Indonesian academic and cultural traditions to develop an FDI specifically for Indonesian clinical teachers, rather than simply transplanting or imposing an external (i.e. Western) teaching model.

Research into successful international education partnerships has identified several key elements to ensure success with the most important of these being communication, mutual respect, humility and trust (Tupe, Kern, Salvant, & Talero, 2015). The relevance of a trusting relationship to collaborative performance has been repeatedly emphasised (Bachmann, 2001; Das & Teng, 2001; Fryxell, Dooley, & Vryza, 2002) and Bovill, Jordan, and Watters (2014) have highlighted that partners need to share a sense of mutual responsibility and benefit from a project, contribute expertise, effort and resource equally and for this contribution is to be recognised by the other partner (Bovill et al., 2015).

To ensure that externally the FMUI–UoM partnership was perceived as a genuine collaborative process, one of the very first initiatives undertaken was a needs assessment activity involving a broad mix of clinical teachers from FMUI. This activity was facilitated by staff from the FMUI Department of Medical Education with staff from UoM as active observers. This activity resulted in a mutual sharing of ideas and perspectives thereby allowing clinical teachers from FMUI to 1) share information on the current status of clinical teacher training at FMUI; 2) identify internal and external factors that influence the introduction and efficacy of FDIs at FMUI; 3) reach a consensus on practical visions of future health professions education at FUMI and; 4) discuss methods of delivering FDIs and the pros and cons of each format.

Whilst the focus of the needs assessment was to inform the development of the FDI, the learning for the research team was the importance of active engagement with clinical teaching leaders and a greater understanding for the UoM team of the cultural and academic context in which FMUI clinical teachers deliver their teaching activities. This led to a recognition of the cultural importance of negotiation and discussion when proposing change and of spending time in person and in location with those impacted by change (Tupe et al., 2015; Zhang & Huxham, 2009). Of significance, this activity emphasised the bilateral exchange of educational expertise and experiences rather than a unilateral flow of ideas, materials, and experts from one context (UoM) to another (FMUI) as well as the process of developing the collaborative partnership rather than concentrating merely on the educational product (Keay, May, & O’Mahony, 2014).

Importantly, a small but significant part of actively maintaining a collaborative mindset and approach was regular contact between the researchers, through both formal (e.g. email and exchanging documentation) and informal (e.g. social media) means. These methods of collaboration, whether scheduled or unscheduled, contributed to building and maintaining rapport which then enhanced mutual respect and co-construction of strategies and approaches to achieving the collaborative project goals.

B. Insight 2 – Utilise Curriculum Blueprinting as a Means Rather Than an End

There are three well-documented barriers to curriculum delivery in international partnerships–that a shared curriculum will inevitably result in a ‘variability in expectations, decision-making, and academic performance’ (Coleman, 2003, p. 359); content knowledge and delivery, and teaching skills, will differ between academic contexts (Heffernan & Poole, 2005; Shams & Huisman, 2012); and the inherent weakness of relying only on documents when engaging in curriculum mapping processes as these maps only describe what is intended to take place in the learning environment, not necessarily what does take place (Hays, 2016) and why.

To overcome these barriers a three-step process was undertaken using the paradigm of the designed-delivered-experienced curriculum (Prideaux, 2003): 1) a formalised curriculum blueprinting exercise comparing the CTC and EXCITE program at the Graduate Certificate level (i.e. the designed curriculum); 2) the curriculum map was then supplemented with experiences of the research team who had delivered into their respective FDIs (i.e. the delivered curriculum); and 3) acknowledging the experiences of participants of both FDIs (i.e. the experienced curriculum). This blueprinting activity highlighted areas of pedagogical similarities (e.g. the characteristics of providing effective feedback to students; using OSCEs to assess student performance in the clinical setting) and differences (e.g. engaging peers in a process of peer feedback of teaching) and provided a trigger for frank discussion and reflection, with both groups of researchers freely and honestly questioning the pedagogical decisions made for their individual FDIs. It was through this iterative process of challenge and reflexivity, rather than the blueprinting activity itself, that meant that decisions on the pedagogical framework and selection of teaching and learning activities and education resources was a collaborative and shared process.

Visualising the curriculum and making visible the structure of both programs made decisions related to modifying pedagogical approaches self-evident and consequently, the goals and objectives of the FDI become more important in guiding planning and development, rather than control of the content, and recognition that content can be represented and interpreted from multiple perspectives. Through this process, the curriculum blueprint represented the collaborative thought process used to establish the FDI. The presence of the document encouraged dynamic discussions among the researchers in attempting to create an evidence-based, best practice FDI while still considering the characteristics of those who would be participating.

C. Insight 3 – Awareness of Cultural Nuances is Vital

Successful international collaborations necessarily involve multiple interwoven dimensions of leadership, organisation, collaboration, and personal growth, the relevance of which is inseparable from society and social frameworks (Eldridge & Cranston, 2009). In the context of this project, not only did societal cultural differences have to be considered but also the different academic and clinical medicine and teaching cultures of Australia and Indonesia. When undertaking transnational teaching projects in other countries, it is important that the assumptions made about one’s own and others’ cultures are both questioned (Maher, Sicchia, & Stein, 2003). But this itself provides an opportunity to compare and contrast both cultures, thereby fostering greater understanding, and appreciation of, the nuances of both.

Although the researchers had well established professional and personal relationships and extensive knowledge of both countries and cultures, there was still a need–especially on the side of the UoM team–to observe the Indonesian academic culture in vivo and the interaction and relationships between faculty members from different clinical disciplines. This then needed to be overlayed with an understanding of the social structures which govern Indonesian life and the influences of factors such as age, gender and religious background on how individuals and communities of practice interact. As others have highlighted (Yudhi, Nanere, & Nsubuga-Kyobe, 2006) difficulties in negotiation between Indonesia and Australia can be avoided by having a better cultural understanding of each other.

