Submitted: 2 May 2025
Accepted: 8 September 2025
Published online: 7 April, TAPS 2026, 11(2), 89-101
https://doi.org/10.29060/TAPS.2025-11-2/OA3735

Ardo Sanjaya^1,2, Ray Sebastian³, Kevin Gunawan³, Christian Edwin⁴, Nathanael Andry Mianto¹ & Cindra Paskaria⁵

¹Department of Anatomy, Faculty of Medicine, Maranatha Christian University, Indonesia; ²Maranatha Biomedical Research Laboratory, Faculty of Medicine, Maranatha Christian University, Indonesia; ³Undergraduate Program in Medicine, Faculty of Medicine, Maranatha Christian University, Indonesia; ⁴Medical Education Unit, Faculty of Medicine, Maranatha Christian University, Indonesia; ⁵Department of Public Health, Faculty of Medicine, Maranatha Christian University, Indonesia

Abstract

Introduction: Medical students often face psychological distress affecting their academic performance and well-being. While coping and resilience may buffer this stress, their roles in academic outcomes across different training stages are poorly understood. This study explored how distress, coping, resilience, and learning perception relate to academic performance across semesters.

Methods: A cross-sectional study of 677 pre-clinical medical students was conducted in 2024 across Semesters 1, 3, 5, and 7. Standardised instruments measured psychological distress, burnout, resilience, coping, and perceptions of the learning environment. Data were analysed using ANCOVA to compare constructs across semesters. Principal Component Analysis (PCA) and Structural Equation Modeling (SEM) assessed the direct and indirect pathways linking distress to Grade Point Average (GPA).

Results: Psychological distress and burnout increased during mid-training while resilience traits such as perseverance and help-seeking consistently decreased. Coping styles remained stable. PCA identified three latent constructs: distress, coping, and resilience. SEM revealed that distress negatively predicted GPA both directly (β = –0.186, p < .001) and indirectly via resilience (β = 0.052, p = .003). Coping was positively associated with resilience (β = 0.412, p < .001), but its effect on GPA was marginal. A multi-group SEM confirmed a consistent relationship across academic semesters.

Conclusion: Although the effects were small, psychological distress significantly influenced academic performance, partially mediated by resilience. While coping remained stable, resilience declined and did not recover, highlighting the need for support. Interventions to enhance coping may bolster resilience and improve academic outcomes.

Keywords:           Medical Students, Resilience, Coping Strategies, Academic Performance, Psychological Distress

Practice Highlights

• Distress and resilience vary by semester, supporting tailored interventions in medical training.
• Psychological factors weakly predict GPA; wellness should target broader student outcomes.
• Adaptive coping links to greater resilience, underscoring its role in early medical training.
• Early-semester students report more distress, marking a window for mental health support.
• Structural modeling reveals psychological pathways for targeted interventions in education.

I. INTRODUCTION

The medical profession demands lifelong learning and commitment to high standards of care, requiring academic proficiency and a strong foundation of psychological well-being, resilience, and work-life balance (Braquehais & Vargas-Cáceres, 2023; Fares et al., 2016). However, increasing pressures within medical education have led to a mismatch between academic and clinical expectations with available personal resources, placing these students at risk for stress and burnout (Shanafelt, 2021; Siddiqui & Malik, 2019). These challenges are compounded by an often competitive and high-pressure environment that lacks adequate support (Almansour et al., 2024; Kassab et al., 2024; Wasson et al., 2016). Research has shown that the early years are often marked by adjustment difficulties, which heighten stress levels. Reports indicate that the prevalence of stress in medical students ranges from 20.9% to 90%, with burnout affecting up to 75% (Fares et al., 2016). Some students cope through constructive mechanisms like time management, help-seeking, and emotional regulation (van der Merwe et al., 2020), while others turn to avoidance, denial, or emotional withdrawal (Neufeld & Malin, 2021).

Stress and burnout are two related constructs that originated from distinct sources. Stress arises from outside demands exceeding personal resources, while burnout is typically defined as a prolonged response to chronic stress, manifesting as emotional exhaustion and depersonalisation (Bayram Deger, 2024; Dyrbye et al., 2008). Both are influenced by external factors such as academic load, social expectations, and institutional support, as well as internal factors like coping styles and resilience (Dyrbye et al., 2009; Findyartini et al., 2021). According to Lazarus and Folkman’s transactional stress model, individuals experience stress when their perceived demands outweigh their coping resources (Ben-Zur, 2019; Folkman, 2013). Coping mechanisms are broadly categorised into problem-focused, emotion-focused, and avoidant coping. Adaptive coping using problem-focused and emotion-focused strategies is associated with better academic and mental health outcomes (O. Ogoma, 2020; Simons et al., 1999), while avoidant or maladaptive forms of emotion-focused coping are linked to increased distress, poorer performance, and higher dropout risk (Abreu Alves et al., 2022; Ding et al., 2021; Holahan et al., 2005). Resilience, the capacity to recover from adversity, is a protective buffer against stress and burnout. It encompasses traits like perseverance, optimism, and help-seeking behavior (Lin et al., 2019). Resilience is dynamic, and changes are made in response to stressors and interventions (Wang et al., 2022). Programmes that incorporate cognitive, behavioral, and mindfulness strategies have demonstrated success in bolstering resilience and adaptive coping in medical students (Liu & Cao, 2022; Nguyen et al., 2023).

Although stress, coping, and resilience have been widely studied among medical students, most research has focused on these constructs independently and within a single academic stage. Few have examined how these psychological factors evolve across different phases of training or how they interact to influence academic performance. To address this gap, the present study compares levels of psychological distress, coping styles, resilience, and learning perceptions across semesters. Additionally, it integrates these constructs into a structural framework to explore their direct and indirect effects on academic performance, aiming to identify periods and mechanisms for intervention.

II. METHODS

This was a cross-sectional, single-center study involving medical students enrolled in four academic semesters (1, 3, 5, and 7), representing the pre-clinical years, conducted in 2024. The target population comprised 1,012 students, all invited to participate in an on-site survey administered via the SurveyMonkey platform using their electronic devices. 862 students responded, yielding an 85.2% response rate, with 726 students completing the survey. Students who had retaken any semesters were excluded from subsequent analyses to minimise potential confounding effects. Following these exclusions, the final sample consisted of 677 participants.

A. Instruments & GPA Calculations

This study initially gathered data using a set of standardised, validated instruments translated into Indonesian. The full details regarding the instruments and GPA calculations can be found in Appendix 1.

B. Demographics

Descriptive statistics were used to summarise the demographic and contextual characteristics of the participants across the four academic levels. Continuous variables were assessed for normality and were described using either means and standard deviations or medians with interquartile ranges. Categorical variables were reported as frequencies and percentages.

C. Analysis of Covariance

A series of ANCOVA models were conducted to examine differences in psychological and academic variables across semesters, using validated instrument scores as dependent variables (Appendix 1). Assumptions were checked prior to analysis. Minor non-normality was accepted, but models with robust standard errors were used when heteroscedasticity was detected.

Bivariate analyses identified significant demographic and lifestyle covariates, which were included in the models. For significant ANCOVA results, pairwise comparisons with Holm’s correction were performed. Analyses and visualisations were conducted in Python (v3.10.15) using seaborn (v0.13.2) and statsmodels (v0.14.4).

D. Structural Equation Modeling Analysis

A two-step approach was used to develop the Structural Equation Model (SEM). First, Principal Component Analysis (PCA) was performed on nine normalised psychological variables to address conceptual overlap and identify latent components. Variables were grouped, and composite scores were calculated by averaging items within each component for use in the SEM as observed variables.

The SEM tested the hypothesised relationships between psychological stress, coping, resilience, and learning environment perception, with GPA as the primary outcome. The model was guided by theories suggesting that stress negatively impacts academic outcomes (Almarzouki, 2024) and that this effect may be buffered through adaptive responses and psychological resources (Masten, 2001). The models were estimated using maximum likelihood (ML) estimation with bootstrapping (1,000 draws) and evaluated using multiple fit indices. A multi-group SEM was also conducted by semester to assess whether these relationships varied across academic stages. Constrained and unconstrained models were compared using a chi-square difference test. Analyses were conducted in R (v4.4.2) using the lavaan package (v0.6-19) for SEM and psych (v2.4.6.26) for PCA.

III. RESULTS

677 medical students were included in the final analysis. The demographic characteristics of the sample are summarised in Table 1. The majority of the participants are females (71.2%), and a considerable proportion (15.95%) reported having received formal mental health diagnoses. Daily routines such as average sleep duration and social media usage remained relatively stable across groups. However, some variability was observed in study-related behaviors. Similarly, involvement in extracurricular activities was more common among students in semesters 3 and 5, with participation rates exceeding 47% and 50%, respectively, reflecting higher engagement. A series of ANCOVAs were conducted to examine the influence of semester progression, and the full results are available on Figshare.

Table 1. Demographic Characteristics of the Research Participants

A. Psychological Distress and Burnout are Affected by Academic Progression

Semester progression had a significant effect on DASS-21 scores (F [3, 663] = 8.35, p < .001, η² = .036). Post-hoc comparisons (Figure 1) revealed that students in Semester 1 reported significantly lower distress compared to those in Semester 3 (adjusted mean difference = –0.27, 95% CI [–0.43, –0.11], p = .006) and Semester 5 ( –0.26, 95% CI [–0.42, –0.09], p = .010), suggesting a rise in psychological burden as students progressed. However, distress levels declined by Semester 7, possibly reflecting increased adaptation and adjustment over time. Mental health diagnosis was an even stronger predictor (p < .001, η² = .057), followed by gender (p < .001, η² = .043) and average sleep and social media time. The full post hoc results are available on Figshare.

Figure 1. Adjusted Mean Scores of Measured Variables Across Academic Semesters

Barplot displays adjusted means from ANCOVA analyses across four academic stages (Semesters 1, 3, 5, and 7) after adjustment for relevant covariates. Variables include psychological distress (DASS-21), school burnout (SBI), educational environment perception (DREEM), resilience traits (ARS-24), and coping strategies (Brief-COPE). Note that students in Semester 1 showed the most favorable characteristics, with lower distress and burnout and higher DREEM and positive resilience traits. In the middle of their training (particularly Semester 3), students were characterised by high distress, burnout, and low positive resilience traits. Error bars denote the 95% confidence intervals.

Student progression also influenced School Burnout Inventory scores (F [3, 663] = 5.33, p = .001, η² = .024). Post-hoc comparisons revealed that Semester 3 students reported the highest levels of burnout, with greater scores than those in Semester 7 (0.60, 95% CI [0.24, 0.96], p = .006) and a marginally significant difference than those in Semester 5 (0.40, 95% CI [0.08, 0.72], p = .075). These findings suggest a pattern of increased stress during the early-to-mid stages of medical training, which appears to taper off in later semesters. Like DASS-21, students with a mental health diagnosis and more time on social media reported higher burnout (p = .009, η² = .010 and p < .001, η² = .024, respectively).
B. Academic Progression and Lifestyle Factors Influenced Students’ Perception of the Learning Environment
DREEM scores differed significantly by semester (F [3, 663] = 14.53, p < .001, η² = .062) and represent one of the strongest effects observed in this study. These suggest that students’ perceptions are influenced by their stage of training. Post-hoc comparisons revealed that students in Semester 1 reported significantly higher DREEM scores compared to those in Semester 3 (0.31, 95% CI [0.20, 0.43]), Semester 5 (0.30, 95% CI [0.18, 0.42]), and Semester 7 (0.38, 95% CI [0.25, 0.51]). All pairwise comparisons were statistically significant at p < .001. These consistent declines in the perceived learning environment across semesters may reflect growing academic pressures and a gradual expectation shift, although we did not explore these potential causes. DREEM scores were also significantly influenced by chronic illness, sleep duration, daily social media use, and time spent studying (p < .05 for all), suggesting that these factors influence students’ perceptions of the learning environment.

C. Resilience Evolves with Academic Progression, while Coping Styles Remain Stable

Perseverance and Adaptive Help-Seeking differed significantly across semesters (F [3, 663] = 6.09, p < .001, η² = .027 and F [3, 663] = 6.92, p < .001, η² = .030, respectively). Post-hoc analysis revealed a consistent decline from Semester 1 compared to Semester 3 (0.20, 95% CI [0.07, 0.33], p = .013), Semester 5 (0.19, 95% CI [0.06, 0.31], p = .013), and Semester 7 (0.30, 95% CI [0.17, 0.44], p < .001). A similar pattern was observed for Adaptive Help-Seeking, with statistically significant declines in Semester 3 (0.27, 95% CI [0.13, 0.41], p = .002) and Semester 7 (0.22, 95% CI [0.07, 0.37], p = .023), and a marginally significant decline in Semester 5 (0.17, 95% CI [0.03, 0.32], p = .069). These findings suggest that these two resilience traits diminish as students progress through medical school, potentially due to academic fatigue or limited support. Both traits were associated with longer average study time (p < .001, η² = .025 and p < .001, η² = .022, respectively), reflecting a bi-directional relationship between them. In contrast, Negative Affect and Emotional Response did not differ significantly by semester (F [3, 663] = 2.21, p = .086, η² = .010). However, it was strongly associated with a history of mental health diagnosis (p < .001) and greater social media use (p < .001, η² = .026). These findings suggest that positive resilience traits like perseverance and help-seeking change dynamically with academic progression and reflect greater study effort. In contrast, negative emotional responses may reflect underlying mental health challenges and lifestyle factors.

Problem-focused, emotion-focused, and avoidant coping demonstrated non-significant effects during the semester. However, avoidant coping was significantly more prevalent among students with a history of mental health diagnosis (p < .001, η² = .038). The influence may be bidirectional as avoidant coping may exacerbate psychological distress, and vice versa. (Holahan et al., 2005) Additional factors such as chronic illness (p = .018), alcohol consumption (p = .004), and gender (p = .001) also showed small but statistically significant associations with avoidant coping. These findings suggest that coping styles are likely shaped more by individual characteristics and previous experiences than by semester progression.

D. Principal Component Analysis (PCA) Identified Distress, Coping, and Resilience as Latent Constructs

A PCA was conducted on the nine standardised variables to address conceptual overlap among psychological variables and improve model stability. Several prerequisites were tested, indicating that the data were suitable for subsequent PCA (Kaiser-Meyer-Olkin test = 0.77; Bartlett’s test of sphericity = p < .001). As shown in Figure 2A, the scree plot supports a three-component solution, which explains approximately 74.3% of the total variance. The component matrix (Figure 2B) showed the pattern of loadings. We interpret component 1 (RC1) as Distress with strong loadings from DASS-21, SBI, avoidant coping, and negative affect. Component 2 (RC2) was interpreted as Coping, haracterized by loadings from problem-focused and emotion-focused coping strategies. Lastly, Component 3 (RC3) was interpreted as Resilience with loadings from perseverance, adaptive help-seeking, and DREEM. Model fit was adequate, with a root mean square residual (RMSR) of 0.065 and an off-diagonal values fit of 0.969.

