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

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

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

Abstract

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

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

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

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

Practice Highlights

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

I. INTRODUCTION

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

II. LEARNINGS FROM VARIOUS SESSIONS

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

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

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

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

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

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

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

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

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

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

IV. CONCLUSION

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

Notes on Contributors

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

Acknowledgement

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

Funding

There is no funding for this paper.

Declaration of Interest

The author declared no conflict of interests.

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

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

Juliet Mathew¹, Hazlina Binti Abu Bakar² & Shilpa Murthy²

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

Abstract

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

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

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

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

Practice Highlights

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

I. INTRODUCTION

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

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

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

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

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

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

II. METHODS

A. Structured Workshop Flow

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

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

Session 1: Introduction to Resilience

Session 2: Activity on Resilience

Session 3: Discussions on Resilience

Session 4: Reflection on Resilience

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

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

B. Reflection Analysis

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

III. RESULTS

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

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

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

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

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

IV. DISCUSSION

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

The challenges encountered can be described within the following phases:

A. Pre-workshop Challenges

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

B. Workshop Challenges

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

C. Post-workshop Challenges

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

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

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

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

V. CONCLUSION

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

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

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

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

Notes on Contributors

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

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

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

Acknowledgements

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

Funding

There is no funding for this paper.

Declaration of Interest

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

References

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

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

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

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

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

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

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

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

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

Abstract

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

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

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

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

Practice Highlights

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

I. INTRODUCTION

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

II. THE SHIFT TOWARDS COMPETENCY-BASED DENTAL EDUCATION

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

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

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

III. FRAMEWORK FOR COMPETENCY-BASED DENTAL EDUCATION

A. Miller’s Pyramid

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

B. Accreditation Council for Graduate Medical Education (ACGME)

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

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

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

D. The Graduating European Dentist Curriculum

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

IV. DESIGNING A COMPETENCY-BASED DENTAL CURRICULUM

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

A. Identifying Core Competencies

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

B. Defining Competency Levels

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

C. Mapping Competencies to Learning Outcomes

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

D. Selecting Effective Teaching Methods 

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

E. Utilising Assessment Strategies

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

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

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

VI. CONCLUSION

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

Notes on Contributors

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

Funding

No funding is required for this paper.

Declaration of Interest

All authors have no conflicts of interest.

References

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

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

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

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

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

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

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

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

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

Abstract

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

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

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

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

Practice Highlights

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

I. INTRODUCTION

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

II. PROGRAMME DESCRIPTION

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

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

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

III. CHALLENGES

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

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

IV. PROPOSED STRATEGIES

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

A. Promoting Interdisciplinary Teaching and Learning

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

B. Alignment with Individual Needs and Organisational Goals

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

C. Developing Research Capability

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

V. CONCLUSION

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

As Carlo Rubbia, Nobel prize winner in physics says,

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

Notes on Contributors

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

Acknowledgements

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

Funding

No funding was received.

Declaration of Interest

Both OEK and SWS state no conflicts of interest.

References

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

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

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

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

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

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

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

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

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

Abstract

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

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

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

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

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

Practice Highlights

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

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

Cheng Li & Gunjeong Lee

School of Nursing, Ewha Womans University, Republic of Korea

Abstract

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

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

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

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

Keywords:           Nursing, Health Professional, Prescribing

Practice Highlights

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

I. INTRODUCTION

A. Background

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

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

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

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

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

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

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

B. Nursing in China

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

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

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

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

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

II. METHODS

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

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

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

A. Data Collection

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

B. Data Analysis

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

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

III. RESULTS

A. Search Outcomes

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

Figure 1. Screening Flow Diagram

CINAHL – Cumulative Index to Nursing and Allied Health Literature

CNKI – China National Knowledge Infrastructure

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

Table 1. Summary of included studies

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

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

B. Development of Nurse Prescribing in China

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

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

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

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

Figure 2. Nurse Prescribing Timeline in China

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

C. Present Nurse Prescribing in China

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

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

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

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

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

Figure 3. Nurse Prescribing Region Mapping of China in 2023

D. Indicated Challenges

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

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

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

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

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

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

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

IV. DISCUSSION

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

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

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

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

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

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

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

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

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

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

A. Limitation & Implication

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

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

V. CONCLUSION

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

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

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

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

Notes on Contributors

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

Ethical Approval

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

Data Availability

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

Funding

No funding sources are associated with this study.

Declaration of Interest

No conflicts of interest are associated with this paper.

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

Submitted: 6 April 2024
Accepted: 10 December 2025
Published online: 1 April, TAPS 2025, 10(2), 57-64
https://doi.org/10.29060/TAPS.2025-10-2/OA3332

Chatchai Kreepala¹, Srunwas Thongsombat², Krittanont Wattanavaekin³, Taechasit Danjittrong⁴, Nattawut Keeratibharat⁵ & Thitikorn Juntararuangtong¹

¹School of Internal Medicine, Institute of Medicine, Suranaree University of Technology, Thailand; ²Department of Orthopedics, Faculty of Medicine, Prince of Songkla University, Thailand; ³Department of Surgery, Faculty of Medicine, Ramathibodi Hospital, Mahidol University, Thailand; ⁴Department of Anesthesiology, Chulabhorn Hospital, Thailand; ⁵School of Surgery, Institute of Medicine, Suranaree University of Technology, Thailand

Abstract

Introduction: Factors affecting decision-making duration in MCQs can enhance assessment effectiveness, ensuring they accurately measure the intended objectives and address issues related to incomplete exams due to time constraints. The authors aimed to explore the aspects of medical student’s perspective regarding the factors influencing their decision making on MCQ assessments.

Methods: A mixed-methods explanatory sequential design was utilised. Initial surveys were conducted using percentages, mean and non-parametric analysis obtained via online questionnaires from the sample group: all 2^nd – 5^th year medical students from SUT, Thailand. The validity of the questionnaires was verified by three independent reviewers (IOC=0.89). This was followed by semi-structured group interviews to explore student’s perspective on the factors affecting their decision. Qualitative analysis was conducted to explore detailed information until data saturation was achieved.

Results: Data from the quantitative analysis identified four factors that students believe affect the duration of the exam: the total word count of each question, test difficulty, and images in tests. Meanwhile, the qualitative analysis provided additional insights on factors such as the examination atmosphere affecting their decisions.

Conclusion: This report indicated that data acquired from a comprehensive reading question should be distinguished from those requiring decisive reading. Apart from text length, question taxonomy-such as recall or application- and questions with given images and tables should be considered as factors determining time allocation for an MCQ. Future research based on these results should aim to develop a mathematical formula to calculate exam duration, accounting for question difficulty and length.

Keywords:           MCQ, Medical Assessment, Medical Education, Testing Time Estimation, Qualitative Research, Students’ Perspective

Practice Highlights

• The multiple-choice question (MCQ) stands as one of the objective assessment methods, widely regarded as the most utilised form of assessment.
• The word-length effect has been proposed to determine the length of each examination.
• Educational theories on decision-making have posited that decision-making is a dynamic process stemming from prior experiences.
• The authors were interested in exploring the aspects of the medical student’s perspective about the factors affecting their decision on MCQs answering.