The aforementioned needs analysis activity was an important lens through which the UoM researchers could observe how clinical teachers as individuals within FMUI interact, as well as how FMUI as an educational organisation functions. This was developed further when the FMUI researchers had the opportunity to audit the EXCITE Graduate Certificate in Clinical Teaching program. This allowed the FMUI researchers to observe the Australian context within the same paradigms as the UoM researchers had the Indonesian context. An outcome of this was the opportunity to compare, contrast and challenge perceptions about teaching and learning in both settings and how this is influenced by social and cultural norms. Extensive discussion within, and between, both teams of researchers were vitally important to explicitly examine, and challenge, established assumptions (Bleakley et al., 2008) around teaching in the clinical environment and the pedagogical structure of an FDI. Early and Ang’s (2003) model of cultural intelligence − cognition (‘do I know what is going on?), motivation (‘am I motivated to act?’ which the research teams re-visualised as ‘what needs to be changed?’) and behaviour (‘can I act appropriately and effectively?’ which again was re-visualised as ‘can I make change appropriately and effectively?’) − provided a framework for these discussions and led to a better understanding of the working context of both partners. As observed by others, the need for genuine respect for complex contexts, practices, and paradigms of thinking, as an integral part of developing cultural competence among the researches, cannot be overemphasised (Mertens, 2009).

D. Insight 4 – Actively Engage and Empower Colleagues to Champion the Work of the Transnational Collaboration

Developing collaborative partnerships based on sustainable equitable relationships in which sociocultural and power differences are acknowledged, demanded participation and a shared vision at every stage of the project (Heron & Reason, 2001). From the outset, both FMUI and UoM had an agreed goal to provide a pathway for FMUI clinical teachers to further develop their teaching practice including articulation into a higher degree program at UoM and/or advanced study in clinical teaching and clinical leadership delivered locally.

Success required, not just a program built on a sold and justifiable pedagogy but ‘buy-in’ from senior clinical teaching leaders who not only share a passion for teaching themselves, but also recognise the need to support the development of junior teachers by exposing them to innovative and best practice methods of teaching training; and long term sustainability through training a pool of FMUI education leaders who could not only deliver the FDI as designed but also make changes in response to feedback from both participants and local needs. Importantly, the collaborative partnership needed to acknowledge the hierarchical nature of academic culture in Indonesia. This type of academic culture has been recognised as a potential impediment to the selection of participants for FDIs as this can restrict the pool of participants because of screening by senior academics and administrators (Kim et al., 2017).

The 1st Advanced Clinical Teacher Training and Training on Trainers Workshop was an important step in ensuring senior clinical teaching/education leaders were involved in the process of developing the FDI, thereby becoming de facto members of the research team, and took ownership of the program structure and curriculum objectives. Importantly, these ‘champions’ were able to describe to their teaching colleagues that rather than a transplanted, imposed and/or culturally misaligned program, the newly developed FDI grew out of a shared desire to create a program developed specifically for Indonesian clinical teachers. At all times the researchers were aware of the risk of education imperialism (Bleakley et al., 2008) and the perception that the UoM approach was the only way to deliver an FDI. The ideas of Bruning, Schraw, and Ronning (1999) and Hodges et al. (2009) resonated with our thinking: that learning is highly dependent on individual and social context and activity (Bruning et al., 1999) and therefore by whose criteria should ‘standards…and other culturally specific constructions associated with the practice of medicine’ (Hodges et al., 2009, p. 916) be applied. It is only through having conversations that acknowledge and address these issues – with clinical teaching/education leaders as both participants of the FDI, as well future program leaders – are the seeds of long-term viability planted. These ‘champions’ become co-creators and owners of the program through active contribution, rather than simply passive recipients of learning.

The companion paper published in this issue explores in detail the experiences of participants from the Training on Trainers Workshop (Findyartini et al., 2019).

E. Insight 5 – Identify Resource Challenges to Implementation and Sustainability

Identifying challenges that impact on, and developing strategies to effectively utilise financial, institutional, and human resources, are vital to developing transnational collaborations that are sustainable (Wiek et al., 2013) and successfully capitalise on intercultural, linguistic, and national differences (Pashby & de Oliveira Andreotti, 2016). Caniglia et al. (2017) in their review of factors that influence sustainability in high education collaborations have identified resource allocation as an important consideration for the implementation of a transitional collaboration.

We would agree, but also argue that resource allocation is important for ensuring sustainability. One of the crucial aspects to the success of this project was the funding from the Australian-Indonesia Institute which allowed the research team to meet regularly face-to-face and attend activities in both countries. However, this grant was limited to costs associated with travel and accommodation and consequently much in-kind support was required from both institutions; for example, none of the costs associated with delivery of the Training the Trainer workshop was covered by the Australia–Indonesia Institute grant and expenses such as room hire, catering and photocopying were provided in-kind by FMUI senior management. Another factor which soon became evident was that much of the success of the collaboration depended on the researchers allocating time from other academic activities which could not be backfilled by other staff. This meant much of the time spent working on this project was after-hours or on the weekend. Further, the involvement of administrative staff from both institutions was limited for similar reasons which meant most of the organisational workload also fell back on the researchers.

Although there is an acknowledgment that goodwill from senior management and a commitment to the partnership are important factors ensuring the success of transnational collaborations, very few studies have formally looked at this and to our knowledge, only one (Caniglia et al., 2017) has attempted to systematically evaluate challenges (such as those described above) and strategies related to financial, institutional, and human resources in relation to implementation and sustainability. Given our experiences of having to find the capacity to undertake tasks peripheral to, but important for the success of, the partnership described in this paper, we see an opportunity for further work in this area.

V. CONCLUSION

The approaches that were undertaken in this project actively sought to develop a non-economically driven partnership between universities from Indonesia and Australia. This focus on expanding knowledge and best-practice teaching training, rather than ‘selling of a product’, resulted in pathways of reciprocal learning, the development of new ways of thinking about clinical teacher training and a synergistic approach to designing and implementing a culturally resonant FDI. As a transnational collaboration, the context and requirements of the Indonesian partner were central to the quality of the FDI, and its sustainability. Shared experiences among the researchers and flexibility to implement the best evidence, with adaptation to local needs and values – often referred to as glocalisation – was a key to success. This, in conjunction with a constructivist approach to curriculum mapping, and negotiation over the pedagogical content of the curriculum, mitigated several challenges identified with establishing successful transnational educational collaborations.

Notes on Contributors

Dr Justin Bilszta is a Senior Lecturer in Medical Education, Department of Medical Education, Melbourne Medical School University of Melbourne.

Dr. Jayne Lysk is a Lecturer in Clinical Education, Department of Medical Education, Melbourne Medical School University of Melbourne.