A. Scree plot showing eigenvalues from principal component analysis across component numbers. Note that the inflection point supports a three-component solution.

B. Heatmap of loadings for the three retained principal components. Component 1 (RC1) has strong loadings from DASS-21, SBI, avoidant coping, and negative affect. Component 2 (RC2) has loadings from emotion- and problem-focused coping. Component 3 (RC3) includes loading from perseverance, adaptive help-seeking resilience traits, and DREEM. Loadings below 0.5 are not shown

Figure 2. Dimensional Reduction Using Principal Component Analysis for the Measured Variables

E. Direct and Indirect Pathways Linked Distress to Academic Performance

A structural equation model (SEM) was tested to examine distress’s direct and indirect effects on GPA, with coping and resilience mediating variables (Table 2). The model was just-identified, and global fit indices indicated perfect fit (CFI = 1.000, TLI = 1.000, RMSEA = 0.000). Our interpretation centers on the theoretical basis and the significance of the individual path estimates. Figure 3 shows that distress significantly negatively affected resilience (β = –0.34, p < .001) and weakly positively affected coping (β = 0.08, p = .045). Coping was positively associated with resilience (β = 0.41, p < .001), suggesting that students using more adaptive coping reported higher resilience. Distress also negatively predicted GPA (β = –0.19, p < .001), while resilience (β = –0.15, p = .002) and coping (β = 0.18, p < .001) were also associated with GPA. Mediation analysis revealed a significant indirect effect of distress on GPA via resilience (β = 0.05, p = .003), while the path through coping was not significant (β = 0.02, p = .069). The total indirect effect was significant (β = 0.06, p < .001), supporting the role of coping and resilience as partial mediators. Note that indirect paths are not shown in Figure 3.

*Ardo Sanjaya
Maranatha Biomedical Research Laboratory,
Faculty of Medicine,
Maranatha Christian University
Jl. Surya Sumantri No. 65
Bandung, Indonesia, 40164
+62 859 1066 09851
ardo.sanjaya@med.maranatha.edu

Submitted: 8 April 2025
Accepted: 27 August 2025
Published online: 7 April, TAPS 2026, 11(2), 81-88
https://doi.org/10.29060/TAPS.2026-11-2/OA3714

Vy Van Thao Ngan Nguyen & Nguyen Bao Phuc Diep

School of Nursing and Medical Technology, The University of Medicine and Pharmacy at Ho Chi Minh City, Vietnam

Abstract

Introduction: Self-efficacy significantly impacts academic performance and clinical competence in healthcare education. Students need to develop confidence and adaptability to handle unpredictable situations in high-pressure fields like anaesthesia nursing. While global studies emphasise self-efficacy’s role in clinical training, research on Vietnamese nursing students is limited. This study aimed to evaluate the clinical self-efficacy beliefs of anaesthesia nursing students to understand their confidence levels and identify factors influencing this.

Methods: A cross-sectional descriptive study was conducted from February to June 2024, with Stratified sampling of 205 third- and fourth-year anaesthesia nursing students at the University of Medicine and Pharmacy in Ho Chi Minh City. The Self-Efficacy in Clinical Performance (SECP) scale was used to evaluate students’ self-efficacy, and the Critical Thinking Disposition Inventory for Medical College Students (CTDI-M) measured critical thinking disposition.

Results: The overall clinical self-efficacy score for students was 105.4±12.87. A statistically significant positive correlation was found between self-efficacy and critical thinking disposition among students (r_s = 0.37, p < 0.001). Furthermore, a significant linear regression analysis indicated that critical thinking disposition (coefficient = 8.6, p < 0.001), attitudes regarding the characteristics of anaesthesia nursing students (coefficient = 0.9, p < 0.001), and academic year (coefficient = 6.1, p < 0.001) are significant predictors of clinical self-efficacy.

Conclusion: Integrating the promotion of critical thinking, addressing specific attitudes, and considering students’ academic progression into clinical training programmes is essential. This has important implications for developing training programmes that enhance essential skills and better prepare students for their professional careers.

Keywords:           Anaesthesia Nursing Students, Clinical Self-Efficacy, Critical Thinking Disposition, Clinical Practice

Practice Highlights

• Anaesthesia nursing students demonstrated a moderate level of self-efficacy in clinical practice, highlighting the need for targeted interventions to enhance their confidence and competency.
• A significant positive correlation was identified between self-efficacy and critical thinking disposition (p = 0.001), suggesting that students with stronger critical thinking skills tend to have higher confidence in clinical settings.
• Strengthening critical thinking skills and positive attitudes concerning professional characteristics may serve as a key strategy to enhance clinical self-efficacy among anaesthesia nursing students, improving their readiness for professional practice.

I. INTRODUCTION

In nursing education, the concepts of self-efficacy and critical thinking are essential for developing competent practitioners who can make sound clinical decisions.

Self-efficacy, as defined by Bandura, refers to an individual’s belief in their ability to perform the behaviours required to achieve specific outcomes (Bandura, 1991). Higher self-efficacy in nursing correlates with improved clinical performance, motivation, job satisfaction, and patient care outcomes (Köseoglu, 2015; Shorey & Lopez, 2021). Nursing students, especially those in the Anaesthesia specialisation, face unique clinical challenges, including high-pressure hospital environments, which necessitate strong self-efficacy to manage professional responsibilities and emergencies (Albooghobeish et al., 2023). Additionally, errors in this field can lead to serious consequences for both patients and practitioners, including legal issues and psychological trauma.

Critical thinking is equally vital, as it involves the objective analysis of information necessary for effective clinical decision-making (Nederland, 2010; Yildirim et al., 2012). This is particularly important for nurse anaesthesia students, who must cultivate strong critical thinking skills to navigate the complexities of anaesthesia care. They need to make quick and accurate decisions in unpredictable situations during operations (Burns et al., 2013; Scott Imus et al., 2017).

Moreover, transitioning from classroom learning to clinical practice presents significant challenges for students. Numerous studies have highlighted the connection between critical thinking skills and confidence in clinical practice. Students who possess strong critical thinking abilities are more likely to demonstrate greater confidence in making clinical decisions and performing nursing tasks (Albooghobeish et al., 2023; Dehghani et al., 2011; İşeri et al., 2023; Sahebi & Barkhordari-Sharifabad, 2023; Salimi et al., 2017). This connection not only enhances students’ clinical experiences but also creates a bridge between theory and practice.

Some Research indicates that educational interventions, such as simulation-based learning and case-based learning platforms, can enhance essential competencies in nursing education, especially having positively impacted nursing students’ self-efficacy and clinical performance (Azizi et al., 2022).

Despite the recognised importance of self-efficacy and critical thinking in nursing education, there is a notable lack of research specifically focused on anaesthesia nursing students, particularly in Vietnam. Understanding the relationship between these constructs is crucial for developing targeted educational strategies that enhance clinical competence. Therefore, the research question focuses on whether there is a relationship between students’ clinical self-efficacy and their critical thinking disposition, as well as the factors that influence this relationship.

The University of Medicine and Pharmacy in Ho Chi Minh City (UMP HCMC) is a leading institution for training anaesthesia nursing professionals in southern Vietnam, emphasising the importance of assessing and enhancing students’ self-efficacy and critical thinking skills.

This study aims to evaluate the levels of self-efficacy and critical thinking disposition among third- and fourth-year anaesthesia nursing students at UMP HCMC. Additionally, it seeks to examine the relationship between these variables and their combined impact on clinical performance. The findings are expected to inform curriculum development and instructional methodologies, ultimately improving the preparedness of anaesthesia nursing students for clinical practice. This, in turn, will contribute to enhancing the quality of training and support the comprehensive development of students, ensuring they meet the demands of the profession in the near future.

II. METHODS

A. Design and Setting

This cross-sectional research employed an exploratory, descriptive, and quantitative study design that utilised a structured questionnaire to gain insights into nursing students’ perspectives. It was conducted at the School of Nursing and Medical Technology at the University of Medicine and Pharmacy in Ho Chi Minh City from February 2024 to June 2024.

B. Sample

This study involved 205 students enrolled in the anaesthesia nursing degree programme at the University of Medicine and Pharmacy in Ho Chi Minh City, Vietnam. The sample size was determined through a two-step process: first, an initial sample size for the mean was calculated, and then Cochran’s formula for finite populations was applied to make the necessary correction. A stratified random sampling method was employed, based on the academic year, to ensure proportional representation. Since the curriculum for this four-year programme requires students to begin clinical practice related to their major in their third year, we stratified the population of eligible students into two groups: third-year students and fourth-year students. Simple random sampling was then applied within each stratum to select participants until the required sample size for that stratum was reached. This process resulted in 53% of the participants (110 students) being in their third year, accurately reflecting their proportion within the total student population. Only students who provided informed consent were included in the study.

C. Instruments

This study evaluated the self-efficacy of nursing students in the clinical practice environment using the Self-Efficacy for Clinical Performance (SECP) scale (Cheraghi et al., 2009). The translation and back-translation technique was used to convert the English version to Vietnamese, and four experts assessed the content validity with a CVI (content validity index) of 1. The SECP scale includes 37 questions divided into four subcategories: Assessment (12 items), Diagnosis and Planning (9 items), Implementation (10 items), and Evaluation (6 items). Each item on the questionnaire is rated on a Likert scale ranging from 1 (not relevant) to 5 (very relevant). The total score is calculated by summing the ratings for all questions, with possible scores ranging from a minimum of 37 to a maximum of 148. A higher score reflects greater self-efficacy. The questionnaire demonstrated a high Cronbach’s alpha coefficient of 0.96 in a pilot test, indicating strong reliability.

This study also utilised the Critical Thinking Disposition Inventory for Medical College Students (CTDI-M) to assess critical thinking skills. Developed by Wang et al. in 2019 (Wang et al., 2019), the inventory consists of 18 items categorised into three factors: open-mindedness, systematic/analytical thinking, and truth-seeking. To adapt the instrument for the Vietnamese context, a translation and back-translation methodology was employed. The content validity of the translated instrument was then independently assessed by four experts, who collectively assigned a Content Validity Index (CVI) of 0.9. Participants respond using a Likert scale that ranges from 1 (strongly disagree) to 5 (strongly agree). The overall score for each factor is calculated by averaging the scores of the relevant questions. The questionnaire achieved a Cronbach’s alpha of 0.85, indicating good reliability.

To evaluate the internal reliability of the questionnaire, a pilot study was conducted with 25 students from the anaesthesia nursing programme at the University of Medicine and Pharmacy in Ho Chi Minh City. We employed a stratified simple random sampling method to select participants, ensuring the sample was representative of the different academic years (third and fourth year) engaged in clinically relevant practice. The study included only students who provided informed consent and did not participate in the main study.

D. Data Analysis

The study data were processed using Stata 15.0, a statistical software. The first step involved analysing background variables through descriptive statistics, which included calculating the mean, standard deviation, percentiles, and ranges for all parameters. To examine the relationship between sociodemographic characteristics and nursing students’ self-efficacy and critical thinking, we used one-way analysis with the Kruskal-Wallis test and the Mann-Whitney U test. Spearman’s correlation was employed to identify the relationship among the main variables. We set the threshold for statistical significance at p < 0.05. Finally, we used multivariate linear regression to predict self-efficacy in clinical practice based on several independent variables.

III. RESULTS

A. Participant Characteristics

In the study, 74.1% of the participants were women. The youngest student was 21 years old, while the oldest was 30, with an average age of 21.69 years (± 1.01 years). The majority of the students (95.1%) identified as belonging to the Kinh ethnic group, which is the predominant ethnic group in Vietnam. Additionally, more than half of the participants (65.9%) did not identify with any specific religious affiliation. Third-year students made up the largest proportion of participants at 53.7%, while fourth-year students accounted for 46.3%. Moreover, the average score of students’ attitudes towards the professional characteristics of anaesthesia nursing students in clinical practice was 27.50 ± 3.80, with a minimum score of 16 and a maximum score of 33.

Table 2. Descriptive Analysis of Critical Thinking Disposition and Self-Efficacy for Clinical Practice of Nursing Students (N = 205)

Regarding critical thinking disposition, the students exhibited relatively strong critical thinking skills, demonstrated by an average score of 3.7 ± 0.47. Among the various categories of critical thinking dispositions, “open-mindedness” received the highest average score of 3.8, with an interquartile range (IQR) of 3.4 to 4.0. In terms of self-efficacy, the total score was 105.4 ± 12.87. The highest score was obtained in the area of “Assessment” (mean = 34.7, IQR = 31-37), while the lowest score was in “Evaluation” (mean = 16.5, IQR = 14-18).

Table 3. The Correlation Between Self-Efficacy for Clinical Practice and Critical Thinking Disposition (N=205)

The results presented in Table 3 show a significant positive correlation between nursing students’ self-efficacy in clinical practice and their disposition toward critical thinking (rs = 0.37, p < 0.0001). There are also notable relationships with factors associated with critical thinking (p < 0.001). The highest score was recorded in the area of “Systematicity” (rs = 0.40, p < 0.001), while the lowest score was noted in “Open-mindedness” (rs = 0.24, p < 0.001). Additionally, the strongest correlation was found between the “Systematicity” aspect of critical thinking disposition and self-efficacy in “Evaluation” (rs = 0.43, p < 0.001). Conversely, the weakest scores were observed for the “Open-mindedness” disposition concerning the “Evaluation” skill (rs = 0.20, p < 0.001), as well as the “Diagnosis and Planning” skill of self-efficacy (rs = 0.20, p < 0.001).

This study employed linear regression analyses to investigate the impact of several factors on students’ self-efficacy in clinical practice. The model satisfied the assumptions of multicollinearity and homoscedasticity, ensuring the reliability of the regression estimates. Table 4 presents the confidence intervals for the predictors of self-efficacy.