I. INTRODUCTION

The multiple-choice question (MCQ) stands as one of the available objective assessment methods, widely regarded as the most utilised form of assessment, particularly within the fields of medical sciences and technology. Evidence suggests that the recall of short words often surpasses that of longer words (Tehan & Tolan, 2007). This observation is frequently analysed within the framework of a working memory model and the role of the phonological loop in immediate recall. However, the word-length effect has also been observed in delayed tests and in lists that surpass the memory span, thereby challenging the working memory interpretation of the phenomenon. Three alternative interpretations of the word-length effect have been proposed to explain how an exam length should be determined (Arif & Stuerzlinger, 2009; Kumar et al., 2021).

Educational theories on decision-making have posited that decision-making is a dynamic process stemming from prior experiences (Phillips et al., 2004) and meaningful learning (Foley, 2019). As a result, the ability to comprehend text while reading does not automatically equate to reading for decision-making or answering questions. From the literature, the context of factors influencing medical students’ decisions on MCQs includes 1) Length or number of words: The time students need to read to gather information before making a decision on an answer (Arif & Stuerzlinger, 2009). 2) Difficulty of the questions: analytical thinking, especially calculations are involved, may increase decision-making time. This depends on the students’ prior learning experiences before the exam (González et al., 2008). 3) Language comprehension: since exams in medical schools are often in English, non-native speakers may take longer to read and understand the questions (Schenck, 2020). 4) Visuals and tables: these serve as symbols that help students retrieve information from their prior learning experiences more easily (Ziefle, 1998). It is certain that teachers want academic assessment tests, such as MCQs, to be used to distinguish between high-performing and low-performing students and to assess the knowledge and understanding they have acquired. However, these objectives may be undermined by issues such as students running out of time and resorting to guessing. This inevitably reduces the reliability of the test.

The authors were interested in exploring medical student’s aspect regarding factors affecting their decision on MCQs answering. Previous studies focused on duration required for question comprehension and understanding but not for analysis. These were also mostly done in native Englisher speakers. This study builds upon previous studies but with an emphasis on factors affecting non-native English speakers’ decision making after analysis of the provided questions to answer MCQs in English. This research should be approached from the perspective of the student to obtain appropriate data. Semi-structured qualitative interviews were analysed in conjunction with quantitative data to identify and clarify the reasons and factors that students believe influence their performance on exams.

II. METHODS

A. Study Population

The research participants were second to fifth-year Thai medical students who had taken MCQ tests during their preclinical and clinical years between the academic years 2021-2022. Questionnaires were sent to all students without sampling.

To minimise data artifacts caused by recall bias, the online questionnaires were distributed the first week after each MCQ test before the study to the students who completed the exams. All examinations in this study were computer-based, closed book, single best answer MCQs written in English. The participants were non-native English speakers of Thai nationality (as detailed in Definition of Terms). An online survey or questionnaire-based study was used to collect information from participants in this study. If the data was unsaturated, triangulated data from a group of interviews consisting of students from different rotations was included to receive as much information from students’ perspectives as possible.

B. Study Design and Data Collection

The authors employed a mixed method study comprising a quantitative approach and a sequential, explanatory approach. The literature review unveiled several factors influencing MCQ test duration, including the number of questions, question types (recall or comprehension), subject matter difficulty, calculation items, and picture identification, as outlined in the questionnaire (O’Dwyer, 2012). 

An online survey or questionnaire-based study was used to collect information from participants with minimal disruption to their learning activities. The quantitative research section was managed by CK, NK and TJ.  Students completed the questionnaire once, based on their experiences in medical school. This, therefore, necessitates the researcher to summarise the responses and, if required, categorise interviews into groups according to their year of study. Open-ended questions were included in the last section of the questionnaire. The open-ended questions about the factors that, in the student’s opinions, were helpful information about the other factors affecting MCQ time (Lertwilaiwittaya et al., 2019). Survey research was employed as a quantitative method, while semi-structured group interviews were utilised in qualitative data collection to gather insights from medical students’ perspectives. The interview questions were designed to investigate whether students possessed any additional insights regarding the factors influencing MCQ test duration (Carnegie Mellon University, 2019; Schenck, 2020; Wang, 2019).

There were three sections in the questionnaire. Part I consisted of the instruction and informed consent. Part II consisted of general information of the participants, including sex, age, and academic year. Part III consisted of the questionnaires covering all four constructive domains previously mentioned (the domains affecting MCQ time from the literature included: 1) the number and total word count, 2) English language questions, 3) calculation questions, 4) the analytical thinking questions and open-ended questions about the factors that, in the students’ opinions, were helpful information about the other factors affecting MCQ time. After the questions in Part One were completed, they would be taken away so that the researchers would not be able to identify whose students have answered Part II and Part III.

To prevent neutral opinions from students, each questionnaire item featured a four-point Likert scale corresponding to levels of agreement: ‘Strongly disagree,’ ‘Disagree,’ ‘Agree,’ and ‘Strongly agree.’ The researcher wanted clear opinion whether the students were trending towards which side, hence the four-point Likert scale to prevent neutral opinion which may complicate statistical analysis. Validity of the questionnaires were verified by three independent reviewers with an Index of Item-Objective Congruence (IOC) value of 0.89.

Semi-structured group interviews were adopted into this study as insufficient flexibility is provided by a structured interview, whereas unstructured interviews would be too flexible. Semi-structured group interviews were the combination of formal and informal interviews focusing on personal experience; this often leads to unexpected results, enhancing the quality of data collected.

These interviews would take place after class by independent interviewers without any conflict of interest. Two facilitators were present in each session, CK facilitated the conversation and NK contributed ideas. The two facilitators were known by the student participants as faculty members, but they were not actively engaged in their academic learning.  Audio and written recording would be coded then decoded by the researchers (SK, KW and TD).

The interview would take around 30-45 minutes per group, with each group consisting of five to eight people. Analysis would be done after the first three groups using relevant domain analysis and further analysis done after new interviews until data saturation was achieved.  Coding, theme identification, and triangulation would be undertaken following the analysis and evaluation of the quantitative and qualitative data of which the analysis could be extrapolated to form a conclusion of the study. In this study, the open-end question would be analysed, and the semi-structured interview would be done.

Triangulation helped to provide meaning and helped to gain broader and more precise understanding. It could help increase validity. Triangulation was undertaken following the analysis and evaluation of the quantitative and qualitative data of which the analysis was extrapolated to form a conclusion of the study.

C. Definition of Terms

1) Multiple choice question (MCQ): This paper exclusively focused on the Single Best Answer (SBA) Multiple Choice Questions (MCQs), which were structured as questions followed by 4 or 5 potential answers, with only one correct response per question (Coughlin & Featherstone, 2017).

2) Taxonomy MCQ: MCQs were formulated based on two assumptions: that they could be categorised into higher or lower orders according to Bloom’s taxonomy (Stringer et al., 2021). This study sought to comprehend students’ approaches to questions by examining variances in their perceptions of the Bloom’s level of MCQs regarding their knowledge and confidence. The authors employed Bloom’s taxonomy in this study, classifying questions as “recall,” “comprehension,” and “application” (Stringer et al., 2021).