Dr Ardi Findyartini is a Senior Lecturer in Medical Education, currently the Head of Department of Medical Education and Head of Medical Education Unit, Faculty of Medicine Universitas Indonesia.

Dr Diantha Soemantri is a Senior Lecturer in the Department of Medical Education and currently the Vice Director (Medical Education) of the Indonesian Medical Education and Research Institute (IMERI), Faculty of Medicine Universitas Indonesia.

Ethical Approval

Ethical approval is not required for a program evaluation type of study as employed in this paper.

Acknowledgements

The authors would like to thank the Faculty of Medicine, Universitas Indonesia and the Department of Medical Education, Melbourne Medical School, University of Melbourne for this support of this collaboration.

Funding

This project was supported by the Commonwealth of Australia through the Australia-Indonesia Institute of the Department of Foreign Affairs and Trade (Application No: AII00004 of AII Grant Round 1 2014). Generous in-kind support was provided by Faculty of Medicine, Universitas Indonesia and the Department of Medical Education, Melbourne Medical School, University of Melbourne.

Declaration of Interest

The authors declare that they have no conflict of interest.

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*Diantha Soemantri
Department of Medical Education,
Faculty of Medicine, Universitas Indonesia,
Salemba 6 Central Jakarta,
DKI Jakarta, Indonesia 10430
Email: diantha.soemantri@ui.ac.id
dianthasoemantri@yahoo.com

Published online: 7 January, TAPS 2020, 5(1), 16-24
DOI: https://doi.org/10.29060/TAPS.2020-5-1/OA2126

Junji Haruta¹, Ai Oishi² & Naoko Den³

¹Department of Medical Education, Faculty of Medicine, University of Tsukuba, Japan; ²Primary Palliative Care Research Group, Centre for Population Health Sciences, Usher Institute of Population Health Sciences and Informatics, University of Edinburgh, United Kingdom; ³Ouji-Seikyo Hospital, Japan

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Abstract

Practice Highlights

• We developed an end-of-life (EoL) care education program using narrative, and have clarified how and what lay-people learned through the program.
• Interaction among laypeople inspired the five process; reconstructing their understanding, recalling emotions, evoking other perspectives, inspiring altruism and reflection on their own death.
• A narrative about end-of-life care created the opportunities to face the inconceivable death and deepened lay participants’ understanding of the concept of EoL care.
• A narrative has the potential to enhance the engagement of the community in EoL care.

I. INTRODUCTION

The World Health Organization recommends that end-of-life (EoL) care be approached by integrating general population with hospital-level care (World Health Organization, 2014). While EoL care and health promotion are understood to belong to different categories (Rosenberg & Yates, 2010), there is a need for a more open societal attitude in facing and discussing death and dying (Kellehear, 2012). In addition to individuals who are receiving EoL care themselves, their family and social group also become aware of their own health and well-being in the context of life-limiting illnesses (Radbruch et al., 2009). However, laypeople tend to experience more problems near death than medical professionals, such as stigma and loneliness, which might cause distress among patients and their families. Various education programs have been developed around the world to solve these problems.

Our review of published education programs for EoL care found that community resources have been used in a number of projects, such as naturally occurring social networks (Leonard, Horsfall, & Noonan, 2015; Mills, Rosenberg, & McInerney, 2015) and externally facilitated networks (Leonard et al., 2015). Community resources have also been used in direct support from trained community volunteers (Jack, Kirton, Birakurataki, & Merriman, 2011), and in programs such as work with schools (Hartley, 2012), businesses (Hall, Shucksmith, & Russell, 2013) and professionals (Richardson, 2002). Further, seed grants have been awarded to support community-led projects in the field of death, dying, loss and care (McLoughlin, 2013.). Conducting a program requires several areas of focus, such as writing a will and advance care planning (Seymour, Almack, Kennedy, & Froggatt, 2013), but can also involve exploring society’s perception of death and dying through local or national conversation (Patterson & Hazelwood, 2014) or improving the experiences of those living with life-limiting illnesses (Mitchell & Burton, 2006). However, few studies have examined how laypeople learn in education programs.

Story-based learning (McQuiggan, Rowe, Lee, & Lester, 2008), which combines story contexts and pedagogical support strategies, may be an effective way to deliver an educational experience because laypeople are more likely to adopt the narrative mode over the logico-scientific mode of thinking (Clandinin & Connelly, 2000). Narratives are widely used in public health promotion in the UK (Talley, 2011). However, a systematic review of narrative-based interventions for health promotion concluded that more research is needed to determine how these interventions can best be used (Perrier & Martin Ginis, 2016). Process evaluation can allow the examination of participant views on the intervention, as well as investigation of any contextual factors and determination of the processes that mediate observed intervention effects (Al-HadiHasan, Callaghan, & Lymn, 2017). It is important to evaluate “how” laypeople learn in public health promotion, as the learning process uses narrative to improve health literacy.

II. METHODS

A. Aim

We clarified how lay participants learned through an EoL care education program using narrative.

B. Design

We conducted a case study in educational research (Creswell, 2012). The case was constructed by the interaction of laypersons and healthcare professionals, with a program constructed using narrative. Since our focus was on gaining an in-depth picture of the learning process through narrative among individuals, we involved only a series of cases in a community hospital. To focus on the learning process of lay participants, we undertook qualitative process evaluation using audio-recordings of the group dialogue in each session and focus group (FG). We reported in accordance with the consolidated criteria for reporting qualitative research guidelines (Tong, Sainsbury, & Craig, 2007).

Table 1. Contents of the program

C. Setting of the Education Program

The study setting was a 150-bed hospital in Tokyo with a palliative care unit established in May 2014. We delivered a community education program to laypeople at the hospital to enhance their understanding of EoL care from July 2014 to February 2015. The learning outcome of the program was “to learn together about EoL care and to take action to promote health and well-being at the EoL based on one’s own values”. We adopted a narrative-centred approach as a learning strategy. Narrative-centred learning is defined as a narrative pedagogy that integrates methods such as case method teaching and problem-based learning to encourage self-directed learning and participant engagement (McQuiggan et al., 2008). Each session was 2 hours, during which the participants were engaged in constructing and telling stories in a small group. Healthcare professionals in the hospital played the role of facilitators, after prompting information from the lecture was given (Table 1). Participants were given an assignment at the end of each session to write their own story relating to the given topic. If a lay participant could not participate in the session, he or she was asked to watch a video recording of the session. We deliberately placed a 3-month interval between sessions with the expectation that participants would reflect on what they had learned from the sessions in their daily lives.