Karahan Okuroğlu, G. (2022). Hemşirelik Öğrencilerinin Klinik Performanslarına İlişkin Öz Yeterliklerinin Akademik Öz Yeterlikleri ve Akademik Başarıları ile İlişkisi: Tanımlayıcı Araştırma [The relationship between Nursing students’ self-efficacy regarding clinical performance and their academic self-efficacy and academic success: A descriptive study]. Turkish Clinics Journal of Nursing Sciences / Turkiye Klinikleri Journal of Nursing Sciences, 14(1), 125-31. https://doi.org/10.5336/nurses.2021-83326

Submitted: 26 March 2025
Accepted: 5 November 2025
Published online: 7 April, TAPS 2026, 11(2), 73-80
https://doi.org/10.29060/TAPS.2026-11-2/OA3702

Maheen Zulfiqar, Muhammad Khalil ur Rahman, Behram Khayyam, Naeem Sarwar, Ashbil Malik, Ayesha Mazhar Khan & Hassan Saleem

Department of Surgery, Arif Memorial Teaching Hospital/Rashid Latif Medical College, Lahore, Pakistan

Abstract

Introduction: Absenteeism during clinical rotations among medical students is on the rise, adversely affecting both patient care and the development of essential clinical skills. Factors such as inadequate learning resources, exhaustion, and disengagement contribute to this trend, which must be addressed to safeguard the quality of medical training and future healthcare quality. This study aimed to identify the underlying causes of absenteeism among undergraduate medical students and to propose strategies to improve attendance and learning outcomes.

Methods: A cross-sectional study was conducted on third, fourth, and final-year students of primary medical qualification at Rashid Latif Medical College, Lahore, Punjab, Pakistan, from June 2024 to July 2024. A validated, self-structured questionnaire was distributed during clinical rotations. Data were analysed using SPSS version 25. Frequencies and percentages were calculated to summarise attendance patterns and perceived barriers. Pearson’s correlation was used to examine associations between absenteeism factors—personal health, family obligations, academic workload, perceived relevance of rotations and academic year, with statistical significance set at p ≤ 0.05.

Results: Out of 450 surveys, 270 students responded: 31% third year, 27% fourth year, and 43% final year students. Faculty-related barriers included poor feedback (3.2), ineffective communication (3.2), lack of preparation (3.3), and unprofessional attitude (3.3). Personal obstacles included personal health (3.2), lack of learning resources (3.4), and family obligations (3.3). Additionally, 41% of the students believed that non-exam-specific rotations were irrelevant.

Conclusion: Faculty dissatisfaction, peer pressure and downplaying non-exam specific rotations cause clinical rotation absenteeism. Systemic reforms and enhanced faculty engagement are essential to improve students’ professional development and clinical engagement.

Keywords:           Medical Education, Absenteeism, Faculty, Clinical Rotations

Practice Highlights

• Many students do not find non-exam-specific rotations valuable due to the heavy workload.
• Students often feel demotivated to attend rotations because of uncooperative and unprofessional behaviour from faculty members.
• It is recommended that institutions implement policies to manage student workload, uphold professional conduct, and create a more motivating environment for clinical rotations.

I. INTRODUCTION

Absenteeism refers to the habitual absence from classes/ clinical rotations without a valid or justifiable reason (Qureshi & Ahmad, 2019). Student absenteeism is a common issue observed globally across all academic fields, and medicine is no exception (Gul et al., 2016). However, in the field of medicine, absenteeism has several negative consequences. It impacts students not only academically but also in terms of their professional development (Shenawi et al., 2021). Absenteeism, especially during clinical rotations, hinders both academic learning and patient care as well (Qureshi &
Ahmad, 2019).

Despite strict policies regarding attendance at clinical rotations and lectures, absenteeism remains prevalent among students (Sharmin & Azim, 2017). In Pakistan, there is a growing trend where medical students primarily attend clinical rotations for subjects that carry weight in their current year of study. According to student feedback and informal discussions, many students tend to skip ward rounds, following the example of their seniors, who claim that the material will be thoroughly covered the following year when the subject becomes compulsory. Even those who wish to attend non-compulsory wards often feel pressured by their peers to do otherwise. Additionally, a lack of professionalism among some faculty members and the overall ward environment can diminish students’ morale and motivation (Khan et al., 2019; Mitra et al., 2022).

Despite being a widespread issue, there is no valid justification for the absence of undergraduate medical students from their clinical rotations. To date, no study has been published that thoroughly investigates the key factors contributing to student absenteeism from clinical rotations, particularly at Rashid Latif Medical College and Arif Memorial Teaching Hospital in Lahore. Therefore, this study was undertaken to explore the primary reasons for low attendance among third year, fourth year and final year students of primary medical qualification (PMQ) at Rashid Latif Medical College and to identify initiatives that could improve their participation in clinical rotations.

II. METHODS

This cross-sectional study was conducted from June 2024 to July 2024 on 450 students after taking approval from the Institutional Review Board (RLMC/IRB/2024/153). The aim was to explore the factors influencing attendance in clinical rotations among undergraduate medical students. A self-designed, validated questionnaire was used. The study targeted 3rd, 4th and final year students of primary medical qualification (PMQ) at Rashid Latif Medical College, Lahore, Punjab, Pakistan.

Non-probability purposive sampling was used to recruit students. A total of 450 students were approached during their ward rotations. Out of those, 270 completed the survey, yielding a response rate of 60%. The inclusion criteria were students who were currently enrolled in the clinical years and attending rotations during the study period. Students in pre-clinical years (namely first and second year), those on academic leave or suspension, or those who declined participation were excluded. While purposive sampling allows access to students in relevant clinical settings, it does, however, carry the inherent limitation of selection bias, potentially over-representing students with better attendance or stronger academic engagement.

Data were collected using a self-designed, validated questionnaire. A thorough analysis of the body of research on medical school absenteeism and suggestions from three senior medical education specialists guided the development process. The questionnaire underwent content validation by the expert panel to assess clarity, relevance, and alignment with study objectives. There were both closed-ended and open-ended questions on the finished form.

Closed-ended questions included demographic variables, frequency of clinical attendance, and 5-point Likert scale items evaluating perceived faculty behaviours, personal and academic barriers, and attitudes toward clinical teaching. Preliminary reliability testing using pilot data yielded a Cronbach’s alpha of 0.779, indicating moderate internal consistency. Factor analysis revealed that the questionnaire could be sub-grouped into eight distinct domains, collectively accounting for 97% of the variance in responses.

Participation was entirely voluntary, and informed consent was implied through the completion and return of the questionnaire. Anonymity and confidentiality were ensured to encourage honest and uninfluenced responses. Questionnaires were distributed in printed form during each academic year’s scheduled ward rotations, with responses collected immediately to minimise non-response and preserve the context of clinical learning environments. Data were entered and analysed using IBM SPSS version 25.

Quantitative variables were presented as mean ± standard deviation (SD). For qualitative variables, mean scores were used to assess correlations between causes of absenteeism among third, fourth, and final year MBBS students. Frequencies and percentages were calculated to summarise attendance patterns, causes of absenteeism, and deficiencies in clinical faculty impacting attendance. Pearson’s correlation was employed to assess the relationships between absenteeism factors (such as personal health, family responsibilities, workload, perceived relevance of rotations) and academic year, with significance set at p ≤ 0.05.

III. RESULTS

This study explores the factors influencing attendance in clinical rotations among medical students. The data supporting the finding is available at Figshare (https://doi.org/10.6084/m9.figshare.28602041.v1) (Mazhar Khan, 2025).

Evaluating responses from 450 students we found that 270 students participated in the survey, representing diverse academic years: 31% from the third year, 27%

from the fourth year, and 43% from the fifth year. Notably, gender distribution among respondents included 133 males (49.1%) and 137 females (50.9%).

A. Regularity of Attendance

The attendance at clinical rotations was recorded as follows: 29% of third-year students, 40% of fourth-year students, and 36% of final-year students reported attending all required rotations in their third and fourth academic years (Figure 1).

Figure 1. Regularity of Attendance in Clinical Wards

Among these students, a significant proportion missed their clinical wards sometimes (3–4 times per month; 24%) and often (5–6 times per month; 20%), respectively (Table 1). Further analysis of exam-specific and non-exam-specific rotations showed that only 18.5% of students attended both rotations equally, whereas 40.7% reported attending exam-specific rotations more frequently. The most important reasons for attending exam specific rotation were because it was required for their course completion (63%) and was directly related to their assessments and exam (56%).

Academic Year	All (100%)	Most (75–99%)	Some (50–74%)	Few (25–49%)	None (0–24%)
Third Year	25 (29.4%)	20 (23.5%)	15 (17.6%)	15 (17.6%)	10 (11.8%)
Fourth Year	28 (40.0%)	18 (25.7%)	15 (21.4%)	5 (7.1%)	4 (5.7%)
Final Year	35 (30.4%)	40 (34.8%)	20 (17.4%)	15 (13.0%)	5 (4.3%)
Total	88 (33%)	78 (29%)	50 (19%)	35 (13%)	19 (7%)

Table 1. Regularity of Attendance in Current Clinical Rotations (Third to Final Year)

B. Causes of Absenteeism

Furthermore, students expressed that discouragement from attending clinical rotations stemmed primarily from faculty behaviours. The mean scores for these factors were as follows: unprofessional behaviour (3.3), lack of preparation for teaching sessions (3.2), inadequate feedback on performance (3.2), ineffective communication (3.2), overemphasis on rote learning over critical thinking (3.1), and lack of enthusiasm in teaching (3.1) (Table 2). Specifically, Barriers to attending non-examination-specific rotations were identified, with 41% of students citing a lack of perceived value, 30% referring to heavy workloads as a limiting factor.

Submitted: 10 February 2025
Accepted: 17 October 2025
Published online: 7 April, TAPS 2026, 11(2), 64-72
https://doi.org/10.29060/TAPS.2026-11-2/OA3666

Sameera Anuruddha Gunawardena, Rovindu Sandul Hettige, Yap Hui Nee & Tai Suyee Sophia

School of Medicine, IMU University, Kuala Lumpur, Malaysia

Abstract

Introduction: English is the main medium of medical education in many institutions worldwide. However, several terms in the medical lexicon carry colonial, cultural, or linguistic origins that may be outdated or confusing for students from non-English-speaking backgrounds. This study explores culturally exclusive and outdated metaphorical terms in medicine and debates their continued usage.

Methods: A two-stage protocol was followed. First, textbooks and teaching material from the pre-clinical phase of the medical curriculum at the authors’ institution were screened for metaphorical medical terms with outdated concepts or Anglo-European cultural elements. Next, the definitions and origins of each term were explored using open-source etymological resources and peer-reviewed literature from PubMed and Google Scholar. Terms were then thematically grouped and narratively analysed.

Results: Twenty Anglo-European references were identified and categorised into sub-themes: Western food (e.g., “port-wine stain,” “maple syrup urine disease”), fiction (e.g., “Alice-in-Wonderland syndrome”), religion (e.g., “Hand of Benediction”), and foreign languages (e.g., “café-au-lait spots,” “tache noire”). These may be unrelatable to students from diverse cultural or religious backgrounds. In addition, ten obsolete societal references were noted (e.g., “Washerwoman’s hands,” “rugger jersey spine,” “Indian file pattern”), which are no longer part of common knowledge.

Conclusion: While such terms aided understanding for Anglo-European learners, they may now burden today’s diverse student population. Medical educators should reassess their continued use to ensure clarity and equity in global medical education. This review, based on single institutional findings, provides a foundation for broader, multi-institutional studies to explore the prevalence and impact of these terms across curricula.

Keywords:           Medical Terminology, Equity in Medical Education, Colonialism in Medicine, Obsolete Medical Terms, Global Medical Education

Practice Highlights

• Several medical metaphors are based on culturally exclusive and outdated references.
• Many metaphorical terms require knowledge of Anglo-European history, culture, or religion.
• Some metaphors refer to societal elements or occurrences that are no longer common knowledge.
• Such metaphors would be meaningless to students who do not understand their relevance.
• Learning these outdated terms intended to simplify medicine would now be an additional burden.

I. INTRODUCTION

Medicine is an extremely challenging and complex program of study (Davis & Harden, 2003; Ogden et al, 2023; Woodruff, 2019) and many medical undergraduates face numerous difficulties in mastering the program, especially during the early years of the course (Kirtchuk et al, 2022; Malau-Aduli BS et al, 2020). Amidst the countless hours of study, clinical rotations, and immersive learning experiences, medical students are also expected to acquire a robust vocabulary of medical terms that enables them to comprehend, communicate, and apply complex medical concepts. Language has been identified as one of the main challenges in medical education programs. (Tayem et al, 2020) Since most institutions deliver their medical programs in English, there is a high expectation of English language proficiency among medical entrants (Chan et al, 2022; Hayes & Farnill, 1993; McLean et al, 2013). English has been considered as a barrier for understanding basic medical disciplines among non-native English-speaking students (Bendriss & Bendriss, 2015; Lucas et al., 1997) and interviews with trainers have found that the deficiencies in the figurative and colloquial language affected the performance of international students even at the graduate level (Henderson et al., 2017). Although studies like Jain & Krieger (2010) and Byrne et al. (2019) highlight the linguistic and cultural adaptation struggles among medical students, they do not specifically address the difficulties in comprehending medical language.

Medical lingo is as complex as the science itself and is rife with idiosyncrasies and irregularities that can confound even native English speakers. Modern English has evolved through the influence of Greco-Roman, French, and Germanic languages. (Van der Auwera & Genee, 2002) Many medical terms, therefore, have etymological roots in Latin, Greek or French (Banay, 1948; Faure, 2018). Some terms are often shaped by scientific advancements and technological innovations, and quite a number of them are eponymous references to a person or persons who described a particular phenomenon. (Thomas, 2016; Whitworth, 2007) Similarly, some terms originate from specific cultural and linguistic nuances to English folklore, literature, and society while some others have an archaic origin or are metaphors representing a phenomenon that is non-existent or inapplicable in today’s context. Many clinicians and lecturers continue to use these terms in medical education and in the authors’ experience, students from non-English speaking backgrounds, tend to learn these terms without truly understanding their relevance. Although there have been concerns raised over the authenticity and appropriateness of use of eponyms in medical literature (Strous & Edelman, 2007; Whitworth, 2007; Woywodt & Matteson, 2007), however, there is very little attention given to the propriety of culturally specific and obsolete metaphorical terms in the medical lexicon. This study explores culturally exclusive or outdated metaphorical medical terms and traces their meanings and etymological origins with the aim of stimulating dialogue on whether their continued use in contemporary medical education is justifiable. Except for a few articles (Cohen et al., 2013; Gheewala et al., 2022; Torrey, 2023), no published study has systematically undertaken an exploration of the historical and cultural context of these terms.

II. METHODOLOGY

We followed a two-stage qualitative approach that combined a document analysis with an exploratory targeted search to identify and contextualise terms that were metaphors, figurative labels, or colloquial descriptions of a medical condition. This approach followed previously published strategies for mapping and contextualising terminology from medical documents (Bearman et al., 2021; Bowen, 2009; Dalglish et al., 2020).