3) Non-native English speakers: The term non-native English speakers was defined as those students who spoke a language other than English domestically. Non-native English speakers were inclusive of both competent bi-literate and limited English proficiency students. In addition, it is also defined as students who learn the language as older children or adults (Cassels & Johnstone, 1984).

D. Statistical Analysis

Statistical analyses were performed for quantitative analysis with SPSS Statistics for Windows, Version 18.0 (SPSS Inc., Chicago, Illinois, USA). Information in the quantitative section was elaborated and displayed in and counts percentage. The qualitative data was analysed by code grouping of text fragments based on content. Subsequently, the codes were reorganised and grouped, main themes and subthemes were identified, and illustrative quotations were selected. The authors assigned other three medical teachers to undertake independent coding of the transcripts for each interview. The final coding and discussions continued until the frameworks were agreed upon and new themes were derived (CK, SK, KW and TD).

III. RESULTS

A. Demographic Information

The questionnaire was done online by the participants from second to fifth-year medical students in the academic year 2021-2022. There were 93 second-year medical students, 92 third-year medical students, 92 fourth-year medical students, and 93 fifth-year medical students, respectively, with 370 participants in total. It was found that there were 298 respondents (a return rate of 81%). 73 second-year medical students (78% response rate) answered the questions, while 70 third year (76%), 75 fourth year (81%), and 80 fifth year medical students (86%) answered the questions respectively as shown in Table 1.

D. The Number Tests and Total Word Count

The exam questions, according to some students, were challenging and time-consuming, and the answer options were likewise lengthy. It was shown that not only the number of tests, but the length of each test item also affected the testing time.

Quote: Student B1F*; “The questions were too long. I can’t complete them in time.”

Quote: Student A2M*; “If there are too many questions in the exam, I wouldn’t be able to finish it”

* student’s code

English Language Questions and Examiners (Native Versus Non-Native English Speakers): The respondents, who were not native English speakers, believed that the English-language test took longer to finish than the Thai-language test. Accordingly, they decided to guess or answer each question slowly since they could not understand the questions. They believed that the English-language tests took longer to finish than the Thai-language tests. Accordingly, they decided to guess or answer each question slowly since they could not fully understand the English questions.

Quote: Student D1F*; “I’m not good at reading English. Sometimes I just have to guess on the exam.”

Quote: Student C1M*; “The language in the test is too hard to understand.”

* student’s code

E. Test Difficulty Determining Time Allocation

For the analysis of coding, grouping, and generating themes, the author found that the medical students paid attention to the difficulty level of the questions which affected the decision to answer the questions.

1) The Calculation and Analytical Thinking: The calculation and analytical thinking tests took students longer to read. Additionally, students believed that examinations they had never taken before or exams that required knowledge application took longer to complete, such as exams that included questions requiring the students to diagnose patients by themselves which occasionally left them unsure of how to respond.

Quote: Student C2M*; “Calculation tests take a long time to get the answers.”

* student’s code

2) Recall Question Leads to Quick Answers: Students commented that recall-type questions, including tests from previous academic years, contained duplicated sentences, pictures, or messages from textbooks that students remembered. This led to students being able to complete the test in a short thinking time.

Quote: Student K1M*; “If the teacher copied the exact words from the course sheet, I would remember and answer questions quickly.”

Quote: Student L1M*; “If the questions are the same as in the sheet provided, I can answer them.”

*student’ code

This information indicated that the taxonomy of the test (recall -compression-application) had a large effect on decision time. Applied questions, not direct or calculated questions, required more attention and time for decision-making when compared to comprehensive questions (questions about knowledge understanding). In contrast, recall questions required the least decision-making time.

F. The Visual Image and Atmosphere of the Examination: the New Derived Domains Recognised by Qualitative Analysis

1) Questions with images, graphs, or tables serve as key guides for decision-making: The students thought that the exams that consisted of graphs and tables helped them understand the questions and were better than the questions that only had descriptions. That would lead to less time consumed.

Quote: Student L2M*; “If the test got the exact same summary table from the book, I could remember and get the answers right away.”

* student’s code

2) The Atmosphere of the Examination: The environment and atmosphere of the exam were also mentioned. The student’s response time was slowed down by the distractions during the exam. The environment such as brightness, temperature, and examination devices affected the concentration of the students.

Quote: Student H1F*; “The atmosphere in the exam venue, noise, and the air quality in the room affect the exam results.”

*student’s code

IV. DISCUSSION

The results revealed that students perceived lengthy exam content or a large number of questions as time-consuming, particularly when exams were conducted in English. Studies indicated that English speakers could read up to 150 words per minute (Trauzettel-Klosinski et al., 2012). However, for non-native English speakers, the expected reading time for exams was longer. Hence, using the English reading rate as a basis for determining exam duration was deemed unsuitable for Thai students, given that English was not their primary language of communication. When compared with a previous study (Trauzettel-Klosinski et al., 2012), the increased duration may result from decision making, thus this implicates reading for decision making requires more time than reading for the context which is cumulatively longer for non-English native speakers.

Qualitative findings indicated that irrespective of the exam duration set by the administering professor, students generally completed exams within the allotted time frame. This often entailed guessing answers towards the end of the exam period, as students might not have adequate time to complete the exam thoroughly. It was observed that students tended to resort to guessing exam questions approximately five minutes before the exam conclusion, thereby minimising threats to validity posed by guessing due to time constraints during exam (Foley, 2019).

There may be limitations if the exam questions contain lengthy content that cannot be comprehended and decided upon within one minute. Furthermore, the difficulty level of the exam questions is often established as a passing criterion, prioritising validity considerations in terms of content format and achieving the intended objectives. Moreover, students naturally desire to obtain the highest possible score on the exam, regardless of the level of difficulty or length of the exam. Therefore, it is important for students to manage their time effectively to ensure they can complete all the exam questions within the given timeframe.

The qualitative results indicated that regardless of the exam duration set by the administering professor, students ultimately would complete the exam within the allotted time frame. Additionally, students agreed that application and calculation questions on the exam require more time to read and decide upon, as opposed to questions with figures and tables that aided in faster decision making. Based on these findings, it could be concluded that comprehensive reading rates may not be a reliable indicator of decision-making reading rates, particularly in the context of medical school exams. Therefore, studying decision-making reading rates within the context of medical school exams was crucial.

The researcher, therefore, examined the domain and specific factors on the characteristics of the MCQ test. Additionally, the study scope was limited to English tests administered to non-native English speakers and onsite computer-based tests, thereby eliminating unrelated factors that could impact exam duration. The analysis yielded the following results: Firstly, factors positively correlated with exam duration (negatively correlated with decision-making) included the number of questions, total word count, calculation questions, and analytical thinking questions. Secondly, factors negatively correlated with exam duration (positively correlated with decision-making) were recall questions, questions with provided images, and tables.

A factor contributing to longer reading times for decision-making purposes was when the exam contained a higher proportion of application or calculation questions, comprising over 33% of the exam questions, as evidenced by qualitative data from students. Therefore, analysing exam completion time based on reading comprehension data for decision-making purposes is not recommended. Moreover, it should be noted that these factors present internal threats to validity, but they can be managed to ensure that examination tools are effectively used and aligned with intended objectives. Incorporating data from research can lead to the identification of new themes related to factors influencing examination time.