D. Participants

Using a community publication on health information produced by the hospital and convenience sampling, we recruited laypeople living in the catchment area of the hospital to attend all four sessions of the program (Babbie, 2007). Lay participants contacted the hospital after having seen an advertisement for the course in the community publication. The first author (JH, male) sent letters to the participants to confirm their willingness to participate in the study. We did not establish exclusion/inclusion criteria for literacy level or health status. Since JH and the third author (ND, female) had worked in the hospital, some lay participants knew JH and ND. Other participants built a proper relationship with JH and ND through the EoL program. At the start of the program, during the educational sessions, and during the FGs, we informed the participants that they were not obliged to talk and could leave if they became emotionally upset or experienced a breakdown.

E. Data Generation

All group dialogues during three sessions (excluding the fourth session in order that participants did not hesitate to share their own view on life and death) in a room of the hospital were audio-recorded to mainly focus on the learning process. Additionally, we conducted three 90-minute FGs, namely two FGs within one month after completion of the program and a third FG eight months after completion. JH facilitated the FGs using prompt questions and took field notes while preparing and conducting the program and in post-program FGs. All FGs were conducted in a quiet room in the hospital. All audio-recorded dialogue and FGs were transcribed verbatim by JH. We could not return the transcripts to lay participants because some participants were reluctant to do so. Accordingly, AO and healthcare professionals who joined the program checked for discrepancies between group dialogues during the three sessions and the verbatim transcriptions of the FGs. JH was a general physician in the hospital and a final-year PhD student at the time of data collection. JH had received training in qualitative research as part of the PhD program.

Table 2. Prompting questions in FGs

F. Analysis

A thematic analysis was adapted for data analysis (Braun & Clarke, 2006). First, JH and second author (AO, female) separately read and deductively coded the transcripts. AO had undertaken qualitative research training by the time of data analysis in the UK. JH then created inductive codes based on the research questions and initial coding, with any disagreements with AO resolved by discussion. Once JH and AO agreed on the coding, all researchers discussed the themes that emerged from the codes and how these themes interacted until we were in full agreement. The whole process was iterative, which allowed us to achieve a richer interpretation of the data. Thus, researchers crystallised the data and confirmed the interpretation based on the field notes as a triangulation process.

III. RESULTS

A. Participants

Eighteen laypeople living in the local area of the hospital participated in this program. All participants were aged 50–70 years and all but one participant was female. The backgrounds of all participants and their presence/absence in the four sessions and three FGs are shown in Table 3. Four lay participants watched the video because they could not participate in the session. All cases of absence from the sessions or FGs were due to personal reasons of the participants.

Note: FG 1, FG2 – Focus groups within one month after completing the program.
FG 3– Focus group eight months later after completing the program.
Table 3. Backgrounds of all participants and presence (〇)/absence (－) in four sessions and three FGs

Table 4. Emergent themes and sub-themes based on analysis of group dialogue and FGs

We focused on how laypeople learned in the program throughout the study. A total of 12 lay participants participated in the FGs. Through the analysis, we extracted five themes: reconstructing the concept of EoL care, recalling feelings and emotions, evoking other perspectives through metacognition, inspiring altruism, and reflection on one’s own death (Table 4).

B. Theme Analysis

1) Reconstructing the concept of EoL care: The program deepened participants’ understanding of the concept of EoL care by allowing them to compare their own experience with relatives or friends at the EoL and their image of EoL with those of other participants. Each session led participants to reconstruct their stories about the EoL. Triggered by these stories, participants discovered situations in their daily lives with a link to EoL, as follows.

“I thought that hospices were a place where morphine would be given to patients until their death. I have learned a lot about palliative care from the program, which has improved my understanding of palliative care.”

Additionally, reading related books that were introduced in a series of sessions and dialogue with others allowed them to consolidate and articulate their previously vague understandings. For example, they generated a new understanding of EoL care by reflecting on such things as their own experience after gaining new knowledge about the difference between hospice care in a palliative care unit and the concept of EoL care, including its connection with the community and family/psychological support, and realisation of the spread of EoL care, as follows.

“I reached the conviction that I could receive family/psychological support. I have learned that if my husband is admitted to this hospital, I will also be supported as a family member.”

Furthermore, their new-found understanding motivated them to contribute to disseminate the ‘right’ concept of EoL. On the other hand, some healthcare professionals who joined the small group dialogues as facilitators faced challenges in being unable to control the participants’ story-telling.

2) Recalling feelings and emotions: Constructing stories stimulated participants to recall their inner experiences and emotions. As a result, participants verbalised their recalled feelings such as conflict, regret and perplexity in a group dialogue. This verbalisation of their emotions was a catharsis of the stress they had felt, as follows.

“My husband died two years ago. I think that I have become able to accept his death since attending the program. Learning and having a chance to learn have helped me to accept my mental condition of the past two years. I feel calm now.”

Moreover, through the program, participants embodied emotions associated with their experience with relatives or friends at the EoL when recalling their internal feelings. These narrative-based experiences widened their cognitive understanding of EoL care at the emotional level.

3) Evocation of other perspectives through metacognition: Specific external experiences during the sessions stimulated participants’ interest. Additionally, by verbalising their interests, participants noticed their emotions, differences between their own and others’ perspectives, and the context to which they belonged, such as families and professionals. Participants understood the need for expert assistance as they came to understand these perspectives. For example, participants showed appreciation to healthcare professionals for providing emotional support and management, which was given according to the different perspectives of different family members, as follows.

“I thought that families of cancer patients could not be as generous to patients’ emotional changes, including anger as the family in the role play. I think it is preferable that specialists help families overcome such difficulties.

Through their cognition of other perspectives, they learnt how to access self-monitoring and self-representation as metacognition.

4) Inspiring altruism: Considering the understanding of EoL care inspired altruism as a latent need, defined as a desire that cannot be expected to articulate due to a lack of information (Langford, 1995). Participants expressed their understanding of EoL as stories through their participation in the program and their reading of books, which reminded them of their altruistic feelings, embedded as latent needs. Participants were motivated to commit to supporting patients and their families who were suffering at the EoL as volunteers.