A. Stage 1: Document Analysis

During the period from November 2023 to November 2024, all four authors screened the teaching-learning material and textbooks within the pre-clinical medical program at the authors’ university. The pre-clinical curriculum is distributed within 12 modules over four semesters and delivered in the form of synchronous and asynchronous lectures, practical’s, team-based learning, problem-based learning, case-based learning, and self-directed learning. Teaching-learning material for all lessons are uploaded and accessible via the university’s e-learning portal, either in document form, voice-over narrations, microlearning videos, or interactive SCORM packages. We also identified the most frequently borrowed textbook within each of the six main pre-clinical disciplines through the institutional library resource utilisation data. The indices of the textbooks in anatomy (Agur et al., 2019), pathology (Rubin & Reisner, 2019), and pharmacology (Whalen, 2019) were screened by the first and second authors while physiology (Widmaier et al., 2019), biochemistry (Abali et al., 2022), and microbiology (Bauman, 2015) were screened by the other two authors.

The terms were eligible for inclusion if they met at least one of the two following criteria: 1) Anglo-European connotations – terms including Latin and French words and terms requiring knowledge of Western culture, literature or history. 2) Outdated terms – references to phenomena or practices that used to be common knowledge during previous times but are no longer present or rarely encountered in modern-day living. We did not collect data on the frequency of the use of the terms. We also did not screen any formative or summative assessment documents.

B. Stage 2: Contextualisation of Identified Terms

We then conducted an exploratory targeted search of the definitions, etymological origins and medical relevance of each term. We did not intend to conduct an exhaustive review based on any systematic protocol but instead focused on gathering sufficient contextual information using the term itself as a key word, or where necessary, combining them with words such as ‘origin’, ‘history’ or ‘etymology’. Our sources included online open-source etymological databases, such as the online etymology dictionary (https://www.etymonline.com), Oxford reference (https://www.oxfordreference.com), the Oxford concise medical dictionary and peer reviewed publications indexed in PubMed and Google Scholar.

Terms were grouped into subcategories, and each term was then charted according to definition, medical usage, historical or etymological context and justification for inclusion. Any disagreements on the meaning of the terms or the justification for their inclusion in this study were resolved through mutual consensus among the authors.

III. RESULTS AND DISCUSSION

We identified 20 terms as Anglo-European references and 10 terms as obsolete phenomena. A summary of the terms and their medical context is given in Table 1 and is discussed in more detail below.

Submitted: 8 January 2025
Accepted: 25 August 2025
Published online: 7 April, TAPS 2026, 11(2), 54-63
https://doi.org/10.29060/TAPS.20256-11-2/OA3622

Zaw Phyo, Ye Phyo Aung, Tun Tun Naing & Tayzar Hein

Department of Medical Education, Defence Services Medical Academy, Myanmar

Abstract

Introduction: This study evaluates military medicine education at the Defence Services Medical Academy (DSMA) in Myanmar, focusing on curriculum structure, practical training quality, and alignment with evolving military and civilian healthcare needs. Despite a comprehensive approach, identified gaps in practical training (e.g., trauma care, CBRN management) and curriculum continuity hinder student preparedness for modern military medicine.

Methods: This qualitative study used Focused Group Discussions (FGDs) with 24 participants (12 students, 12 faculty) to explore themes like time constraints, practical training, curriculum integration, and modern technology integration. Data were analysed using MAXQDA 24 to identify key themes related to the curriculum’s content and effectiveness.

Results: Findings indicate that while the military medicine module of DSMA covers a broad range of topics, practical training remains inadequate, especially in critical areas such as trauma care, CBRN management, and digital health technologies. Furthermore, curriculum continuity issues, marked by disconnected annual topics, impede clear progression. The study recommends revising the module to include modern warfare medicine, expanding hands-on training, and incorporating mobile learning platforms. It also suggests increasing simulation-based training, restructuring the module to enhance its practical application, and establishing a dedicated military medicine department.

Conclusion: The study identifies critical gaps in DSMA’s curriculum, particularly in practical training (e.g., trauma, CBRN) and coherence. These must be addressed to better prepare students for the challenges of modern military and civilian healthcare. Proposed improvements will ensure DSMA graduates are equipped to handle contemporary healthcare demands, reinforcing the academy’s role as a leader in military medical education.

Keywords:           Military Medicine, Curriculum Development, Practical Training, Outcome-Based Education, Tactical Combat Casualty Care, Qualitative Analysis

Practice Highlights

• Extending the duration of military medicine training will provide more hands-on practice, ensuring students are better equipped to handle high-pressure medical situations.
• Making “THAMAR ZARNI” field exercises mandatory and increasing their frequency will offer students the essential real-world medical experience necessary for operational readiness.
• Updating the curriculum to incorporate modern medical technologies and advanced trauma care will prepare students to effectively address the challenges posed by modern warfare.
• Improving resource allocation, including the integration of mobile learning platforms and high-fidelity simulations, will enhance the overall training experience and increase student engagement.
• Establishing a dedicated military medicine department at DSMA will centralise education, improve curriculum coherence, and provide students with a focused space for more in-depth learning.

I. INTRODUCTION

Military medicine is a vital branch of healthcare that ensures the operational readiness of armed forces personnel in high-stakes environments such as combat zones, disaster areas, and peacekeeping missions (van der Wal et al., 2024). Unlike traditional civilian healthcare, military medicine integrates clinical expertise with operational skills, including trauma care, medical logistics, crisis management, and adaptability under resource-constrained conditions (Woolley et al., 2017). Given the complexity and high-pressure nature of military operations, it is essential that healthcare professionals are trained to handle rapidly evolving situations (McGraw, 2023).

As global security landscapes evolve, with rapid advancements in warfare technologies and the rise of hybrid threats, military medicine has adapted to meet new challenges. Training programs worldwide now integrate contemporary medical practices to address the shifting dynamics of military operations. For example, the Tactical Combat Casualty Care (TCCC) guidelines have significantly reduced battlefield fatalities, demonstrating how modern medical education can improve outcomes (Butler Jr et al., 2007). Additionally, NATO’s initiatives to standardise medical practices across member states have emphasised the importance of interoperability in multinational military operations (Onderková et al., 2024). While studies like Butler Jr et al. (2007) and Kollek et al. (2009) establish best practices in TCCC and CBRN training, few explore their integration into OBE curricula in resource-constrained regions like Southeast Asia, where there are significant gaps in practical training.

Military medicine programs in NATO aligned countries and U.S. based institutions also face similar gaps in training, particularly in areas such as trauma care and the management of chemical, biological, radiological, and nuclear (CBRN) incidents. However, what sets the Defence Services Medical Academy (DSMA) in Myanmar apart is the unique context within Southeast Asia, where resource constraints are more pronounced, necessitating tailored strategies for integrating modern military medical practices. This underscores the challenges DSMA faces compared to other institutions and highlights the need for resource-sensitive solutions in military medical education.

DSMA in Myanmar has played a significant role in shaping military medicine education in Southeast Asia since 1992. The academy’s curriculum combines traditional medical education with specialised military training, equipping graduates with skills in combat casualty care, medical logistics, disease prevention, and trauma management (Naing et al., 2022). Since 2017, DSMA has implemented an Outcome-Based Education (OBE) curriculum, which aligns with global standards set by the World Federation for Medical Education. This approach focuses on measurable outcomes and competency-based learning, marking a shift from traditional teacher-centred methods to student-centred learning. Despite these advances, integrating a comprehensive military medicine module remains a challenge due to the need for specialised skills and faculty development (Garg et al., 2017).

DSMA employs innovative teaching strategies, such as case-based learning (CBL), problem-based learning, and simulation exercises to equip students with high-pressure competencies. However, the academy continues to face significant gaps in practical training, particularly in trauma care, CBRN incident management, and the application of digital health technologies. These gaps indicate a misalignment between the academy’s training programs and the evolving demands of modern military medicine. While CBRN preparedness and digital health solutions are critical for addressing military and civilian crises, these areas remain underdeveloped within military medicine module of DSMA’s curriculum (Kollek et al., 2009).

This study aims to assess how military medicine is integrated into DSMA’s OBE curriculum, focusing on aligning it with essential military medical competencies. By evaluating the effectiveness of current teaching methods and identifying areas for improvement, this research seeks actionable insights to enhance military medicine module of DSMA’s curriculum and offer a model for other countries with similar resource constraints. The ultimate goal is to ensure DSMA graduates are prepared to meet the multifaceted demands of both military and civilian healthcare sectors, particularly in the context of modern warfare and global health challenges. Furthermore, this research will highlight how countries facing resource limitations can adapt military medical education strategies to overcome gaps and improve operational readiness.

II. METHODS

A. Research Design

This study utilised a qualitative research design to examine the military medicine module of DSMA’s curriculum and identify areas for improvement. A qualitative approach was chosen to capture participants’ perspectives, particularly on practical training, integration of modern warfare knowledge, and the curriculum’s effectiveness in preparing students for both military and civilian medical roles. Data were primarily collected through Focused Group Discussions (FGDs) to gain in-depth insights into participants’ experiences and perceptions.

B. Interview Guide Development

The interview guide for military medicine education was developed through a review of literature and consultations with the DSMA curriculum committee. It focused on key aspects such as practical training, curriculum continuity, modern warfare strategies, and simulation effectiveness. The guide began with broad open-ended questions and gradually moved to specific ones. Pilot testing provided feedback that helped refine the guide before the main study.

C. Validity and Reliability

To ensure the validity and reliability of the data collection instruments, the interview guide was reviewed by three expert researchers in the field of military medicine education. These experts provided feedback on the relevance and comprehensiveness of the questions, which enhanced the study’s overall rigor. Additionally, all FGDs and interviews were conducted in a controlled environment to minimise external influences and ensure consistency across data collection sessions.

D. Participant Selection and Data Saturation

Data collection for this study was conducted over a three-month period. A total of 24 participants, comprising 12 students and 12 teachers, were organised into two main groups. These groups were further divided into four FGDs, with six participants in each. Participants were selected using a purposeful sampling method to ensure a representative mix of perspectives from both students and faculty across various academic years.

Each session was led by the principal investigator, who ensured a conducive environment for open dialogue, encouraging active participation and ensuring all voices were heard. Data collection continued until thematic saturation was achieved, meaning no new themes or significant insights emerged from the discussions.

E. Data Analysis

The data were transcribed and analysed using MAXQDA 24. A codebook was created to guide the analysis, and themes were identified both deductively (based on research objectives) and inductively (emerging from the data). To ensure consistency, intercoder agreement was checked by comparing codes with a second researcher. While MAXQDA was used for systematic analysis, manual coding could have been sufficient given the small dataset.

F. Informed Consent

Prior to participation, informed verbal consent was obtained from all respondents, ensuring that they understood their autonomy in deciding whether to participate in the study. Participants were also made aware that they could withdraw from the study at any time without consequence.

G. Ethical Considerations

Ethics approval was obtained from DSMA ethical Committee, and participant confidentiality and anonymity were ensured by assigning unique identifiers and securely storing personal data, accessible only to the research team. The Principal Investigator (PI), a lecturer at the Defence Services Medical Academy, conducted the FGDs. To mitigate the potential power imbalance and encourage open dialogue, several measures were implemented.

Participants were assured of complete anonymity and confidentiality, and informed consent was obtained with the explicit understanding that they could withdraw at any time without consequence. The PI began each session by emphasising that the research’s sole purpose was to improve the curriculum, fostering a non-judgmental environment where all feedback was valued, regardless of its critical nature. These steps were crucial to ensure participants felt safe to speak their minds freely.

III. RESULTS

This qualitative study explores the military medicine module at DSMA, focusing on the perspectives of both students and faculty. By examining their experiences, perceptions, and suggestions, the study identifies critical gaps and areas for improvement in the integration of military and civilian medical education. The findings reveal that the current military medicine module struggles to meet the practical and theoretical needs of students preparing for both military and civilian medical roles.

The results are categorised into two primary areas of focus:

• Table 1: Challenges and Relevance of Military Medicine Education – Summarises concerns regarding insufficient training time, lack of curriculum cohesion, and the relevance of military medicine education.
• Table 2: Curriculum Structure, Practical Training, and Improvement Strategies – Proposes strategies for improving curriculum integration, expanding practical training, and enhancing resource availability.

These findings underscore the urgent need for strategic reforms to improve DSMA’s curriculum, better preparing students for the multifaceted challenges of both military and civilian healthcare.

A. Challenges and Relevance of Military Medicine Education

The following table presents the challenges and relevance of military medicine education, as viewed by both students and teachers. It outlines key concerns regarding time constraints, curriculum integration, and the importance of military medicine across different sectors, particularly in response to real-world scenarios such as national disasters.

	Theme	Sub-Theme	Student Perspectives	Teacher Perspectives
1.	Challenges in Military Medicine	Time Constraints and Practical Exposure	“We only spend one to two weeks per year learning about military medicine, insufficient for crisis management.” (Student 5)   “Field training, like ‘THAMAR ZARNI,’ should be extended to a minimum of two weeks during the internship.” (Student 12)	“The military medicine module lasts around 150 hours from Year 1 to internship, with a need for more time during internships to develop essential skills for future military doctor duties.” (Teacher 10)
		Curriculum Integration	“Annual topics aren’t connected, making it feel like starting from scratch.” (Student 1)	“Curriculum needs real time, relevant topics with more hands-on training.” (Teacher 4)
2.	Relevance of Military Medicine	Importance Across Sectors	“Military medicine is important not just for military doctors, but also for civilian doctors, especially given the current situation in our country, Myanmar.” (Student 3)	“Essential knowledge for all medical students, regardless of future sectors.” (Teacher 3)   “Given the current situation in our country, military medicine is crucial for supporting both military personnel and civilians during times of crisis.” (Teacher 8)
		Real World Application	“Crucial for work in the military and responding to national disasters.” (Student 2)   “Military medicine is essential for both military operations and providing critical healthcare during national disasters, ensuring support for civilians in times of crisis.” (Student 11)	“In recent years, our country has faced numerous crises, including the COVID-19 pandemic, natural disasters, and ongoing conflicts. Military doctors have played a crucial role in responding to these challenges, providing essential healthcare not only to military personnel but also to civilians in need.” (Teacher 9)

Table 1. Challenges and Relevance of Military Medicine Education

The study found that the limited time for military medicine training at DSMA—only two to three weeks each year—impedes students’ crisis management development. The academic year structure, with time allocated to commemoration parade training and national holidays, further reduces training opportunities. The study recommends restructuring the military medicine module of the curriculum to allocate more time for military medicine.