Five constructive domains were identified: 1) the number and total word count, 2) positive difficulty factors (application/calculation questions), 3) negative difficulty factors (recall questions), 4) examiners (non-native English speakers or not), and 5) pictures/symbols in tests.

A distinctive aspect of this study was its targeted focus on Thai medical students who were non–native English speakers. While many studies have examined MCQ performance across broad and diverse populations, this research concentrated on a specific demographic, enabling a more in-depth exploration of how cultural and linguistic factors influence test-taking behaviour. The study uniquely combined quantitative survey data with qualitative insights from semi-structured group interviews. While some research utilised either quantitative or qualitative methods, this study’s integration of both provided a more holistic understanding of student perspectives and experiences (Lertwilaiwittaya et al., 2019). This methodological triangulation strengthened the validity of the findings by cross-verifying quantitative data with qualitative insights. In contrast to many existing studies that focused predominantly on performance metrics (such as scores or pass rates), this research examined the cognitive processes and decision-making strategies students employed while answering MCQs. It investigated how elements like question difficulty, language comprehension, and prior experiences shaped students’ approaches to test questions—a dimension less frequently explored in previous literature.

In conjunction with examination-related factors, students also recognised the importance of considering the test environment within the examination room which was a new finding found using qualitative analysis from this research. This was crucial for promoting student concentration and facilitating accurate response selection in line with assessment tool objectives. It aligned with existing literature, which suggested that the test environment poses a construct irrelevant threat to the validity of educational measurement. The findings from this study may have led to future research on developing a mathematical formula to tailor the exam duration for different sets of questions. This would have involved analysing factors such as the number of words, length, difficulty, and the presence of images and tables in the exam. Additionally, the impact of language proficiency on reading and decision-making time should have been considered, as there may have been differences between native and non-native speakers. The study suggested that the future research direction should include diverse populations of non-native English speakers from different countries and educational contexts. This could help identify whether the findings are consistent across various cultural backgrounds and educational systems. Moreover, conducted longitudinal studies should be used to track students’ performance and decision-making processes over time. This approach could provide insights into how experiences and familiarity with MCQs influence their strategies and confidence levels throughout their medical education.

A major limitation of this research was the variation in learning experiences, exam-taking skills, and analytical thinking among medical students at different year levels, which might lead to differing opinions. Therefore, the researcher needed to conduct qualitative analysis to examine the reasons behind these differences. However, the diversity of experiences might also introduce bias due to varying familiarity with different types of exams. The online format restricted the depth of responses, as students often did not fully articulate their thoughts without immediate follow-up questions, which limited the richness of the qualitative data. Additionally, the focus on Thai medical students constrained the applicability of the findings to other populations or contexts, thereby limiting broader conclusions about non-native English speakers in different educational settings.

V. CONCLUSION

Based on the student’s perspective, data showed questions with lengthy content required more time whilst those with tables or diagrams required less time. This report indicated that the data acquired from a comprehensive reading examination should be distinguished from a decisive reading examination.

In addition to the number of questions and the length of text, factors that should be positively correlated with the duration of the exam include the number of questions, word count, calculation-based questions, and analytical thinking questions. These factors should be considered for additional time allocation beyond the regular exam duration, particularly when the proportion of analytical thinking questions exceeds one-third of the total question set. On the other hand, recall questions, as well as questions accompanied by images and tables, should be taken into account to ensure a balanced distribution of exam time, as they can be answered more easily and quickly in terms of decision-making compared to general questions.

Notes on Contributors

CK conceived of the presented idea, developed the theory, and performed the computations and discussed the results and contributed to the final manuscript. ST, KW, and TD. discussed the results and wrote the manuscript with support from CK, NK, and TJ, designed the model and the computational framework and analysed the data.

Ethical Approval

All participants voluntarily signed a consent form prior to participating in the study. The participation protocol was approved by the Human Research Ethics Committee, Suranaree University of Technology (Issue # EC-64-102).

Data Availability

Institutional ethical clearance was given to maintain the data in the secure storage of the principal investigator of the study. The data to this study may be provided upon reasonable request to the corresponding author. A preprint of our manuscript, which is not peer-reviewed, is available at https://www.researchsquare.com/article/rs-3019852/v1

Acknowledgement

The authors would like to thank the participants of this study, the medical students in the Institute of Medicine, Suranaree University of Technology. Without their passionate participation and input, the validation survey could not have been successfully conducted.

Funding

This work was supported by the Grant of Suranaree University of Technology (contract number SUT-602-64-12-08(NEW)).

Declaration of Interest

The authors have no conflicts of interest to disclose.

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*Assoc. Prof. Chatchai Kreepala, M.D.
Institute of Medicine
Suranaree University of Technology
Thailand
+66(93)3874665
Email: chatchaikree@gmail.com

Submitted: 17 April 2024
Accepted: 18 December 2025
Published online: 1 April, TAPS 2025, 10(2), 65-70
https://doi.org/10.29060/TAPS.2025-10-2/OA3336

Rachael Tufui Masilomani¹, Sophaganie Jepsen¹, Maria Lourdes Villaruel¹, Aying Wang¹, Alena Kotoiwasawasa¹, Lusiana Naikawakawavesi¹, Norman Bartolome¹, Claudia Paterson², Andrew Hill² & Maria Concepcion Bartolome¹

¹Basic Clinical Medicine, Fiji National University, Fiji; ²Department of Surgery, Middlemore Hospital, University of Auckland, New Zealand

Abstract

Introduction: The MBBS programme at Fiji National University reduced its teaching weeks from 18 to 14 weeks in 2018. The purpose of this study was to assess student perceptions of learning and teachers following the reduction in the number of teaching weeks from 18 to 14 weeks.

Methods: A questionnaire was created using a modified Dundee Ready Education Environment Measure (mDREEM) tool (23 items). This was comprised of two subscales; Students Perception of Learning (SPL – 12 items) and Students Perception of Teachers (SPT – 11 items). This was circulated to Year 5 MBBS students through an online survey in 2020.

Results: The response rate was 96%. The students regarded their educational environment as positive in both length of teaching weeks, with an overall mDREEM mean score of 63.29 in 18 weeks and 62.03 in 14 weeks. No statistically significant differences were found between 18 week and 14 week scores across mDREEM scores, SPL scores or SPT scores. The highest scoring item over both was ‘teachers are knowledgeable’.

Conclusion: A positive perception was noted for both lengths of teaching weeks. Reducing the teaching weeks from 18 to 14 did not statistically significantly reduce students’ perception of their educational environment. Items identified with low scores will give a window of opportunity for lecturers and to improve these areas. Future studies may explore the use of the five subscales of the DREEM tool and this study can be integrated into further evaluations of educational environment at Fiji National University.

Keywords:           Medical Students, Educational Learning Environment, DREEM Tool, Fiji National University, Teaching, Medical Education

Practice Highlights

• mDREEM scores did not significantly differ between 18 weeks and 14 weeks of teaching.
• The highest scoring item over both weeks was ‘teachers are knowledgeable’.