“For me, I want cancer patients and their families to spend the rest of their lives in peace. And I have learned to feel compassion for families with cancer patients. It is important to support such families.”

5) Reflecting on their own impending death: By gaining an understanding of EoL care, during which time they consulted with others who felt fear and anxiety regarding facing their death, participants started to anticipate their own deaths. This helped them to alleviate their fear and anxiety on the subject. In addition, they developed an appreciation for those on whom they will rely at their own EoL.

“I used to think that death was cruel, painful and scary, but I do not really think that now because there are people we can talk to as part of palliative care services. I don’t think it is necessary to be afraid of death but I am confident that I have been living well up until now.”

IV. DISCUSSION

We described laypeople’s learning patterns through an EoL care education program, in which EoL care through narrative-centred learning and interactions with other participants inspired five processes, namely reconstructing their understanding, recalling emotions, evoking other perspectives, inspiring altruism and reflection on their own death. The process led them to convince that EoL was individual for every person and the EoL care was rooted in the understanding of their own life.

Lay participants learned not only about EoL care but also about the value of their own life in this education program. In previous studies of palliative education for healthcare professionals, undergraduate education on palliative care covers humanistic aspects and holistic views (Centeno, Ballesteros, Carrasco, & Arantzamendi, 2016; Horowitz, Gramling, & Quill, 2014). In graduate education, palliative care experts define comprehensive and essential palliative care competencies for internal medicine or family medicine residents, and residents improve their knowledge in a 2-week palliative rotation (Olden, Quill, Bordley, & Ladwig, 2009; Schaefer et al., 2014). In reality, it is nonetheless difficult for residents to alleviate the psychological distress felt by patients and families in palliative care (McFarland, Maki, & Holland, 2015). Considering this challenge, it is understandable that laypeople are more likely to harbour a stereotyped understanding of EoL and stigma around death compared to healthcare students or professionals. However, this study suggests that constructing stories enables lay participants to recognise their perception of the EoL and reflect on their own experience and feelings, similar to healthcare professionals (Arai et al., 2017). Narratives evoked participants’ feelings and induced a catharsis of emotions after they expressed and verbalised these feelings. Through this process, lay participants acquired metacognition of death and dying by sharing and verbalising their own understanding and feelings about dying and well-being, which voluntarily promoted an altruistic desire to commit to EoL care and motivated them to contribute to disseminating the interpretation of EoL. In addition, they had opportunities to leverage their own existing experiences based on constructing stories, which is different from Kolb’s experiential learning (Kolb, 1984). In previous health education programs, health professionals used information from standard epidemiological studies to change the misapprehensions of laypeople (Allmark & Tod, 2006; McConnachie, Hunt, Emslie, Hart, & Watt, 2001; Prior, 2003). However, in addition to providing knowledge, encouraging participants to construct their own stories deepened their understanding of EoL care with respect to their own values.  While lay participants reflected on their own impending death, lay participants anticipated death as an extension of their own life and learned how healthcare professionals provide care to dying patients and their families through stories. Moreover, lay participants anticipated their own death with respect to their relationship with others. In social psychology, existential terrors, which are a basic psychological conflict that results from having a self-preservation instinct whilst realising that death is inevitable, can be managed by embracing cultural values or symbolic systems that provide enduring meaning and value to life (Curtis & Biran, 2001). A narrative-based program may provide laypeople with a sense that they are connected to someone, which will ultimately enable laypeople to deflect fear and manage their fear of death. Through this process, participants may attain an altruistic desire to express personal preferences for situations in which others benefit (Batson, 1997) because they realise the stress of the situation on others and develop respect for their well-being (Batson, 2010). Lay participants gained enhanced empathy for patients or their families who were suffering in the face of death and dying, which motivated altruistic behaviours to commit to EoL care.

Throughout the narrative-centred learning, rather than learning through structured knowledge in textbooks and lectures from healthcare professionals, lay participants reconstructed their own narratives consisting of a series of actions and stories describing concrete events and experiences. Bruner illustrated that there are two distinct modes of understanding (Bruner, 2009). The first is the logico-scientific mode of organised thinking based on reason. The second is the narrative mode associated with the creation of stories. People complementarily use the two cognitive modes to understand the world according to the situation. Laypeople are more likely to adopt the narrative mode in daily life. Through communication with others, laypeople realise how they understand the world they live in. However, healthcare professionals tend to use the logico-scientific mode in public health promotion for laypeople because they themselves learned through structured knowledge in textbooks. This leads to a mismatch between healthcare professionals and laypeople, and highlights the need to reflect on differences in modes of thinking when developing learning strategies. A chain or sequence of narratives from scattered experiences can be connected and arranged into an identifiable structure (Prins, Avraamidou, & Goedhart, 2017). In addition, stories motivate people to identify novel perceptual, emotional, and motivational experiences and are suited to alternative learning paradigms such as guided discovery (McQuiggan et al., 2008). Lay participants were able to enhance their understanding of the EoL through sharing and comparing their experiences with each other using the narrative mode. As a result, they acquired the metacognition and motivation to commit to the suffering of others.

A. Strengths and Limitations

There are three main limitations of this study. First, lay participants who participated in the program might be more open to learning about EoL among the general population. However, most participants initially misunderstood the concept of EoL care and some hesitated to share their experiences with relatives or friends at the EoL. This narrative-based approach was useful for such participants in deepening their understanding of EoL care and leading them to acknowledge that death is an extension of life. Second, two researchers (JH and ND) participated in developing the program and JH acted as a facilitator in the FGs. While we tried to provide a neutral environment and asked questions to encourage free speech, we may have asked inductive questions. Additionally, lay participants might have unconsciously or consciously mimicked the intentions of researchers due to self-selection bias and reporting bias because they agreed to participate in the study. To evaluate data credibility, JH, ND and another researcher (AO) who did not participate in running the program conducted a triangulation of the data (Walker, Holloway, & Wheeler, 2005). We assessed data that arose from free, frank and honest interactions and found that the group which included one particular researcher (JH) maintained a good relationship in which everyone asked frank questions or provided dissenting opinions. We might have missed critical views which could have been raised by other potential participants who were absent at the FGs. Third, we could not follow up on outcomes such as engaging community and social networks. Further study is needed to continue participation observations and follow-up to determine the longer-term outcomes of this narrative-based program.