The study also highlighted a need for more practical training. Despite the introduction of OBE, faculty resistance limits its impact. Increasing field exercises and internships, such as “THAMAR ZARNI”, would better prepare students for real-world military medical challenges.

B. Curriculum Structure, Practical Training, and Improvement Strategies

This table highlights student and teacher views on military medicine education, emphasising the need for a more focused curriculum, modern warfare updates, and increased practical training. Both groups called for better resource allocation, use of technology, and consistent assessments, with students suggesting mobile platforms and teachers recommending a dedicated department.

No.	Theme	Sub-Theme	Student Perspectives	Teacher Perspectives
1.	Curriculum Structure and Integration	Overlap and Redundancy	“I suggest reviewing and reorganising these areas to eliminate overlap, making the curriculum more focused and efficient for better learning outcomes” (Student 6)	“Beneficial to remove overlapping topics to focus on practical aspects.” (Teacher 2)
		Modern Warfare Updates	“As a medical student, I suggest incorporating updates on modern warfare into the curriculum, focusing on new medical technologies, advanced trauma care, and the evolving challenges of treating injuries in current conflicts.” (Student 8)	“Need updates to include relevant modern warfare information.” (Teacher 5)   “It is important to update our curriculum to reflect on the current national and global situations.” (Teacher 7)
2.	Practical Training and Hands-On Learning	Increased Field Exercises	“Annual field training like ‘THAMAR ZARNI’ should be mandatory.” (Student 4)	“Strong need for more practical learning opportunities.” (Teacher 6)
		Hands-on Experience during Internship	“Opportunities like ‘THAMAR ZARNI’ are crucial for practicing essential skills.” (Student 2)	“Hands-on experience is vital for building competence for real world situations.” (Teacher 4)
3.	Improvement and Evaluation	Use of Technology in Learning	” If there are no limitations on using mobile devices, we can learn more effectively, not just in military medicine but across all modules” (Student 10)	“While the Learning Management System (LMS) is currently running, it is not fully activated.” (Teacher 6)
		Need for Resources	“There is a significant limitation of resources for military medicine training.” (Student 4)	“Limited resources means students can only see, not use, items like first aid kits and other essential tools during internships.” (Teacher 5)
		Curriculum Assessments	“It’s important to assess these topics across all years, not just in Year 4, to ensure consistent learning and engagement throughout the program.” (Student 5)	“We conduct formative assessments in Years 1, 2, 3, 5, and during internships, with a summative assessment in Year 4.” (Teacher 1)
		Establish a Dedicated Department	“If a military medicine department is established, we would have a dedicated space to learn more and ask questions about any unclear concepts, ensuring a deeper understanding of the field.” (Student 12)	“No dedicated department at our university; coordinators come from other departments specialising in relevant fields.” (Teacher 4) “The plan to establish a military medicine department is still ongoing, but once it’s in place, it will provide students with a dedicated space to deepen their knowledge and address any uncertainties in the field.” (Teacher 8)

Table 2. Curriculum Structure, Practical Training, and Improvement Strategies

This table highlighted key insights from both students and teachers regarding the DSMA military medical curriculum. Both groups agreed on the need to eliminate military medicine module of the DSMA’s curriculum overlap and incorporate updates on modern warfare, such as new medical technologies and advanced trauma care to keep pace with global needs.

Regarding practical training, both students and teachers emphasised the importance of increasing field exercises, particularly “THAMAR ZARNI”, and providing more hands-on experience during internships to improve real-world competence. Both groups also noted resource limitations, including a lack of access to essential tools like first aid kits. Lastly, the creation of a dedicated military medicine department was supported to facilitate deeper learning and address any gaps in knowledge.

IV. DISCUSSION

The research analyses DSMA’s military medical curriculum, focusing on its strengths and areas for improvement. This study emphasises the importance of specialised training, the quality of practical training, curriculum continuity, the relevance of military medical education to civilian healthcare, and the need for updates reflecting modern technologies. The study concludes with evidence-based recommendations to improve DSMA’s military medical education and better prepare students for real-world healthcare challenges.

A. Time Constraints in Military Medicine Education

A significant limitation identified in the study is the insufficient time allocated to military medicine within the DSMA curriculum. The time spent on military medicine—no more than two or three weeks per academic year—is inadequate for developing the necessary skills for effective crisis management. Furthermore, the academic structure of DSMA consists of a ten-month academic year, in addition to approximately 30 national holidays within that year. Each year, students undergo one month of commemoration parade training, followed by an additional month off. This schedule is consistently followed each calendar year as part of the academic calendar. These time constraints exacerbate the gap in students’ preparedness for real-world military medical challenges. This aligns with findings from Ellington and Farrukh (2020), who argue that time constraints are a major obstacle in military medicine education. To address this, this study suggests a restructuring of the curriculum to emphasise military medicine. Extending the duration of military medicine training would provide students with the necessary time to gain hands-on experience and develop critical competencies for high-pressure situations, ultimately enhancing their operational readiness and ability to respond effectively to emergencies (Watson et al., 2025).

B. Enhancement of Practical Training

The study finds consensus among both students and faculty on the need to enhance the practical training components of the DSMA curriculum. While the OBE curriculum introduced in 2017 aims to foster better learning outcomes, faculty resistance remains due to their familiarity with previous teaching methods. Increasing hands-on experiences, such as field exercises and internships, is crucial for developing the competencies required for real-world medical challenges. This finding is consistent with Vogel and Harendza (2016), who emphasise that practical training directly impacts clinical competence, especially in military environments.

The study also highlights the importance of mandatory field exercises like “THAMAR ZARNI”, which are essential for preparing students for emergency situations. Increasing the frequency and intensity of such training will significantly enhance the competence and confidence of DSMA graduates, aligning with Dieck-Assad et al. (2021)’s recommendation for more frequent high-stakes training to improve real-world emergency response skills.

C. Curriculum Disjointedness and Continuity

The study reveals a critical issue in the lack of continuity and integration within the military medicine of DSMA’s curriculum. The curriculum does not progressively build upon itself from year to year, leading to fragmentation in the educational experience. This finding mirrors the research by Brauer and Ferguson (2015), who argue that fragmented curricula hinder the development of cohesive medical knowledge.

The study contributes to the growing body of literature by identifying this issue as not unique to DSMA but prevalent in military medical education programs worldwide. Vertical integration of the curriculum is proposed as a solution to this problem. By ensuring that content from earlier years builds upon that of subsequent years, students will be able to better understand military medicine as a cohesive discipline and apply their theoretical knowledge in practice. A unified curriculum will improve both learning outcomes and operational readiness, enabling students to apply what they have learned in real-world scenarios (O’Connell et al., 2021).

While both students and faculty acknowledged the disjointedness, their perspectives on its impact differed. Students, such as Student 1, described it as “starting from scratch” annually, highlighting the learning burden and lack of a foundational understanding. In contrast, faculty members, like Teacher 4, focused more on the need for “real-time, relevant topics,” which suggests a priority on content relevance over the structural flow of the curriculum. This nuanced finding is a significant contribution to the literature, showing that even with a shared concern, the specific priorities of stakeholders can vary significantly. This requires a dual approach that not only updates the content but also ensures its logical progression throughout the academic years. The current structure, which dedicates a few weeks each year to isolated topics, prevents students from developing a deep and cumulative understanding of military medicine as a cohesive discipline.

Vertical integration of the curriculum is proposed as a solution to this problem. By ensuring that content from earlier years builds upon that of subsequent years, students will be able to better understand military medicine as a cohesive discipline and apply their theoretical knowledge in practice.

A unified curriculum will improve both learning outcomes and operational readiness, enabling students to apply what they have learned in real-world scenarios (O’Connell et al., 2021).

Furthermore, the study highlighted a subtle but important divergence in views on resource limitations. Both groups agreed on the lack of resources, but their specific concerns differed. Students focused on the lack of hands-on access to essential tools like first aid kits, which directly impacts their ability to practice skills. In contrast, teachers’ concerns centred more on the overall resource allocation, including the need for a dedicated department and functional digital platforms, which they see as necessary for institutional-level improvement. This highlights the need for a two-pronged strategy: addressing the immediate, practical needs of students while simultaneously working towards the long-term, structural improvements advocated by the faculty.

D. Relevance to Civilian Roles

Another key finding of the study is the relevance of military medicine training to civilian healthcare. Both students and faculty agree that skills acquired in military medicine, such as triage, emergency response, and disaster management, are increasingly relevant in civilian healthcare systems. The integration of military medical knowledge into civilian contexts is beneficial not only for DSMA graduates but also as a model for global healthcare systems, where military and civilian medical teams often collaborate during disasters and public health crises.

The study suggests that DSMA should incorporate more dual-use military medical knowledge, such as trauma treatment and public health strategies, into its curriculum. These additions would better prepare students for both military and civilian healthcare roles, improving the overall military medicine module of DSMA’s curriculum and ensuring that DSMA graduates can transition seamlessly between the two sectors (Cole et al., 2024; Michaud et al., 2019).

E. Curricular Updates for Modern Warfare

The study also identifies the need for curricular updates to include modern military and medical technologies. DSMA’s current module of the curriculum fails to adequately cover emerging topics such as drones, cyber warfare, and modern medical technologies used in combat situations. As Lewis et al. (2024) note, outdated curricula do not prepare students for the evolving complexities of modern medical practice in conflict zones.

To address this, the study recommends that DSMA regularly update its curriculum to include the latest advancements in battlefield medicine. For example, training on medical drone operations could enhance the ability of military medical teams to deliver supplies to remote areas under combat conditions. Furthermore, training in cyber warfare would ensure that students understand how to protect military medical infrastructure from digital threats. Incorporating such cutting-edge technologies would ensure that DSMA graduates are prepared to handle the future challenges of military medicine (Fuentes, 2021).

F. Practical Training and Hands-On Learning

As noted earlier, field exercises and internships are essential for bridging the gap between theoretical knowledge and real-world application. However, the limited frequency and scope of these opportunities hinder effective training. While the “THAMAR ZARNI” exercise is a valuable learning tool, its infrequency limits students’ exposure to real-world complexities (McGraw, 2023).

To improve this, the study suggests expanding opportunities for hands-on learning through more frequent and diverse field exercises. Kolb’s Experiential Learning Theory suggests that learners best acquire skills through reflection on experience. The lack of hands-on training at DSMA limits opportunities for reflective learning, which may hinder students’ development in real-world medical scenarios (Kolb et al., 2014). Additionally, the integration of virtual simulations and augmented reality (AR) platforms could create simulated combat medical environments, allowing students to practice trauma care and disaster response in a controlled, virtual setting, thus overcoming logistical constraints of traditional field exercises.

G. Improvement and Evaluation

The study highlights the underuse of the Learning Management System (LMS) at DSMA, which remains a missed opportunity for self-directed learning. Mobile platforms and real-time feedback through LMS could significantly enhance the training experience, creating a more dynamic and responsive learning environment. This challenge is mirrored in other military medical institutions worldwide, where underutilisation of technology limits students’ ability to engage with learning materials outside of the classroom.

The study also suggests that increasing the frequency of formative assessments could help reinforce key concepts and improve knowledge retention over time. By providing more consistent feedback, DSMA could better prepare students for military medical practice. Furthermore, the lack of a dedicated department for military medicine education results in a fragmented approach to military medicine module delivery. A specialised department would ensure better curriculum coherence and oversight, ultimately improving the quality of military medical education.

V. CONCLUSION

This research identifies key areas for improvement in the DSMA military medical curriculum, focusing on time management, practical training, curriculum integration, and content modernisation. Findings show that limited training time, insufficient practical opportunities, and a lack of curriculum continuity hinder students’ preparedness for real-world military medical challenges. Recommendations include extending training durations, increasing hands-on experiences like field exercises, and reorganising the military medicine module for better integration.

The study also stresses the need for military medicine module updates to include emerging medical technologies and dual-use knowledge relevant to both military and civilian healthcare. Enhancing technology use and improving assessment structures are also proposed to create a more dynamic learning environment. Implementing these changes will better prepare students to meet the evolving demands of military and civilian healthcare.

These recommendations have global relevance, offering valuable insights for institutions in resource-constrained regions to bridge the gap between military medicine and civilian healthcare. By adopting new technologies and integrating dual-use knowledge, military medical education can better equip students for modern warfare and global health challenges.

A clear action plan for restructuring the module of the DSMA’s curriculum includes extending practical training time, integrating simulation-based learning, and establishing a dedicated military medicine department. However, barriers such as budget constraints and faculty resistance to new teaching methods must be addressed for successful implementation.

To address the identified gaps, a phased implementation strategy is recommended, acknowledging the budget constraints and potential faculty resistance.

Phase 1 (Immediate & Low-Cost): Focus on quick, resource-efficient changes. This includes making “THAMAR ZARNI” field exercises mandatory and increasing their frequency to provide more hands-on practice, as noted by both students and teachers. Additionally, the underutilised Learning Management System (LMS) can be fully activated to support mobile learning and self-directed study, a cost-effective solution to improve access to materials. These measures can be implemented quickly with minimal budget impact and will show immediate benefits.
Phase 2 (Mid-Term & Moderate-Cost): This phase involves curriculum restructuring and targeted faculty development. The curriculum should be reorganised to eliminate overlapping topics and vertically integrate content from year to year, a key recommendation from both students and faculty to improve learning continuity. Investment in faculty training is also crucial to ensure they adopt the Outcome-Based Education (OBE) model effectively and embrace modern teaching methods like simulation. This phase requires a moderate investment but will build the necessary institutional capacity for long-term change.

Phase 3 (Long-Term & High-Cost): The final and most impactful change is the establishment of a dedicated military medicine department at DSMA. While this requires significant budget allocation, it is essential for centralising education, ensuring curriculum coherence, and providing a focused space for in-depth learning and expertise development. This step should be pursued after the foundational improvements from the first two phases are successfully implemented, demonstrating the academy’s commitment to prioritising military medical education and justifying the necessary financial investment.

By adopting this strategic, phased approach, DSMA can systematically address its curriculum’s shortcomings while managing resource constraints and garnering buy-in from all stakeholders. This plan offers a clear path forward, ensuring that DSMA graduates are not only prepared for the challenges of modern warfare but also equipped to serve as leaders in both military and civilian healthcare contexts.

Notes on Contributors

Dr Zaw Phyo is the Principal Investigator. As a lecturer at Myanmar’s Defence Services Medical Academy, he played a significant role in the development of the manuscript. His contributions included a thorough review of the existing literature, identification of research gaps, and clarification of the study’s objectives and questions. Additionally, he was involved in drafting and revising the manuscript, ensuring that the content was both relevant and of significant value to the field of medical education.