I. INTRODUCTION

The Fiji National University (FNU) was founded in 2010 by the merging of six academic institutions in the Fiji Islands, including the Fiji School of Medicine (FSM). FNU has continued the FSM’s tradition of educating and training a diverse population of students from Fiji and neighbouring Pacific Island nations.  The Bachelor of Medicine and Bachelor of Surgery (MBBS) programme is a six-year course at FNU. As part of the academic year, each pre-clinical year group have a teaching week block course. During this time, students receive 2-4 hours of scheduled lectures, 2-hour tutorials twice weekly, as well as 2 hours of clinical skills and 2 hours of anatomy, 2 hours of laboratory sessions and a health centre attachment 4 hours a week.

In 2018, FNU reduced the teaching week block course in the MBBS programme from 18 weeks to 14 weeks. The teaching weeks were shortened due to the decision to move specialty courses such as Psychiatry and Public Health to their respective clinical blocks from Years 4 to 6. This adaptation was challenging for the lecturers, who had to reformat their teaching sessions, in addition to providing resources onto an online Moodle platform. It is well established that the educational environment plays an important role in determining the academic success of medical students (Prosser et al., 1999; Ramsden 2003). Therefore, it is important to evaluate the impact of any major changes to the educational environment, such as a reduction in teaching weeks from 18 weeks to 14 weeks.

Previous research has demonstrated that the duration of clinical rotations has been able to be decreased without adversely affecting the academic success of medical students. For example, one group demonstrated that a shortened four-week clinical rotation in Obstetrics and Gynaecology provided enough opportunity for final year medical students to undertake a quality improvement project in the curriculum (Kool et al., 2017).

The Dundee Ready Education Environment Measure (DREEM) is a quantitative tool used to evaluate students’ perceptions of the educational environment in medical schools. The DREEM tool consists of 50 items, each rated on a scale from 0 to 4. It has five domains, allowing for a maximum score of 200. Higher scores indicate a positive perception of the learning environment (Roff et al., 1997).

A systematic review published in 2012 analysed 40 studies reporting DREEM scores from 20 countries. This review demonstrated that DREEM had been used internationally for various purposes, including diagnostic assessments and comparative studies across different groups (Miles et al., 2012). Five studies focused on investigating the impact of a changed curriculum, which was our area of interest (Demirören et al., 2008, Edgren et al., 2010, O’Brien et al., 2008, Riquelme et al., 2009, Till et al., 2004). We identified three key themes: 1) the DREEM tool was able to highlight areas of concern and/or remediation among students (Riquelme et al., 2009 Till et al., 2004), 2) DREEM scores were different in different phases of medical education, with year 3 students having the highest scores, and year 5 students having the lowest scores (Demirören et al., 2008, Riquelme et al., 2009), and 3) the DREEM tool identified clusters of students based on how positively they perceived the curriculum (O’Brien et al., 2008).

The aim of this research was to compare students’ perception of learning and teachers between 18 weeks and 14 weeks, using a modified DREEM (mDREEM) tool which utilises two of the five domains from the original DREEM tool. The authors’ hypothesis was that students’ perception of learning and teaching would be reduced in with a decrease in teaching weeks to 14 weeks compared to 18 weeks.

II. METHODS

A. Participants

An online survey was developed by the authors. This was distributed via email to eligible participants using Google Forms from 12^th December to 17^th December 2020. Eligible participants included the Year 5 MBBS cohort of 2021, as this cohort was exposed to both 18 week and 14 week teaching programmes. Participation in the survey was optional and results were anonymous. Submission of a completed survey was taken as providing informed consent to participate in this research. Full ethics approval was provided through FNU’s College Human Health Ethics Committee (ID: 292.20). Facility approval was granted to conduct the research.

B. mDREEM Tool

The authors selected two of the five domains of the DREEM tool to be included in the survey. The selected two domains included students’ perceptions of learning (SPL) and students’ perceptions of teachers (SPT). The rationale for using only these two domains was that they were the two domains of interest for the teachers, and it was thought that a survey with less questions would be more likely to be filled to completion by more of the students. Using a Likert scale, each item was scored from 0 to 4, with 4 = strongly agree, 3 = agree, 2 = not sure, 1 = disagree and 0 = strongly disagree. Six of the 23 statements in the mDREEM tool were negative statements: 1) the teaching over-emphasised factual learning; 2) the teaching is too teacher-centred; 3) teachers ridicule the students; 4) the teachers are authoritarian; 5) teachers get angry in class and 6) the students irritate the teachers. These were scored in a reverse manner.

The mDREEM tool had a maximum score of 92. The SPL domain included 12 items, with a maximum score of 48. The SPT domain included 11 items, with a maximum score of 44. This research used the following guide to interpret the overall scores:

• 0–23 = Very poor environment
• 24 – 46 = A large number of problems in the environment
• 47–69 = More positive than negative environment
• 70–92 = Excellent

C. Statistical Analysis

Analysis of the collected data was by using R version 4.3.1. Mean scores were reported with standard deviations. Paired t-tests were performed to compare aspects of the mDREEM scores over 18 weeks and 14 weeks, with a statistical significance threshold of p<0.05. Reliability analysis of the mDREEM tool was assessed using Cronbach’s Alpha test, where >0.7 was deemed acceptable internal consistency.

III. RESULTS

Seventy-eight out of eighty-one (96%) MBSS Year 5 students participated in the online survey. Fifty-one (65%) were females and 51% of participants were aged between 23 and 25 years old. Fijian of Indian descent students made up the majority of the responders (67%) followed by other ethnicities (18%) and i-Taueki students (15%). The majority of students resided at the FNU Hostel (69%) while 28% lived within Suva and only 3% lived outside Suva.

Table 1 illustrates the 23 individual mDREEM items with mean scores across 18 weeks and 14 weeks. The item ‘the teaching overemphasised factual learning’ scored the lowest for both 18 and 14 weeks. The item ‘teachers are knowledgeable’ scored the highest for both 18 and 14 weeks.

Items	mDREEM item	Code	18 weeks		14 weeks
			Mean	SD	Mean	SD
1	I am encouraged to participate in class	SPL	3.13	0.91	2.78	1.03
2	The teaching is often stimulating	SPL	2.79	1.02	2.65	0.94
3	The teaching is student-centred	SPL	2.97	0.95	2.79	0.92
4	The teaching helps to develop my competence	SPL	3.06	0.82	2.63	0.92
5	The teaching is well focused	SPL	2.67	1.00	2.55	1.03
6	The teaching helps to develop my confidence	SPL	2.88	1.01	2.79	0.94
7	The teaching time is put to good use	SPL	2.81	1.12	2.60	1.00
8	The teaching over-emphasised factual learning	SPL	1.85	0.92	1.91	0.79
9	I am clear about the learning objectives of the course	SPL	2.77	1.02	2.78	0.98
10	The teaching encourages me to be an active learner	SPL	2.86	1.16	2.97	0.88
11	Long term learning is emphasised over short term learning	SPL	2.59	1.13	2.56	0.98
12	The teaching is too teacher-centred	SPL	2.85	0.80	2.74	0.78
13	The teachers are knowledgeable	SPT	3.18	0.83	3.13	0.80
14	The teachers are patient	SPT	3.01	0.73	2.74	0.89
15	The teachers ridicule the students	SPT	2.49	0.97	2.56	0.97
16	The teachers are authoritarian	SPT	2.49	0.96	2.58	0.91
17	The teachers have good communication skills	SPT	3.04	0.90	2.99	0.71
18	The teachers are good at providing feedback to students	SPT	2.54	1.15	2.86	0.96
19	The teachers provide constructive criticisms	SPT	2.85	0.90	2.92	0.84
20	The teachers give clear examples during class	SPT	2.78	0.91	2.79	0.84
21	The teachers get angry in class	SPT	2.63	1.01	2.63	0.85
22	The teachers are well prepared for their classes	SPT	2.87	0.90	2.92	0.81
23	The students irritate the teachers	SPT	2.23	0.95	2.23	0.83