V. CONCLUSION

We evaluated the process of a health education program on EoL care using the strategy of narrative-centred learning. Lay participants deepened their understanding of EoL care while reconstructing their knowledge, recalling their own experiences and emotions, evoking other perspectives, inspiring altruism and reflecting on their own deaths. Such a program has the potential to enhance community engagement in EoL care.

Notes on Contributors

JH, AO and ND contributed to the design and implementation of the research, analysis of the results and writing of the manuscript.

Ethical Approval

This study was reviewed and approved by the ethical committee of the hospital (No. 69), which considered sampling, informed consent, and the confidentiality of participants. All participants provided written informed consent for participation and audio-recordings of the group dialogue and FGs.

Acknowledgements

We sincerely appreciate the healthcare professional staff at the palliative care unit in the hospital used as a study setting.

Funding

This work was supported by a grant-in-aid from Japan Primary Care Association (no grand number, from April 2014 to March 2016).

Declaration of Interest

The authors declare that they have no competing interests.

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*Junji Haruta
1-1-1 Tennoudai, Tsukuba,
Ibaraki, 305–8576 Japan
Tel: +81-29-853-3189
Email:junharujp@md.tsukuba.ac.jp
junharujp@gmail.com

Published online: 7 January, TAPS 2020, 5(1), 3-7
DOI: https://doi.org/10.29060/TAPS.2020-5-1/GP1086

Mun Loke Wong¹, Teresa Woon Oi Lee², Patrick Finbarr Allen³, Kelvin Weng Chiong Foong⁴

Disciplines of ¹Primary Dental Care & Population Oral Health; ²Oral Sciences; ³Endodontics, Operative Dentistry & Prosthodontics; ⁴Orthodontics & Paediatric Dentistry, Faculty of Dentistry, National University of Singapore, Singapore

Abstract

Practice Highlights

• Dental education plays a pivotal role in training future generations of oral healthcare professionals.
• Dental education will evolve and transform with time as new pedagogical approaches emerge and shape its delivery.
• The planning and delivery of dental education will also be influenced by a myriad of other factors including demographic shifts such as the increasingly ageing population.
• Critical thinking and problem solving skills are essential skillsets to be cultivated through dental education.
• Technology can be a useful and powerful lever to advance and transform teaching and learning in dentistry.

I. INTRODUCTION

A. The Early Years of Dental Education

In 1922, the Council of King Edward VII College of Medicine mooted the idea of establishing a dental school. The first dental course was introduced in 1926 (Ho, Keng & Tay, 1989). A year later, a Department of Dental Surgery in King Edward VII College of Medicine was formed. The early Dental School, the only one in the British Crown Colonies in the East at that time (Lee, 2006), operated from five small rooms in a disused ward (Norris Block) in the General Hospital, Sepoy Lines. Between 1926 and 1927, seven students enrolled in a four-year Licentiate in Dental Surgery (LDS) course but all dropped out of the course after the first year.

Mr E. K. Tratman from Bristol was appointed Professor of Dental Surgery and Head of the Dental School in 1929. Under his leadership, the LDS was lengthened to five years to align with similar courses offered by British schools and with the eventual intention for it to be recognised by the United Kingdom (UK) General Medical Council. The dental course re-started in April 1929 with three of the pioneer LDS students. A new “Dental School and Clinic” building opened in 1938 in Sepoy Lines to cater for an increased student intake (Ho, Keng & Tay 1989; Lee, 2006).

During the war from 1939 to 1945, the Dental School was closed as the premises were occupied by the Japanese Military. At the end of World War II, the UK General Medical Council recognised the LDS in 1946. In 1949, the University of Malaya was formed and the Dental School became the Dental Department within the Faculty of Medicine. In 1950, Professor Tratman retired. Professor R J S Tickle took over as Professor of Dental Surgery, University of Malaya. That year, the dentistry course was revised to conform with the UK General Dental Council requirements and the degree of Bachelor of Dental surgery (BDS) replaced the LDS (Ho, Keng, & Tay, 1989).

 B. Becoming a Dental Faculty

An extension to the Dental School building in Sepoy Lines was completed in 1955. Facilities and equipment were upgraded. The School, comprising three main clinical units – Conservative Dentistry, Oral Surgery and Prosthetic Dentistry, doubled its enrolment to 124 students (Ho, Keng, & Tay, 1989; Tan & Keng, 2005).

In 1962, the Dental Department became part of the University of Singapore, a separate entity from the University of Malaya (Singapore). The Dental School became a Faculty independent of the Faculty of Medicine in 1966. Professor Edmund Tay Mai Hiong, a graduate from the local Dental School, became the first Dean of the new Faculty of Dentistry. The Faculty continued to develop with newer facilities added to it and was later re-structured into three Departments – Operative Dentistry, Oral Surgery and Prosthetic Dentistry. A new School of Postgraduate Dental Studies was also established (Ho, Keng, & Tay, 1989).

In 1986, the Faculty of Dentistry moved to the Kent Ridge campus (Ho, Keng, & Tay, 1989), occupying three floors in the National University Hospital (NUH) Main Building. In 2010, the Faculty moved to a new location on Kent Ridge where the undergraduate teaching clinics, classrooms, pre-clinical simulation and dental laboratories, the graduate clinic for residency training in Orthodontics and Prosthodontics, the Dean’s office and academic staff offices were housed. Clinical services for the public and residency training for Endodontics, Periodontology as well as Oral and Maxillofacial Surgery remained at the Dental Centre in the NUH Main Building. Research laboratories were housed separately in a neighbouring building.

C. A New Home – the National University Centre for Oral Health, Singapore

On 5 July 2019, the National University Centre for Oral Health, Singapore (NUCOHS) was officially opened. Education, research and administrative functions of the NUS Faculty of Dentistry and the clinical services of the NUH University Dental Cluster came under one roof.

Table 1. Deans of the Faculty of Dentistry at Kent Ridge Campus

II. CELEBRATING THE EVOLUTION OF DENTAL EDUCATION

The fundamental goal of nurturing, educating and training competent oral healthcare professionals to deliver high quality and safe care remains a cornerstone of the Faculty’s mission. While this has not changed, significant changes have emerged in the delivery of dental education.