Dr Ye Phyo Aung, serving as a mentor, played a crucial role during the methodology phase of the study. He endorsed the chosen research design, sampling strategies, and data collection techniques, providing valuable insights that greatly enhanced the research execution.

Dr Tayzar Hein contributed by assisting in the meticulous proofreading of the article, ensuring that it met clarity, coherence, and strict academic standards.

Dr Tun Tun Naing was instrumental in analysing the collected data. He applied statistical techniques to ensure the research findings were robust and reliable, further enriching the manuscript’s quality and academic integrity.

Ethical Approval

The Ethical Review Committee of the Defence Services Medical Academy, Yangon, Myanmar, granted ethical approval (2/Ethics/2024).

Data Availability

The data that support the findings of this study are openly available in Figshare repository, https://doi.org/10.6084/m9.figshare.28245230.v1.

Acknowledgement

The author would like to thank his supervisor, the head of the medical education department (DSMA), and his colleagues. Without their help, the author would not have been able to conduct the research. The author is grateful to all the curriculum committee members and students from DSMA, Myanmar, who helped to complete the survey and provide valuable opinions and experiences.

Funding

No financing is associated with this publication; it is produced for personal and professional advancement.

Declaration of Interest

There is no conflict of interest in the current research.

References

Brauer, D. G., & Ferguson, K. J. (2015). The integrated curriculum in medical education: AMEE Guide No. 96. Medical Teacher, 37(4), 312-322. https://doi.org/10.3109/0142159X.2014.970998

Butler Jr., F. K., Holcomb, J. B., Giebner, S. D., McSwain, N. E., & Bagian, J. (2007). Tactical combat casualty care 2007: Evolving concepts and battlefield experience. Military Medicine, 172(suppl_1), 1-19. https://doi.org/10.7205/MILMED.172.Supplement_1.1

Cole, R., Durning, S. J., Shen, C., Reamy, B. V., & Rudinsky, S. L. (2024). Civilian and military medical school graduates’ readiness for deployment: Areas of strength and opportunities for growth. Military Medicine, 189(9), e2220-e2228. https://doi.org/10.1093/milmed/usae167

Dieck-Assad, G., González Peña, O. I., & Rodríguez-Delgado, J. M. (2021). Evaluation of emergency first response’s competency in undergraduate college students: Enhancing sustainable medical education in the community for work occupational safety. International Journal of Environmental Research Public Health, 18(15), 7814. https://doi.org/10.3390/ijerph18157814 

Ellington, M., & Farrukh, S. (2020). Are battlefield and prehospital trauma scenarios an effective educational tool to teach leadership and crisis resource management skills to undergraduate medical students? BMJ Military Health, 166, e34-e37. https://doi.org/10.1136/jramc-2018-001146

Fuentes, M. R. W. C. (2021). Operational curriculum and research initiatives: Shaping the future of military medicine. Federal Practitioner, 38(10), 474. https://doi.org/10.12788/fp.0192

Garg, M., Peck, G. L., Arquilla, B., Miller, A. C., Soghoian, S. E., Anderson, H. L., Bloem, C., Firstenberg, M. S., Galwankar, S. C., Guo, W. A., Izurieta, R., Krebs, E., Hansoti, B., Nanda, S., Nwachuku, C. O., Nwomeh, B., Paladino, L., Papadimos, T. J., Sharpe, R. P., . . . Stawicki, S. P. (2017). A comprehensive framework for international medical programs: A 2017 consensus statement from the American College of Academic International Medicine. International Journal of Critical Illness, 7(4), 188-200. https://doi.org/10.4103/IJCIIS.IJCIIS_65_17

Kolb, D. A., Boyatzis, R. E., & Mainemelis, C. (2014). Experiential learning theory: Previous research and new directions. In Perspectives on thinking, learning, and cognitive styles (pp. 227-247). Routledge.

Kollek, D., Welsford, M., & Wanger, K. (2009). Chemical, biological, radiological and nuclear preparedness training for emergency medical services providers. Canadian Journal of Emergency Medicine, 11(4), 337-342. https://doi.org/10.1017/S1481803500011386

Lewis, K. O., Popov, V., & Fatima, S. S. (2024). From static web to metaverse: Reinventing medical education in the postpandemic era. Annals of Medicine, 56(1), 2305694. https://doi.org/10.1080/07853890.2024.2305694

McGraw, A. P. (2023). “Train like you fight”: A literature review of best practices for training marines to perform in stressful combat situations. North Carolina State University.

Michaud, J., Moss, K., Licina, D., Waldman, R., Kamradt-Scott, A., Bartee, M., Lim, M., Williamson, J., Burkle, F., Polyak, C. S., Thomson, N., Heymann, D. L., & Lillywhite, L. (2019). Militaries and global health: Peace, conflict, and disaster response. The Lancet, 393(10168), 276-286. https://doi.org/10.1016/s0140-6736(18)32838-1

Naing, T. T., Minamoto, Y., Aung, Y. P., & Than, M. (2022). Faculty development of medical educators: Training evaluation and key challenges. The Asia Pacific Scholar, 7(3), 23-32. https://doi.org/10.29060/TAPS.2022-7-3/OA2742  

O’Connell, K., Hoke, K., Berkowitz, A., Branchaw, J., & Storksdieck, M. (2021). Undergraduate learning in the field: Designing experiences, assessing outcomes, and exploring future opportunities. Journal of Geoscience Education, 69(4), 387-400. https://doi.org/10.1080/10899995.2020.1779567

Onderková, A., Quinn, J., Meoli, M., Taylor, D., Nesterenko, S., Schramm, J. M., Gimpelson, A. J., O’Kelly, A., Parks, S., Rizek, J., Davis, T., Surkov, D., Cherniawski, B., & Fernando, R. (2024). Enhancing prehospital care during the conflict in Ukraine: NATO’s role in global health engagement. Military Medicine, 190(3), 86-94. https://doi.org/10.1093/milmed/usae380

van der Wal, H., Duijnkerke, D., Engel, M. F., Hoencamp, R., & Hazelzet, J. A. (2024). Value-based healthcare from a military health system perspective: A systematic review. BMJ Open, 14(11), e085880. https://doi.org/10.1136/bmjopen-2024-085880

Vogel, D., & Harendza, S. (2016). Basic practical skills teaching and learning in undergraduate medical education – A review on methodological evidence. GMS Journal for Medical Education, 33(4). https://doi.org/10.3205/zma001063

Watson, A. L., Anderson, M., Drake, J., Heaston, S., Schmutz, P., Rasmussen, R., & Reed, C. (2025). Nursing and emergency medical technician students’ perspectives on mass casualty simulation training: A phenomenological study. Nursing and Health Sciences, 27(2), e70104. https://doi.org/10.1111/nhs.70104

Woolley, T., Round, J., & Ingram, M. (2017). Global lessons: Developing military trauma care and lessons for civilian practice. BJA: British Journal of Anaesthesia, 119(suppl_1), I135-I142. https://doi.org/10.1093/bja/aex382

*Dr Zaw Phyo
Department of Medical Education,
Defence Services Medical Academy (DSMA),
Yangon, Myanmar
No. 94, Pyay Road, Mingaladon Township,
Yangon, Myanmar Postal code – 1102
+95 92032754
Email: dr.zawphyoo@gmail.com

Submitted: 16 March 2025
Accepted: 11 September 2025
Published online: 7 April, TAPS 2026, 11(2), 49-53
https://doi.org/10.29060/TAPS.2026-11-2/OA3593

Clarisse Chu¹, Rehena Sultana², Neville Wei Yang Teo¹ & Abhilash Balakrishnan¹

¹Department of Otorhinolaryngology – Head and Neck Surgery, Singapore General Hospital, Singapore; ²Centre for Quantitative Medicine, Duke-NUS Medical School, Singapore

Abstract

Introduction: The ACGME-I Singapore Otorhinolaryngology residency programme started in 2011. Our first Exit MCQ Examinations were held at the start of the fifth year of residency, in 2015. Its questions are developed by the American Boards and modified by Singapore’s regulatory bodies to ensure relevance to local clinical practice. In contrast, Otorhinolaryngology residents in both Singapore and the USA take the same Otorhinolaryngology Training Examination (OTE) annually. Otorhinolaryngology residents in Singapore sit for the OTE in their first to fourth years of the five-year residency programme.

Multiple specialities have described a positive association between in-training examination and final board MCQ examination pass rates. Our study aims to demonstrate that that OTE scores may serve as predictors of performance in our local Exit MCQ Examination.

Methods: A retrospective review was performed of all 24 Otorhinolaryngology residents who entered and took the Exit MCQ Examination at a single institution’s residency programme between 2016 to 2023.

Results: 75% (18/24) passed the Exit MCQ Examination in their first sitting. Univariate logistic regression analyses showed lower OTE stanines in the fourth year of residency was significantly associated with failing the Exit MCQ Examination. Youden’s index showed attaining an OTE stanine <4 in the fourth year of residency training was most associated with failing the Exit MCQ Examination.

Conclusion: OTE scores may be a better predictor of Exit MCQ performance in the fourth year of residency. Optimal OTE score targets for each year of residency were established.

Keywords:           Health Profession Education, Board Examinations, Assessments, Otorhinolaryngology, Residency, ACGME

Practice Highlights

• The OTE serves as an important goalpost for resident learning as they work towards specialist accreditation.
• Our findings will facilitate the identification of residents at risk of performing poorly in the final Exit MCQ Examination, such that remediation measures can be instituted early.

I. INTRODUCTION

Medical education is important for doctors in training throughout their years in residency and beyond. A key tenet of medical education is the use of regular examinations and assessments. They serve multiple functions such as evaluating the retention of medical knowledge, the clinical competencies, and tracking of residents’ progress. Multiple specialities such as Anaesthesia, General Surgery, and Internal Medicine have established a positive correlation between in-training examination performance and pass rates amongst their residents in the final board examinations (McDonald et al., 2020; Patzkowski et al., 2023; Stain et al., 2021).

The Accreditation Council for Graduate Medical Education – International (ACGME-I) Singapore Otorhinolaryngology residency programme was started in 2011 to provide a comprehensive and holistic training programme for prospective Otorhinolaryngologists in Singapore. Our first Exit Multiple-Choice-Question (MCQ) examinations were held at the start of the fifth year of residency, in 2015 (Ministry of Health Singapore, 2023).

There are two summative assessments in Singapore’s five-year Otorhinolaryngology residency programme, namely the Master of Medicine (Otorhinolaryngology) (MMed(ORL)) Examination and the Exit Examinations (Figure 1). Residents usually take the MMed(ORL) Examination in their second year. This is set by the Division of Graduate Medical Studies (DGMS), part of the National University of Singapore. It currently comprises an Objective Structured Clinical Examination (OSCE) and Oral Examination (Division of Graduate Medical Studies, Yong Loo Lin School of Medicine, 2024). Residents have to pass the MMed(ORL) Examination by the fourth year of residency in order to sit for the Exit Examinations.

Figure 1. Background of Assessments in Singapore’s Otorhinolaryngology Residency Programme (ABOHNS: American Board of Otorhinolaryngology – Head and Neck Surgery; ACGME: Accreditation Council for Graduate Medical Education; DGMS: Division of Graduate Medical Studies; NUS: National University of Singapore; ABMS: American Board of Medical Specialities; MOH: Ministry of Health)

The Exit MCQ Examination is the first of the two-part Exit Examination comprising both the MCQ and Oral Examinations. Residents take the Exit MCQ Examination at the start of the fifth year of residency. Candidates are required to pass the MCQ in order to be eligible for the Oral Examination at the end of the same year of residency. It is colloquially known as the Exit Examination because it is a regulatory requirement before a resident can complete (and therefore “exit”) specialist training and subsequently obtain specialist accreditation in Singapore. The Exit MCQ Examination is developed by the American Board of Otorhinolaryngology – Head and Neck Surgery (ABOHNS), ACGME-I and Ministry of Health (MOH) Singapore. Its questions are based on the established blueprint used by the three regulatory bodies, and modified to ensure relevance to local clinical practice (ACGME International, 2024).

On the other hand, Otorhinolaryngology residents in the United States of America (USA) take the Board Examinations developed by ABOHNS following completion of specialty training in an ACGME accredited residency programme (Cantrell & Goldstein, 1999; Miller, 2007).

The Otorhinolaryngology Training Examination (OTE) is an MCQ assessment developed by the ABOHNS. It is a formative assessment, and is conducted on an annual basis, to assess Otorhinolaryngology residents’ clinical knowledge. Unlike the Exit MCQ Examination, residents in both Singapore and the USA take the same OTE with the same set of questions. Otorhinolaryngology residents in Singapore sit for the OTE in their first to fourth years, while those in the USA sit for the OTE in their second to fifth years of the five-year residency programme (Puscas, 2019).

Our study aims to demonstrate a similar relationship amongst Otorhinolaryngology residents in Singapore’s largest healthcare cluster, that OTE scores can be used to predict performance in our local Exit MCQ Examination. This enables medical educators to identify residents who are at risk of failing the Exit MCQ Examination and institute remediation programmes early.

II. METHODS

A retrospective review was performed of the examination results of all 24 Otorhinolaryngology residents from our healthcare cluster who entered and took the Exit MCQ Examination between 2016 and 2023. Approval from the SingHealth Institutional Review Board (IRB) was obtained for a waiver of informed consent (IRB reference number 2024-3953). All data was de-identified to ensure anonymity.

Each individual resident’s performance in the OTEs from year one to four of residency and the subsequent Exit MCQ Examination was included in the analysis. The profile and educational background of the individual residents were also obtained. These include their age, gender, primary medical education and the numbers of years spent as a practising medical doctor.

The OTE performance across the first to fourth years of residency is reported in terms of stanines, where raw test scores are converted to a 9-point standard scale across a bell curved distribution of all residents across the same residency training year. An OTE stanine of 9 is the highest, while a stanine of 1 was the lowest – i.e., best and poorest performance respectively. The results of the Exit MCQ Examination are binary, either pass or fail.

Frequencies (proportions) were used to summarise variables. The effects of various factors on Exit MCQ Examination performance was evaluated using logistic regression analyses and association from logistic regression analyses were expressed as odds ratio with 95% confidence interval (CI). Receiver operating characteristic (ROC) curves were also calculated to predict the OTE stanines most associated with a pass result in the Exit MCQ Examination. SPSS for Windows version 25 was used in the analyses.