The mean SPL scores over 18 weeks and 14 weeks were 33.23 (SD 7.38) and 31.74 (SD 7.52), respectively, out of a maximum of 48 (SPL 18 weeks: 69.33%; SPL 14 weeks: 66.13%). The mean SPT scores over 18 weeks and 14 weeks were 30.06 (SD 6.34) and 30.28 (SD 5.74), respectively, out of a maximum of 44 (SPT 18 weeks: 68.32%; SPT 14 weeks: 68.82%). The mean mDREEM scores over 18 weeks and 14 weeks were 63.29 (SD 12.58) and 62.03 (SD 12.01), respectively, out of a maximum of 92 (mDREEM 18 weeks: 68.80%; mDREEM 14 weeks: 67.42%). These results are presented in Table 2.

	SPL 18	SPL 14	SPT 18	SPT 14	mDREEM 18	mDREEM 14
Mean	33.23	31.74	30.06	30.28	63.29	62.03
SD	7.38	7.52	6.34	5.74	12.58	12.01

Table 2. Descriptive summary statistics for 18 and 14 teaching weeks

The mean difference in SPL scores between 18 weeks and 14 weeks was 1.48. This difference was not statistically significant (t (77) = 1.61, p = 0.11). The mean difference in SPT scores between 18 weeks and 14 weeks was -0.22, and this was also not statistically significant (t (77) = -0.43, p = 0.67). The mean difference in overall mDREEM scores between 18 weeks and 14 weeks was 1.27, which was also not statistically significant (t (77) = 1.04, p = 0.30).

The reliability analysis for both 18 and 14 teaching weeks found a Cronbach’s Alpha Test of 0.58 for SPL, which was less than the threshold of 0.7 and 0.84 for SPT, which was greater than the threshold of 0.7. For mDREEM, the Cronbach’s Alpha Test was 0.77, which was greater than the threshold of 0.7 and confirmed acceptable internal consistency for the mDREEM tool.

IV. DISCUSSION

This study has demonstrated that a reduction in teaching from 18 to 14 weeks did not result in a significant decrease in mDREEM, SPL or SPT scores among Year 5 MBBS students at FNU in 2020. This finding refuted the authors’ hypothesis of a reduction in teaching weeks leading to student dissatisfaction of the educational environment.

Both 18 weeks and 14 weeks scored within the range of 47 to 69 out of 92, indicating a ‘more positive than negative environment’ based on predefined thresholds outlined in the methods section. The ‘excellent’ threshold of 70+ out of 92 was not obtained, indicating room for improvement. In particular, the item ‘teachers are knowledgeable’ scored the highest for both 18 and 14 weeks indicating that students perceived their teachers to have high levels of knowledge despite the reduction in teaching weeks. In contrast, ‘the teaching overemphasised factual learning’ was identified as the most significant negative statement and provides an area of focus for the lecturers.

One group used the DREEM tool to assess curriculum changes in an Irish medical school and that found that the new curriculum was associated with students reporting higher mean DREEM scores (Finn et al., 2014). While FNU’s curriculum change did not result in higher mDREEM scores, the maintenance of mDREEM scores is encouraging and provides a framework for ongoing work towards improving students’ perception of their educational environment.

This finding was similar to a previous study reviewing shortened medical education rotations previously discussed in the introduction section of this paper (Kool et al., 2017). Given the concordance with other similar research findings, the authors are of the belief that the results from this study are largely generalisable to MBBS students and lecturers worldwide, despite only being a single-centre study.

A major strength of this study was the high response rate of 96%. This ensures that data collected as part of this research is representative of the population of interest as compared to several studies with lower response rates (Al-Ansari et al., 2015; Ali et al., 2012; Hyde et al., 2018). Moreover, the results are comparable to the high response rates of other DREEM studies conducted internationally (Alraawi et al., 2020; Stormon et al., 2019; Till et al., 2004).

One limitation of this study was using only two domains of the DREEM tool, neglecting the three domains of Students’ Academic Self-Perception (SAP), Students’ Perception of Atmosphere (SPA) and Students’ Social Self-Perception (SSP). The authors selected SPT and SPL as the two key domains for this research, and thought that by selecting the two most relevant domains, that this would shorten the questionnaire and improve completion of the questionnaire amongst participants. Future research at FNU should trial the use of all five domains of the DREEM tool to assess whether this provides further insights into how teaching weeks can be improved for MBBS students. It will be of interest to see whether response rates are reduced with the use of the full DREEM tool in a questionnaire. Furthermore, future surveys should investigate perspectives of MBBS students over a range of year groups, given previous research suggesting that Year 3 MBBS students have higher DREEM scores than Year 5 MBBS students. A second limitation of this study was that the alpha value for SPL failed to achieve the threshold of >0.7, making it concerning that this domain was unable to achieve acceptable internal consistency. However, the authors note that SPT and mDREEM both achieved acceptable internal consistency. A final limitation of this study was the fully quantitative nature of the survey – the authors did not provide an option for students to add comments to this survey. Future surveys should provide an option for students to add comments, in order to provide more insights into the perspectives of MBBS students.

V. CONCLUSION

In conclusion, the students rated FNU’s MBBS programme educational environment positively. A reduction in teaching weeks from 18 to 14 did not result in a statistically significant decrease in SPL, SPT or mDREEM scores. This study identified valuable information for the authors regarding the improvement of educational environment for medical students. Utilisation of these results to guide educational development in these areas needing improvement will be of help in shaping the delivery of quality education to medical students. In addition, this research may open a door for further studies to investigate challenges faced by tutors and link it to the perceptions of medical students in their educational environment. Likewise, this study is important for future studies in evaluating the educational climate for FNU and other local and international universities.

Notes on Contributors

Dr Maria Bartolome is the corresponding author for this research. She is a PBL (problem based learning) lecturer at the School of Medicine, Fiji National University. She was involved in conceptualisation, methodology, investigation, formal analysis, and writing the original draft.

Dr Norman Bartolome is a PBL lecturer at the School of Medicine,  Fiji National University. He was involved in conceptualisation, methodology, investigation, and writing the original draft.

Dr Alena Kotoiwasawa is a PBL lecturer at the School of Medicine,  Fiji National University, and was involved in  conceptualisation, methodology, and investigation.

Dr Rachael Masilomani is a former PBL lecturer at the School of Medicine,  Fiji National University. She was involved in conceptualisation, methodology, investigation, and formal analysis.

Dr Lusiana Naikawakawavesi is a PBL lecturer at the School of Medicine,  Fiji National University, and was involved in conceptualisation, methodology, and investigation.

Dr Maria Villareul is a PBL lecturer at the School of Medicine, Fiji National University. She was involved in conceptualisation, methodology, and investigation.