Such changes stemmed from two factors. The first was a shift from the traditional teacher-centred approach to a more student-centred one. The view that teachers are experts solely responsible for delivering content and student learning is no longer sacrosanct. Instead, students play a significant role in directing their learning while teachers facilitate it. Secondly, the Faculty moved towards a competency-based curriculum driven by clearly defined competencies expected of a newly qualified dentist. This was in line with global best practices in dental education. These changes led to the introduction of various new initiatives between 1990 and 2000.

A. Competency-Based Curriculum

The traditional approach of a requirement-based curriculum where students were deemed competent on completing a fixed number of dental procedures was replaced by a competency-based curriculum. This gave students more flexibility in learning procedures by attaining expected performance standards. It also reduced the attendant stress students faced from the former approach.

 B. High-Fidelity Simulation Technology

The first high fidelity pre-clinical simulation training system was introduced in the Operative Dentistry curriculum using real-time augmented reality feedback to inform students and academic staff of the quality of the students’ performance.

C. Problem-Based Learning

Problem-based Learning (PBL) was introduced to help students become more self-directed in their learning. Under the guidance of PBL facilitators, students took the lead to ask questions and find answers related to pertinent oral health conditions presented through case-based discussions.

D. Undergraduate Research Opportunities Programme (UROP)

Introduced in 1996, UROP comprises a compulsory mini-research project which students undertake over 16 to 18 months. Academic and clinical staff guide students to either develop hypothesis-driven projects or conduct literature reviews of key topics. Through UROP, the students’ intellectual curiosity is piqued and they are guided to discover answers systematically. The students share their findings at an annual Faculty Research Day with the best teams representing the Faculty at regional and international scientific competitions.

E. Developing 21^st Century Skills

Critical thinking and problem solving skills are especially important in a constantly and rapidly evolving clinical dentistry landscape. Towards this end, the BDS curriculum was reviewed in 2015 to reduce content fragmentation and redundancy to allow more opportunity to develop critical thinking and problem solving skills in the students. For instance, the three complementary subjects of Oral Pathology, Oral Medicine and Oral Radiology were integrated to form a new module spanning Years 2 – 4 of the BDS curriculum. This synergised the learning in these areas to help the students better appreciate the diagnostic and clinical aspects of Oral Pathologies and critically apply the knowledge to address real life clinical issues which often involve Oral Medicine and Oral Radiology too.

F. Harnessing Technology

With the proliferation of technology-enhanced learning (TEL), the Faculty has harnessed the potential of emerging technology to enrich the educational journeys of its students. In light of this, the Faculty has intentionally embraced technology on various fronts.

1) Technology-Infused pre-clinical simulation: Simulation training in the Faculty has advanced further with virtual reality simulators that incorporate haptic force-feedback to complement the conventional simulation training used to teach tooth restorations. Students now have a more authentic experience of these clinical procedures prior to managing their patients. Simulation, which brings together 3D printing and augmented reality technology, has also come to the forefront in teaching students to deliver Inferior Dento-Alveolar Nerve blocks effectively and safely. An iBook has also been developed to help students electronically navigate the theory behind such anaesthetic techniques. Extraction of mandibular first molars of complex root forms and minor surgical removal of wisdom teeth of varying impactions have also leveraged similar 3D-printed simulations in undergraduate teaching.

Figure 1. A simulator with augmented reality technology provides real-time visual feedback to students on the placement of the injection needle for Inferior Alveolar Nerve Local Anaesthesia

2) Eye tracking of X-ray reading: A more recent TEL development supported by the MOE Tertiary Education Research Fund employed eye tracking technology to understand eye gaze patterns of students when they read X-rays. In so doing, academic staff are able to tailor their teaching to their students’ needs and guide them more effectively in interpreting radiographs.

G. Technology in Clinical Education

Beyond pre-clinical training, the Faculty has also used technology in these areas of clinical education:

1) Visualisation of anatomy with Cone-Beam Computed Tomography (CBCT): Diagnostic 3D CBCT technology was introduced in 2009. Dental students, residents and clinical staff use this modality to visualise complex anatomy for diagnosis and to plan treatment of impacted teeth, dental edentulism, and jaw deformity.

2) Digital impressions and analysis of virtual dental models: Digital models from digital impressions are generated in PDF file for 360-degree viewing. This facilitates analysis of the dental models by Orthodontics residents.

Given the potential of technology in dental education, the Faculty has introduced a six-stage framework to guide the development, use, and evaluation of technology in teaching and learning. These six stages encourage academic staff to embrace technology in teaching through a systematic approach to:

1. Reflect on teaching practice;
2. Identify learning gap;
3. Design, Develop, and Implement technology solution;
4. Assess learner satisfaction (usability);
5. Assess learner gain (outcomes); and
6. Assess learner impact (behaviours).

With this framework, academic staff can tap on a Faculty-level Technology in Dental Education (TIDE) Fund to champion their technology-enhanced learning (TEL) efforts. In so doing, they will also be able to gather useful data on how their TEL interventions contribute to student learning. Through this fund, academic staff have since developed innovative teaching platforms such as iRadiate and iRadiate 3D which use a multi-media platform and augmented reality technology, respectively, to train dental students to accurately position the intra-oral X-ray tube.

In line with a more student-centric approach of learning, the Faculty has leveraged new technology-driven capabilities to longitudinally track students’ first piece of work to graduation with the Longitudinal Learning and Coaching Management (LLCM) system. With its full roll-out, students’ performance in clinics, laboratories and classrooms can be triangulated to yield patterns of performance for analysis. Through this, students’ poor performance can be more expeditiously identified by academic staff for timely remedial interventions.

H. Responding to Continuing Professional Development

The Faculty has also been proactive in responding to the professional development needs of practising dentists. This is supported by the Division of Graduate Dental Studies (DGDS) and Centre for Advanced Dental Education (CADE) which oversee speciality training and continuing professional development programmes. In 2014, a new three-year full time Master of Dental Surgery Paediatric Dentistry programme was introduced to address a national need to train more specialists in the management of oral diseases in children. CADE introduced a two-year part-time Graduate Diploma in Dental Implantology around 2006 to address the need to train general dentists in dental implantology. A more recent programme in Geriatric Dentistry was introduced to equip dentists with additional skills to manage the oral health needs of the older adults.