III. RESULTS

Between 2016 to 2023, 24 Otorhinolaryngology residents in our healthcare cluster entered and took the Exit MCQ Examination. 45.8% (11/24) were male and 54.2% (13/24) were female. 95.8% (23/24) underwent their undergraduate medical training in Singapore, while 4.2% (1/24) studied overseas. The mean post-graduate year at exits was 8.7 ± 2.3 years. 75% (18/24) passed the Exit MCQ Examination in their first sitting (Table 1).

*A/Prof Abhilash Balakrishnan
31 Third Hospital Ave
Singapore General Hospital
Singapore 168753
Email: balakrishnan@singhealth.com.sg

Submitted: 16 July 2024
Accepted: 27 August 2025
Published online: 7 April, TAPS 2026, 11(2), 40-48
https://doi.org/10.29060/TAPS.2026-11-2/OA3458

Siti Suhailah Zahari¹, Roshan Peiris^1,3,4, Ruhaya Hasan², Nik Aloesnisa Nik Mohd Alwi¹ & Nurhafizah Ghani¹

¹Medical & Basic Dental Sciences Unit, School of Dental Sciences, Universiti Sains Malaysia, Malaysia; ²Dental Public Health Unit, School of Dental Sciences, Universiti Sains Malaysia, Malaysia; ³Department of Basic Sciences, Faculty of Dental Sciences, University of Peradeniya, Sri Lanka; ⁴College of Health Sciences, VinUniversity, Vietnam

Abstract

Introduction: The growing use of social media among students offers educators in dental education enhanced opportunities for student-teacher interaction and improved access to learning materials. This study aims to examine the patterns of social media usage for learning purposes among undergraduate dental students at Universiti Sains Malaysia.

Methods: A cross-sectional questionnaire-based study was conducted involving 222 undergraduate dental students from all academic years, excluding those without social media accounts or who declined participation. A validated questionnaire was distributed online via Google Forms and WhatsApp, collecting data on socio-demographics, smartphone ownership and internet access, preferred social media platforms, and the use of social media for academic purposes.

Results: All 222 respondents completed the survey. The majority (65.8%) were iPhone users, and 95.0% reported access to internet data via Wi-Fi or 4G networks. Almost all participants used social media to connect with friends (99.1%), while 10.4% used it for business. Instagram (99.1%), WhatsApp (97.7%), and YouTube (91.9%) were the most commonly used platforms, with WhatsApp being the most frequently used (86.0%). Gender showed a significant association with academic use, particularly for inquiries and consultations, with female students engaging more than males. No significant differences were found across academic years. Google (91.0%) and YouTube (84.2%) were the preferred platforms for academic content.

Conclusion: Social media presents valuable opportunities to support dental education by enhancing learning engagement and communication. However, as the study focuses on a single institution, broader research involving multiple dental schools is recommended to achieve more generalisable findings.

Keywords:           Dental Education, Dental Undergraduate, Learning, Malaysia, Social Media

Practice Highlights

• Widespread social media usage indicates the extensive integration of social media into their daily lives.
• Gender was significantly associated with the use of social media for academic purposes.
• Google and YouTube platforms are key resources for dental education.

I. INTRODUCTION

The world is in a state of perpetual evolution, particularly in relation to the internet and its various impacts, both positive and negative (Al-Dayyeni, 2021). Acquiring information has never been easier, with social media playing a crucial role in communication and information retrieval (Uma et al., 2021). According to Uma et al. (2021), professional and personal lives have become intertwined as a result of numerous interactions they have with each other on various issues. They elaborated those social media platforms facilitate users in generating and distributing information or engaging in social networking. This includes social networking platforms such as Facebook, YouTube and Instagram (Uma et al., 2021). According to Giroux and Moreau (2022), social media platforms serve both formal and informal learning purposes in health professions education (HPE). Formal learning pertains to structured educational activities like classes or assignments, while informal learning involves knowledge gained from other extracurricular activities.

Social media has become widespread in society and significantly impacts personal and professional aspects, including dentistry (Uma et al., 2021). Social media has been crucial for communication and education throughout the COVID-19 pandemic (Giroux & Moreau, 2022). Amid the pandemic, medical and dentistry education relied on digital tools and social media platforms for information retrieval, sharing learning resources, and conducting virtual meetings. Students and lecturers frequently used these technologies for academic and non-academic activities (Uma et al., 2021).

Currently, more dentists are using social media to share and acquire knowledge, advertise their professional practice, and offer online consultations (Ghandhi et al., 2022). Affendi et al. (2020) investigated the utilisation of social media for advertising by dentists in Malaysia and found that most respondents believe that social media marketing could gain popularity in the field of dentistry, despite its current primary use for personal reasons (Affendi et al., 2020). Meanwhile, Rani et al. (2020) detailed how Malaysian dental undergraduates are educated to utilise social media to advocate for oral health in the community. Social media also plays roles in dental education outcomes. Platforms such as YouTube and Instagram are increasingly used by dental students to access clinical demonstrations, case discussions, and peer-shared learning resources, which can enhance clinical reasoning and practical understanding (Acosta et al., 2025; Khanagar et al., 2022). This growing use of social media shows its expanding role in dentistry, not only for professional promotion and health education, but also as a helpful tool for dental students to support their own learning.

Undergraduate dental students in Malaysia, typically aged 20–27, belong to Generation Z (born 1997–2012), the largest generational group in the country, comprising 27% of the population (DOSM, 2024). Gen Z is known for being digitally connected, well-educated, entrepreneurial, and empowered (Tjiptono et al., 2020). They rely heavily on technology, using the internet and smartphones for communication, news, education, and social interactions (Slepian et al., 2024). Education integrated with social media enhances learning for Gen Z, promoting engagement, collaboration, and the development of critical skills for the digital era. This tech-savvy nature shapes their learning preferences and readiness for modern professional challenges.

Incorporating social media into education has been shown to enhance learning and promote positive behavioral changes in health profession students (Hamid & Jaafar, 2021). Undergraduate dental students reported enjoying online learning more than conventional lectures (Jayasinghe et al., 2021). However, excessive social media use may cause distractions and unethical online behavior (Nieminen et al., 2022). Students with poor social skills and internet usage exceeding 40 hours weekly are at greater risk of internet addiction (Radeef & Faisal, 2019). Thus, while social media offers educational benefits, its overuse poses potential challenges to student well-being and professionalism.

Numerous social media platforms have proven to be effective for educational reasons (Spallek et al., 2015). With reference to the COVID-19 epidemic, technological advancements have radically revolutionised teaching and learning activities. Previous studies had identified social media has been seen as a mean for connection and a substitute for information distribution (Hamid & Jaafar, 2021; Jayasinghe et al., 2021; Nieminen et al., 2022). In Malaysia’s educational context, there has been a strong national push toward digital learning and technology integration across universities, including in dental education (Kathirveloo, 2024). Given these global trends, understanding social media’s role in Malaysian dental education is critical.

Despite these developments, the use of social media for academic purposes among dental undergraduates in Malaysia has not been firmly established.

Therefore, this study intends to investigate the utilisation of social media platforms for educational purposes in Malaysia. The current study aims to establish the prevalence and characteristics of social media usage for educational purposes among dental undergraduates and to identify the association between the type of social media platforms and its educational purposes. Furthermore, this study could offer essential foundational data for further studies on the advantages of integrating social media into education and this data will help educators to determine which platform and engagement strategies will be most effective with the current generation of learners.

II. METHODS

A. Study Design

A questionnaire-based online cross-sectional survey was conducted from April to October 2023 with participation of all dental undergraduates from Year 1 – Year 5 academic session 2022/2023 in Universiti Sains Malaysia (USM). The validated google form questionnaire used was adapted from a previous similar study (Alshuaibi et al., 2015). The questionnaire developed by Alshuaibi et al. (2015) was designed for a similar sample group which are undergraduate students in Malaysia. This justifies its suitability for the current study. This study was approved by the Human Research Ethics Committee USM (HREC) (Ref. No.: USM/JEPeM/KK/23040324). Data were collected via a Google Form link shared through WhatsApp and email to student representatives, who forwarded it to peers. Participation was voluntary, with informed consent obtained by ticking an agreement box. The questionnaire contained no sensitive information, ensuring anonymity, and all responses were kept strictly confidential.

B. Questionnaire Form

The questionnaire, adapted from Alshuaibi et al. (2015) with permission, had a content and face validity index > 0.80 (Hamid & Jaafar, 2021), indicating strong expert agreement on its content and clarity. It comprised four sections: (1) Socio-Demographic Factors: age, gender, year of study, and other relevant details to contextualise findings; (2) Smartphone Ownership and Connection: smartphone usage, features, and preferred internet connection; (3) Social Media Applications: frequently used platforms and purposes; (4) Social Media for Academic Purposes: use of social media for learning, including information exchange, consultations, and educational queries.

A five-point Likert-type frequency scale was used to assess the respondents’ frequency of behaviour, with response options ranging from “Never” to “Almost always”: Never, Seldom, Sometimes, Often, and Almost always. This scale was employed for all questionnaire items, with response options ranging from Never (1) to Almost Always (5). Items were organised into specific domains. To generate a domain score for each respondent, individual item responses within the same domain were numerically coded and then averaged. This method ensured standardisation across domains.

This structured approach provides a holistic understanding of students’ interaction with technology and social media, particularly in academic settings, while ensuring the findings are relevant and actionable for improving educational practices.

C. Sample Size Determination

The outcome variable selected for estimating sample sizes was the use of social media for academic purposes. Finite population correction formula was utilised to estimate the minimum sample sizes at Universiti Sains Malaysia:

Where n= required minimum sample size, P= 95.1% which is proportion of the outcome variable (Hamid & Jaafar, 2021), p(1−p) = variance of the outcome variable, Z= 1.96 for 95% confidence limit with absolute precision (Δ)= ± 5%. For anticipated 10% of non-response rate, the minimum number of participants required is 80.

For the gender variable, a priori power analysis was performed with G*Power version 3.1.9.7 to establish the required sample size for testing the study hypothesis. The study found that a sample size of N=128 is needed to have an 80% power of detecting a medium effect size with a significance level of α=0.05 when comparing two independent means (male and female). The overall sample size of N=128 was sufficient to test the study hypothesis.

For the years of study variable, a priori power analysis is performed with G*Power version 3.1.9.7 to establish the appropriate sample size for testing the study hypothesis. It was found that a sample size of N=200 was needed to have an 80% power of detecting a medium effect in a one-way ANOVA test at a significance level of α=0.05. Therefore, the sample size of N=200 was sufficient to test the study hypothesis. Since the calculated sample size for the difference in social media use among dental undergraduates between years of study was the highest (200), this number was used for the study.

D. Data Analysis

IBM SPSS Statistics for Windows, Version 26.0 (IBM Corp., Armonk, NY, USA) was used for data entry and analysis. Data was presented using tables and graphs. Descriptive analysis included frequencies and percentages for categorical variables and mean with standard deviation or median with interquartile range for continuous variables, depending on normality. An independent t-test assessed differences in social media use between male and female dental undergraduates at Universiti Sains Malaysia.

A one-way ANOVA test was utilised to assess the use of social media for learning in different undergraduate years of study and to differentiate the type of internet access. A multiple logistic regression analysis was also applied to provide insight into how various factors impact learning outcomes. The independent variables are influencing factors (ResearchGate, Google, YouTube, Skype, LinkedIn, WhatsApp, Instagram, Twitter, Facebook, and TikTok). These platforms were selected based on their popularity among the target population, relevance to academic and social communication. Multicollinearity among the independent variables was assessed using Variance Inflation Factor (VIF) and Pearson correlation coefficients. The dependent variable is the outcome (Never, Seldom, Sometimes, Often, and Almost always). The outcome tested in the study significance level was set at p ≤ 0.05. at 95% confidence intervals.

III. RESULTS

A. Demographic Characteristics

There were 222 dental undergraduates who participated in the study. The mean age of the participants was 22.1 ± 1.50 years. The vast majority of the participants were female, accounting for 79.7% of the total sample (n = 177). 20.7% (n = 46) in the first year, 19.4% (n = 43) in the second year, 23.0% (n = 51) in the third year, 14.0% (n = 31) in the fourth year, and 23.0% (n = 51) in the fifth year. While all academic years were represented, the distribution was not exactly even, with slightly lower participation from fourth-year students and slightly higher representation from third- and fifth-year students. This variation reflects natural variation in voluntary participation across cohorts.

B. Smartphone Ownership and Connection

The majority of dental undergraduates were iPhone users (65.8%) while the other respondents were android smartphone users. Particularly, 95.0% (n = 211) of the participants were able to connect to the internet through a fourth generation (4G) mobile carrier and Wi-Fi.

C. Social Media Application

Most participants utilised social media for connecting with friends (99.1%), communicating with family members (92.8%), and acquiring new skills or information (85.1%). About 74.8% of individuals engage with their lecturers through these communication channels. About 67.1% of participants use these tools to build professional or social connections and only 10.4% of respondents focus on promoting their business through these platforms. Most participants had accounts on Instagram (99.1%), WhatsApp (97.7%), and YouTube (91.9%). The most frequently used platforms were WhatsApp (86.0%), Instagram (81.1%), and YouTube (61.7%) (Figure 1).

Figure 1. Social media membership accounts and the most frequently utilised social media accounts by the respondents (n=222)

D. Social Media for Academic Purposes

The social media apps that assist respondents in their education are shown in Figure 2. Participants chose Google (91.0%), YouTube (84.2%), WhatsApp (53.2%), ResearchGate (48.6%), and Instagram (25.2%) as their top five social networking applications. Google was the most popular application.

Figure 2. Social media applications that assist the respondents in the course of their studies

Table 1 displays the respondents’ utilisation of social media for academic purposes. Most respondents selected “often” for the exchange of information, consulting, and queries domains. About 46.4% of respondents prefer to stay updated on a subject/course “almost always,” while 33.3% chose to consult teachers “sometimes” to clarify challenging subjects. The domain of exchange of information, consultation, and queries had a grand mean score of 2.94 (SD = 0.67), 2.81 (SD = 0.75), and 3.09 (SD = 0.74), respectively.

Submitted: 21 June 2024
Accepted: 18 November 2025
Published online: 7 April, TAPS 2026, 11(2), 32-39
https://doi.org/10.29060/TAPS.2026-11-2/OA3446

Prabodha De Silva¹, Kavishan De Silva¹, Supun Deshapriya¹, Sachini Dewagiri¹, Uthpali Dhammadinna¹, Kasun Bandara Ekanayake² & Amal Nishantha Vadysinghe²

¹Faculty of Medicine, University of Peradeniya, Sri Lanka; ²Department of Forensic Medicine, Faculty of Medicine, University of Peradeniya, Sri Lanka

Abstract

Introduction: University students may be influenced by intimate relationships (IR) and extracurricular activities (EA), which can impact academic performance (AP). This study assessed the effects of IR and EA on the AP of medical undergraduates.