Dr Sophaganie Jepson is a PBL lecturer at Fiji National University. She was involved in conceptualisation, methodology, investigation.

Dr Aying Wang is a former PBL Lecturer at Fiji National University. He was involved in conceptualisation, methodology, investigation.

Dr Claudia Paterson is a research fellow at The University of Auckland, New Zealand. She was involved in formal analysis, reviewing and editing.

Professor Andrew Hill is a colorectal surgeon and Professor of Surgery at Middlemore Hospital, Auckland, New Zealand. He was involved in supervision, reviewing and editing.

Ethical Approval

Ethical approval was provided through FNU’s College Human Health Ethics Committee (CHHREC) – reference ID: 292.20.

Data Availability

The corresponding author is able to provide researchers access to our anonymised dataset, on reasonable request.

Acknowledgements

The authors acknowledge the efforts of the students in participating in this study.

Funding

No funding was used for this study.

Declaration of Interest

The authors do not have any conflicts of interest to disclose.

References

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*Dr Maria Concepcion Bartolome
Basic Clinical Medicine Department
School of Medical Sciences (SMS)
College of Medicine, Nursing and Health Sciences (CMNHS),
Fiji National University
Hoodless House, Brown St. Suva, Fiji Islands
+679 3311700
Email: maria.bartolome@fnu.ac.fj

Submitted: 5 June 2024
Accepted: 30 October 2024
Published online: 1 April, TAPS 2025, 10(2), 71-81
https://doi.org/10.29060/TAPS.2025-10-2/OA3424

Mary Xiaorong Chen¹, Meredith Tsz Ling Yeung¹, Nur Khairuddin Bin Aron², Joachim Wen Jie Lee³ & Taylor Yutong Liu⁴

¹Health and Social Sciences Cluster, Singapore Institute of Technology, Singapore; ²Rehabilitation Department, Jurong Community Hospital, Singapore; ³Rehabilitation Medicine, Singapore General Hospital, Singapore; ⁴Clinical Support Services Department, National University Hospital, Singapore

Abstract

Introduction: Transitioning from a novice physiotherapist (NPT) to an independent practitioner presents significant challenges. Burnout becomes a risk if NPTs lack adequate support for learning and coping. Despite the importance of this transition, few studies have explored NPTs’ experiences in Singapore. This study aims to investigate the transitional journey of NPTs within this context.

Methods: Conducted as a descriptive phenomenological study, researchers collected data through semi-structured online interviews with eight NPTs from six acute hospitals across Singapore. Simultaneous data analysis during collection allowed for a reflexive approach, enabling the researchers to explore new facets until data saturation. Thematic analysis was employed and complemented by member triangulation.

Results: The challenges NPTs encountered include seeking guidance from supervisors, managing fast-paced work and patients with complex conditions. Additionally, NPTs grappled with fear of failure, making mistakes and self-doubt. They adopted strategies such as assuming responsibility for learning, developing patient-focused approaches, and emotional resilience. However, a concerning trend emerged with the growing emotional apathy and doubts about their professional choice.

Conclusion: This study provides a nuanced understanding of the challenges faced by NPTs during their transition. The workplace should be viewed as a learning community, where members form mutual relationships and support authentic learning. Recommendations include augmenting learning along work activities, fostering relationships, ensuring psychological safety, and allowing “safe” mistakes for comprehensive learning.

Keywords:           Novice Physiotherapist Transition in Practice, Clinical Learning and Supervision, Mentoring, Emotional Resilience and Support, Safe Learning Environment

Practice Highlights

• Gradual assumption of responsibilities helps Novice Physiotherapists (NPTs) build competence.
• Learning should be augmented along with work activities.
• It is important to support NPTs to overcome the fear of failure and self-doubt.
• NPTs’ ability to negotiate learning and emotional resilience are essential.
• Trusting relationships and a safe learning environment are essential to NPTs’ learning.

I. INTRODUCTION

Novice Physiotherapists (NPTs) are physical therapy graduates with two years or less of clinical practice, and during this transition to independent practitioners in clinical settings, they face significant challenges (Martin et al., 2020; Wright et al., 2018). Despite the expectation  of competence, concerns persist regarding NPTs’ abilities in various aspects of their practice.

It was reported that the persistent challenges faced by NPTs include managing workload, handling patients with complex conditions, seeking adequate guidance, and navigating relationship dynamics (Latzke et al., 2021; Mulcahy et al., 2010). One critical issue is the oversight of NPTs’ “new” status, leading to their assignment of patient loads comparable to experienced practitioners. Consequently, NPTs find themselves under tremendous stress in managing patients with complex conditions and diverse sociocultural backgrounds beyond their abilities (Stoikov et al., 2021; Wells et al., 2021). Workloads and time constraints hinder the development of meaningful connections between NPTs and supervisors, affecting teaching and coping abilities (Rothwell et al., 2021). In the busy clinical environment, NPTs cannot solely rely on their assigned supervisors, the support from senior colleagues around them along their developmental journey is necessary. Unfortunately, studies suggest that inadequate support and guidance from senior colleagues exacerbate these challenges (Forbes et al., 2021; Jones et al., 2021; Phan et al., 2022; Stoikov et al., 2020; Te et al., 2022).

Additionally, as NPTs are inexperienced, communicating with patients, their families, and other healthcare professionals present a significant hurdle in clinical decision-making (Atkinson & McElroy, 2016). The pressure to make informed clinical decisions, drawing upon extensive knowledge and experience, contributes to job-related stress and feelings of inadequacy among NPTs (Adam et al., 2013).

Job stress-related symptoms, including exhaustion, self-doubt, and depression, further impact NPTs’ well-being. These symptoms, akin to burnout, result from a mismatch between the worker’s performance and job expectations (Brooke et al., 2020; Pustułka-Piwnik et al., 2014). Studies reveal that burnout affects approximately 65% of physiotherapists in Spain (Carmona-Barrientos et al., 2020). This is a concern as burnout was found to be correlated positively with intentions to leave the profession (Cantu et al., 2022), leading to low morale, and compromised patient service quality (Evans et al., 2022; Lau et al., 2016).

Studies suggest that ill-prepared PTs may feel inadequate and lack confidence in making decisions which can negatively influence their clinical management and support for patients’ needs. For example, PTs who lack the ability to adopt a person focused approach might not be able to manage patients with chronic lower back pain effectively (Gardner et al., 2017). Furthermore, such impacts are subtle, difficult to pinpoint, and can result in poor care quality, low patient satisfaction and staff morale (Gardner et al., 2017; Holopainen et al., 2020; Marks et al., 2017).

In Singapore, the healthcare system is bifurcated into public and private sectors. Public hospitals, which fall under government ownership (Ministry of Health, 2023), are pivotal in delivering healthcare services. These hospitals are organised into three distinct clusters, each serving specific regions within the country. Table 1 for a comprehensive list of public hospitals categorised by their respective clusters.