III. ADVANCING DENTAL EDUCATION INTO THE FUTURE

As the Faculty sets its sights on its centennial celebrations, it has put in place plans to advance dental education further. One area is continuing professional development of its academic staff. In line with this, the Dental Educators Empowerment Programme (DEEP) has been set up to support, engage, develop the capabilities of its academic staff and empower them to become effective dental educators.

Figure 2. The DEEP framework and the domains of professional development for dental educators to empower themselves to advance dental education into the future

The demographic shifts resulting from an increasingly ageing population will also shape dental education of the future. The curriculum will need to be further enhanced to provide its undergraduates with added exposure in this area to meet the oral health needs of the elderly when they graduate. Increased exposure to the elderly in the community right from the first year of dental school is a possible trajectory for pre-clinical dental education.

Collaborative healthcare practice will also become a critical skillset for our future graduates as oral-systemic relationships become better established. Oral health care should be appreciated in the broader context of healthcare which requires multi-disciplinary and inter-professional engagements. This signals the need for increased opportunities in inter-professional education across the healthcare professions.

IV. CONCLUSION

Dental education is poised for change as it faces a myriad of factors ranging from new evidence-informed educational pedagogies, the advancement of educational technology as well as population changes. The Faculty of Dentistry will continue to embrace change to ensure that its graduates are ready to meet the evolving oral health needs of the population.

Notes on Contributors

Professor Patrick Finbarr Allen is Dean of Faculty of Dentistry.

Associate Professor Teresa Loh is from the Discipline of Oral Sciences.

Associate Professor Kelvin Foong is the Director of the Discipline of Orthodontics and Paediatric Dentistry.

Associate Professor Wong Mun Loke is the Vice Dean (Academic Affairs) of Faculty of Dentistry.

Funding

There is no funding involved for this paper.

Declaration of Interest

The authors declare no conflict of interest for this paper.

References

Ho, K. H., Keng, S. B., & Tay, D. K. L. (1989). 60 years of dental education (1929-1989). Faculty of Dentistry: National University of Singapore.

Tan, K. B. C., & Keng, S. B. (2005). Dental Education in Singapore – From the past to the future. Annals Academy of Medicine Singapore, 34(6), 196C-201C.

Lee, Y. K. (2006). Jottings on the history of dentistry in Singapore. Singapore Medical Journal, 47(4), 346-55.

*Kelvin Foong / Wong Mun Loke
9 Lower Kent Ridge Road,
National University Centre for Oral Health Singapore,
Singapore 119085
Email: denfwc@nus.edu.sg / denwml@nus.edu.sg

Published online: 7 January, TAPS 2020, 5(1), 1-2
DOI: https://doi.org/10.29060/TAPS.2020-5-1/EV5N1

USING ‘GRIT’ TO SELECT STUDENTS FOR ADMISSION INTO MEDICAL SCHOOL

Medical students often represent student cohorts with high scholastic achievements. Consequently, especially in the past, the selection of students for admission into medical school was based mainly on their scholastic achievements. However, such a practice was later found to be unsatisfactory and unreliable, as many graduates (the future medical practitioners) were often unable to deliver optimum healthcare to patients, and many were unable to cope with the rigours of the tasks ahead. This, of course, prompted medical authorities responsible for the selection of students for admission into medical school to expand the selection process through the inclusion of psychological tests such as the Multiple Mini Interviews (Eva, Macala, & Fleming, 2019).

In view of the high predictive value of ‘grit’ we would like to propose that all students, who aspire to become future medical practitioners, take the ‘grit test’ to first determine their individual grit scores and, therefore, their suitability for selection and admission into medical school. After all, the individual grit scores have been confirmed to be highly reliable predictors of the suitability of students for admission into an organisation’s training programme.

More recently, Thomas H. Lee, an experienced “clinician and health care leader”, and Angela L. Duckworth, a distinguished researcher on ‘grit’, have combined their expertise to write the article Organizational Grit in which the authors have highlighted,

contemporary perspectives on organizational and health care cultures [and] … the new model of grit in healthcare—exemplified by leading institutions like Mayo Clinic and Cleveland Clinic—passion for patient well-being and perseverance in the pursuit of that goal [i.e. Grit] become social norms at the individual, team, and institutional levels. (2018, para. 4)

DEVELOPING THE NEW MODEL OF GRIT IN HEALTHCARE

If a health care provider wishes to pursue and develop “the new model of grit in healthcare”, what approach should the organisation adopt? Based on the discussions of Lee and Duckworth (2018), the health care provider should ensure that all participants [i.e. all personnel within the system] “are committed to pursuing a shared high-level goal. Putting patients first is a common and effective objective.” A useful approach, therefore, is for the organisation to develop grit so that “Grit become social norms at the individual, team, and institutional levels” (Lee & Duckworth, 2018, para. 4) with “clear communication of [institutional] values by [the] leadership [within the organisation.]” (Duckworth, 2016, Chapter 12).

“For leaders, building a gritty culture begins with selecting and developing gritty individuals.” (Lee & Duckworth, 2018, para. 5)

Thus, a new model of grit in health care must ensure passion for patient well-being, and perseverance in the pursuit of that goal become social norms at the individual, team and institutional levels- as exemplified by leading institutions such as Mayo Clinic and Cleveland Clinic. Should healthcare organisations in Asia adopt the new model of grit in healthcare in view of the global paradigm shift from individual to team care of patients?

 

Dujeepa D. Samarasekera & Matthew C. E. Gwee
Centre for Medical Education (CenMED), NUS Yong Loo Lin School of Medicine,
National University Health System, Singapore

 

 

Duckworth, A. (2016). Grit: The power of passion and perseverance. United Kingdom: Ebury Publishing.

Eva, K. W., Macala, C., & Fleming, B. (2019). Twelve tips for constructing a multiple mini-interview. Medical Teacher, 41(5), 510-516. https://doi.org/10.1080/0142159X.2018.1429586

Lee, T. H. & Duckworth, A. L. (2018). Organizational grit. Retrieved from Harvard Business Review, https://hbr.org/2018/09/organizational-grit