Submitted: 30 April 2024
Accepted: 25 September 2024
Published online: 1 April, TAPS 2025, 10(2), 82-85
https://doi.org/10.29060/TAPS.2025-10-2/SC3345

Sethapong Lertsakulbunlue & Anupong Kantiwong

Department of Pharmacology, Phramongkutklao College of Medicine, Thailand

Abstract

Introduction: Very Short Answer Questions (VSAQs) minimise cueing and simulate actual clinical practice more accurately than Single Best Answer Questions, as multiple-choice options might not be realistic. Phramongkutklao College of Medicine has developed a Self-Marked VSAQ (SM-VSAQ) for formative assessments. This study determines the validity and reliability of the SM-VSAQs.

Methods: Ninety-four third-year pre-clinical students took two occasions of 10-question SM-VSAQ exams regarding cardiovascular drugs. Each question consisted of two steps: (1) clinical vignettes with questions and (2) expected answers with scores, self-marking, and feedback comprehension. Scores ranged from 0.00 to 1.00 in 0.25 increments, though not every increment was applied to all questions. A distribution of the rating agreement between students’ and teacher’s ratings was presented to determine criterion-related validity and inter-rater reliability.

Results: Criterion-related validity revealed 90.64% and 93.19% of the ratings demonstrated exact agreement between students’ and teachers’ ratings, with an inter-rater reliability of 0.972 and 0.977 for the first and second occasions, respectively (p=0.001). The exact agreement was relatively lower on the first occasion for questions with more diverse expected answers (85.11%, r=0.867, p=0.001) and drugs requiring their specific full names for a perfect mark (74.47%, r=0.849, p=0.001). While questions with specific guides do not require complex answers, they received a higher exact agreement.

Conclusion: The SM-VSAQ format effectively combines guided answers with the VSAQ model. The agreement with teacher-rated is excellent. Marking discrepancies rooted in misconceptions underscores the importance of teacher feedback in improving self-grading in formative assessments. Regular self-assessment practice is recommended to enhance grading accuracy.

Keywords:           Very Short Answer Question, Self-assessment, Medical Education, Undergraduate, Pharmacology

I. INTRODUCTION

Very Short Answer Questions (VSAQs) emerge as a relatively novel assessment format, addressing the constraints of traditional examination methods like Single Best Answer Questions (SBAQs), Constructed Response Questions (CRQs), and Modified Essay Questions (MEQs) (Sam et al., 2018). Although SBAQs are widely adopted in medical education globally, they are prone to cueing effects, leading examinees to depend on contextual clues, promoting a recognition-based learning approach (Sam et al., 2018). Moreover, the absence of multiple-choice options in real-life scenarios diminishes the relevance of SBAQs to medical practice.

Conversely, while CRQs and MEQs better mimic real-life situations, they suffer from rater dependency and significant evaluation time. Whereas VSAQs, free-response questions with 1–5 word answers, lessen rater dependency and evaluation time. Evidence indicates that VSAQs outperform SBAQs in discrimination, validity, and reliability in undergraduate assessments. Their open-ended nature prevents recognition-based learning and cueing. Additionally, VSAQs adeptly pinpoint common errors, often missed by SBAQs, and offer valuable feedback opportunities for educators (van Wijk et al., 2023).

Feedback is crucial for supporting and enhancing learning. Despite its longstanding importance in medical education, effective feedback is frequently deemed insufficient (Kuhlmann Lüdeke & Guillén Olaya, 2020). Self-assessment, enabled by formative exams, allows learners to identify their learning needs (Gedye, 2010). To improve feedback in formative assessments, Phramongkutklao College of Medicine (PCM) developed the Self-marked VSAQ (SM-VSAQ) format, which pairs a VSAQ with possible answers and a marking guide. Students may assess their understanding and pinpoint study areas through SM-VSAQ, enhancing feedback. Although VSAQs offer several benefits, challenges remain in grading the tests, as they may require a longer time. The self-graded format could address this issue in low-stakes examinations. This study assesses whether the SM-VSAQ with partial credit format, utilizing the marking guide, would achieve valid and reliable ratings compared with the teachers.

II. METHODS

Ninety-four third-year pre-clinical students participated in two 10-item SM-VSAQ during a cardiovascular pharmacology course. The exams covered antihypertensive, antiarrhythmic, antianginal, antithrombotic drugs, heart failure drugs, rational drug use, dyslipidaemia treatments, and drugs for atherosclerotic cardiovascular disease (ASCVD). The second SM-VSAQ sessions vary by changing the clinical vignette, the question, or both while maintaining the same underlying blueprint as the first session. Difficulty levels align with the Thai Medical Competency Assessment Criteria. Students had attended lectures on these drug groups before the exams. The VSAQ was content-validated by three professors for relevance, difficulty, feasibility, and simplicity using the Item Objective Congruence method with all over 0.67 of 1.00, indicating acceptable content validity. This approach ensured comparable difficulty.

The formative test was administered through Google Forms under examination conditions within a one-hour timeframe. Ethical approval was obtained from the Institutional Review Board, Royal Thai Army, and the waiver of the requirement for participant consent was deemed unnecessary following national regulations. An information sheet was provided on the first page of the Google Form. This initial test was conducted a day after they completed all lectures. After receiving teacher-led feedback and having time to review, students took a second parallel formative test ten days before the summative exam.

The SM-VSAQs featured four components for each question: clinical vignettes and questions on the first page, answers with scoring guidelines on the next page after they’ve answered, and a self-scoring option with feedback on answer comprehension. Scores ranged from 0.00 to 1.00 in 0.25 increments, though not every increment was applied to all questions. After the students completed the exam, they provided open-ended feedback on the pros and cons of the format. Examples of the format are shown in supplementary figures 1 and 2.

The self-rated, according to the marking guide, were exported into a Microsoft Excel spreadsheet to facilitate teacher ratings of the VSAQ answers. Using the ‘filter’ function in Microsoft Excel, the range of answers for each question was examined, and marks were awarded (Sam et al., 2018). Minor misspellings or alternative correct spellings were considered correct. Three pharmacology professors, who assigned scores, reviewed student answers that fell outside the guide. Consensus-determined scores require agreement from at least two of the three professors.

The data analyses were performed using StataCorp, 2021, Stata Statistical Software: Release 17. College Station, TX: StataCorp LLC. Consistency reliability was analysed using Cronbach’s alpha. Criterion-related validity was demonstrated by the distribution of the rating agreement between student and teacher ratings, presented as frequency and percentages. Inter-rater reliability was calculated using Pearson’s correlation.

III. RESULTS

Cronbach’s alpha for the SM-VSAQ was 0.741 and 0.721 on the first and second occasions, respectively. The teacher-rated alpha was 0.766 initially and 0.735 on the second. Criterion-related validity was assessed through agreement analysis (Supplementary Tables 1 and 2). Table 1 summarises the results of the agreement analysis. 90.6% and 93.19% of the ratings showed exact agreement between the students’ and teachers’ ratings, with an inter-rater reliability of 0.972 and 0.977 for the first and second occasions, respectively. The exact agreement is relatively low on the first occasion of Drugs used in heart failure (85.11%) and Anti-angina drugs (74.47%). Conversely, antithrombotics and drugs used in ASCVD received a high exact agreement of 96.81%. Example of questions with high and low agreement is demonstrated in supplementary figures 1 and 2. Additionally, content analysis of student’s feedback revealed that they perceived that the format helps identify knowledge gaps, encourages review of missed topics, and aids in recognizing their current knowledge level (Supplementary Table 3).