Methods: A cross-sectional study was conducted among 253 medical undergraduates at the University of Peradeniya, Sri Lanka. Data was collected using an online self-administered questionnaire. AP was evaluated using the cumulative grade point average (cGPA) from the previous semester.

Results: Of the 253 participants, 110 (43.5%) were involved in IR and 143 (56.5%) were single; 56.9% were female. Among participants in relationships, 44.5% had partners within the same faculty. There was no significant association between involving in an IR and AP (p=0.651), regardless of the other variables of IR. Most participants (51.8%) believed EA had no impact on AP, and analysis showed no significant association between EA and AP (p=0.394). Economic status of participants was positively associated with their AP (p=0.015). The prevalence of IPV in IR was 18.2% (7.9% of the total sample), with psychological type being the most prominent. Out of those in relationships, 18.2% reported experiencing IPV, of whom 75.0% were male and 25.0% were female, possibly due to underreporting by females. However, there was no significant association between experiencing IPV and AP (p=0.534).

Conclusions: Although involvement in IR and EA did not significantly affect AP, the presence of IPV highlights the need for targeted interventions. Males were more likely to report IPV than females, emphasising the importance of support programs.

Keywords:           Academic Performance, Demographic Data, Intimate Relationships, Extracurricular Activities, Medical Education, Medical Undergraduates

Practice Highlights

• There was no significant association between academic performances and intimate relationships.
• Extracurricular activities didn’t show any impact on academic performances.
• No significant association was observed between intimate partner violence and academic performance.
• Males were more likely to experience intimate partner violence than females.

I. INTRODUCTION

Intimate relationships (IR) include, but are not limited to, heterosexual/homosexual romantic relationships. IR can have a significant impact on the university life of medical students. Medical undergraduates represent a unique population because their training requires them to fulfil high academic demands. Unlike many other undergraduate groups, medical students have limited time for leisure or personal life. These challenges make them particularly vulnerable to stressors arising from balancing IR with academic commitments.

Studies have shown that medical students in IR often experience higher levels of stress, anxiety, and depression than their single counterparts (Dyrbye et al., 2006). This is likely due to the demanding nature of medical school and the pressure to balance academic and personal responsibilities. Additionally, medical students in IR may have a harder time maintaining boundaries and achieving work-life balance. They may also have difficulty finding time for their relationship due to the demands of medical school and clinical rotations.

However, some studies suggest that healthy IRs shown to have a positive impact on students in healthcare professions (Avci et al., 2022). Being in a relationship can provide emotional support, which can be beneficial for coping with the stress of medical education. Additionally, having a partner can provide a sense of social support, which can help medical students feel less isolated and lonely. Despite the potential challenges, many medical students can successfully navigate IR while in medical school. Even so, to prevent the potential harmful impact of IRs, medical schools need to provide support and resources for students in relationships, such as counselling services and relationship awareness programs.

A Sri Lankan study found that 52% of the participants who were university students were engaged in romantic relationships (Gunawardena et al., 2012). Therefore, it’s crucial to understand how these relationships impact their university experience. The majority of studies regarding IRs were focused on violence towards intimate partners, and there was an overall lack of relevant literature when it came to the effects of IRs as general on academic performances (AP). Previous studies have identified vulnerabilities among university students, particularly young women, who are at increased risk of experiencing unwanted sexual attention (Forke et al., 2008) and unhealthy or stressful IRs (Hayden et al., 2016). These findings highlight the importance of further research into how such relational factors may influence AP. A study from the United States involving over 6800 female undergraduates revealed that there is an indirect link between physical and psychological intimate partner violence (IPV) and academic disengagement via depression symptoms (Schrag et al., 2020). Furthermore, American studies involving over 84,000 subjects found that undergraduates experiencing IPV were more likely to have increased academic difficulties (N. Brewer et al., 2018) as well as health impairments (N. Q. Brewer & Thomas, 2019).

These findings suggest that IPV and its consequences may be particularly relevant for medical students, who already face high academic stress. Therefore, exploring not only the general influence of IRs but also the potential academic impact of IPV is essential in understanding the relationship between students’ personal and academic lives. The University of Peradeniya, being one of the largest public universities in Sri Lanka, attracts students from diverse regions and socioeconomic backgrounds. Its academically rigorous environment provides a suitable context to study how interpersonal and extracurricular factors relate to AP. The objective of this study was to examine the association between involvement in IR, AP and extracurricular activities (EA) among the medical undergraduates of the University of Peradeniya, Sri Lanka.

II. METHODS

A descriptive cross-sectional study with an analytical component was conducted with the participation of 2018/19 (3rd year), 2019/20 (2nd year) and 2020/21 (2nd year) batches enrolled at the Faculty of Medicine, University of Peradeniya, Sri Lanka. The senior-most batches were excluded because they were engaged in clinical rotations at external hospitals, making it logistically difficult to ensure their participation. The sample size was calculated based on a total population of 707 students from the 2018/19, 2019/20, and 2020/21 batches. Using a conservative proportion (p=0.5), a 95% confidence level (z=1.96), and a 5% margin of error (e=0.05), the minimum required sample size was 249.

A self-administered questionnaire was newly developed to assess the study objectives. It included sections on demographic factors (age, gender, economic status), IR status, partner characteristics, AP, and EA. Items related to IPV assessed physical, psychological, and combined abuse using Yes/No questions. The questionnaire was pilot tested to ensure clarity and reliability. Economic status was self-reported by participants and categorised as less than 50,000 LKR (1 USD = 323 LKR at the time of data collection in August 2023), between 50,000–100,000 LKR and above 100,000 LKR. IR included romantic relationships, heterosexual or homosexual, in the duration of the last semester’s work. IPV types were specified as physical, mental or both. EA were defined as participation in university clubs, sports, arts or other organised student activities.

Data collected using the questionnaire, via Google Forms, was entered into a Microsoft Excel spreadsheet and analysed using IBM SPSS Statistics 26. Normality of the data collected was assessed, and non-parametric tests (Chi-square tests) were used accordingly. Microsoft Excel was used to calculate a cumulative Grade Point Average (cGPA) value for examination results up to the last semester, based on the university’s 0.000 to 4.000 grading scale. Before administering the questionnaire, written informed consent was obtained from each participant. The ethical approval for the study was obtained from the Ethics Review Committee (2023/EC/SP/38) of the Faculty of Medicine, University of Peradeniya, Sri Lanka.

III. RESULTS

Data was collected from 253 medical undergraduates enrolled in 2018/19, 2019/20 and 2020/21 batches of the Faculty of Medicine, University of Peradeniya, Sri Lanka.

A. Socio-Demographic Profile

The age of the sample ranged from 19 to 26 years, with a mean age of 23.2 years. The sample included 144 females (56.9%) while males accounted for 43.1% (n=109) respondents. Among the 3 batches considered, the 2018/19 batch had the highest number of responses, which amounted to 33.9% (n=86). Respondents from the 2020/21 batch amounted to 33.2% (n=84) while the 2019/20 batch had 32.8% (n=83) respondents. When considering the economic background of the family, 58 subjects (22.9%) represented the group earning less than 50,000 LKR per month, followed by 90 subjects (35.6%) earning 50,000-100,000 LKR per month and 105 subjects (41.5%) earning more than 100,000 LKR per month.

Out of 253 respondents, 110 respondents (43.5%) claimed that they were involved in IR during the last semester. Out of the females in the sample, 58 subjects (40.3%) were involved in an IR during the last semester. Among the 110 subjects who were involved in IR, 67 respondents (60.1%) had their partners in the same university, and 49 of them (44.5%) in the same medical faculty as the subjects. Only 43 (39.0%) claimed to have partners outside the university, including in other universities (34, 30.9%), another residential area (8, 7.2%) and in the health training sector (1, 0.9%).

B. Academic Performance

When the Shapiro-Wilk test was applied to the total sample of 253, the distribution of cGPA significantly deviated from a normal distribution (p<0.001). Therefore, the median (3.200) of the cGPA of respondents was used as a cut-point for assessing AP, differentiating between high-performing and low-performing, instead of the mean (3.065). More than half of the samples (58.1%) had a cGPA of 3.000 or more, while only 7.9% had a cGPA of less than 1.500.

Of the 110 respondents involved in IR, 57 (51.8%) scored lower than a cGPA of 3.200, while 73 (51.0%) of the respondents who were not involved in any IRs scored at or above a cGPA of 3.200 (Table 1). However, this finding was not statistically significant (p=0.651, OR=1.12, 95% CI: 0.68–1.84). The mean cGPA for respondents involved/not involved in IRs was calculated, and respondents who were in an IR had a mean cGPA of 3.05, in contrast to a mean cGPA of 3.08 of the respondents with no involvement in IRs.

Submitted: 29 November 2024
Accepted: 22 September 2025
Published online: 7 April, TAPS 2026, 11(2), 102-113
https://doi.org/10.29060/TAPS.2026-11-2/OA3754

Juveria Arjumand¹, Syed Muhammad Azfar², Syeda Rubaba Azim³ & Rania Alkhadragy^1,4

¹Centre of Medical Education, School of Medicine, University of Dundee, United Kingdom; ²Department of Orthopaedic Surgery, Liaqat College of Medicine and Dentistry, Pakistan; ³Department of Medical Education, Dow University of Health Sciences, Pakistan; ⁴Suez Canal University, Egypt

Abstract

Introduction: The necessity for evaluating the effectiveness of medical education departments (DME) arises from the rapid technological advancements, frequent updates in healthcare paradigms and increasing societal demands. Such evaluations are crucial to understand how DMEs influence the future healthcare workforce and the quality of healthcare delivery. This research aims to explore the functions, procedures, and potential areas for innovation and improvement within DMEs.

Methods: A qualitative study was conducted at Liaquat College of Medicine and Dentistry’s Department of Medical Education, involving two focus groups of seven faculty members each. Participants included both junior and senior faculty. One session was held in person and the online one via Zoom. This was followed by inductive reflexive Thematic analysis.

Results: The study identified several strengths within the Liaquat College of Medicine and Dentistry DME, including robust faculty development programmes and strong student support services. However, areas of concern were highlighted such as research infrastructure and interdisciplinary connections. While faculty members expressed their satisfaction with the provided academic support services, they have reported the need for improving available research resources and faculty development programmes.

Conclusion: The study underscores the significant role of DMEs in medical education and suggests fostering joint research projects, encouraging faculty development, and enhancing student support services. Implementing these recommendations is crucial for advancing medical education and maintaining high standards of excellence. Continuous examination and implementation of these suggestions will ensure that DMEs can adapt to and meet the challenges of an ever-evolving healthcare landscape.

Keywords:           Medical Education Department, Qualitative Study, Action Research, Focus Group

Practice Highlights

• Establish regular interdisciplinary workshops to foster innovative solutions in Medical Education.
• Provide training on innovative teaching techniques with emphasis on Technology Enhanced Learning integration.
• Introduce financial and non-financial rewards to motivate faculty for exceptional contribution.
• Provide comprehensive research training and encourage faculty participation in research activities.
• Develop a systematic student feedback process to continuously enhance teaching strategies and support services.

I. INTRODUCTION

A. Importance and Roles of Department of Medical Education (DME)

Medical education is an interdisciplinary specialty essential for the efficient operation of medical school. The roles of the Medical Education department vary based on institutional principles (Al Sheikh et al., 2022). A primary function of medical education department is to equip teaching staff with the necessary skills for effective role performance (Varpio et al., 2014). This includes course design experience, teaching practices, student assessment expertise, and instructional material development (Yusoff et al., 2014). A comprehensive faculty development programme, with clear goals and dedication, helps nurturing confident and competent staff who can support students’ career progression (Steinert et al., 2005).

The DME should also engage medical teachers in medical education research (Davis et al., 2005) and stimulate intra-departmental research and innovation. This can lead to proposals for action research to improve the teaching and learning environment (Yusoff et al., 2014). Additionally, the DME should organise educational activities that facilitate students’ engagement (Yusoff et al., 2014). These activities should address both personal and professional development, with emphasis on self-directed learning. The latter supports students to maximise their potential and strengthen their commitment to the medical field (Yusoff et al., 2010).

B. Worldwide Impact of DMEs in Medical Colleges

Departments of Medical Education (DMEs) have become integral in medical institutions globally (Alsheikh et al., 2022). DME evolution is shifting from the need to establish one to an increased public expectation (Davis et al., 2005).

The scope of DME activities varies expanding to undergraduates, postgraduates and continuing medical education. However, still flexibility is the key when planning for staffing at DME (Davis et al., 2005).

A study in four African medical universities revealed that medical education departments significantly enhance faculty abilities and student learning, support innovative teaching strategies, and advocate for improved assessment techniques (Kiguli-Malwadde et al., 2015). At the University of Michigan Medical School, DME has increased faculty engagement in scholarly activities through the Medical Education Scholars Program, fostering educational leadership and collaboration among faculty. This network has strengthened interdepartmental collaborations and reinforced education as a crucial element of faculty professional identity (Gruppen, 2004).

C. Context in Pakistan

In Pakistan, medical education requires significant reforms due to outdated practices and resource limitations (Nasim, 2011). Siddiqui & Shaikh (2014) noted a disconnect between basic and clinical sciences, with students lacking early patient contact. Khan et al. (2020) highlighted the need for systemic changes to maintain educational quality. Establishing DMEs is crucial for managing medical education systems (Latif & Wajid, 2018). However, challenges include inadequate infrastructure, qualified personnel, and resistance from management (Latif & Wajid, 2018). The Pakistan Medical and Dental Counsil (PMDC) and Higher Education Commission (HEC) have failed to provide clear guidelines for DME roles and responsibilities, complicating their establishment. The PMDC mandated the establishment of DMEs for accreditation in 2008, but many institutions struggle due to unclear guidelines and lack of skilled educators (Ali & Shamim, 2014). DMEs must develop strategic plans and align tasks with institutional goals. Faculty development programmes should be targeted and resource-efficient (Ali & Shamim, 2014). There is a significant need for faculty training in various skills, including self-directed learning, educational leadership, and research (Anwar & Humayun, 2015). Despite advancements, medical education and research in Pakistan are hindered by low funding and inadequate publication practices (Ghaffar et al., 2013). Improved assessment procedures and centralised evaluation offices are necessary for enhancing educational standards (Ali & Shamim, 2014).

At Liaquat College of Medicine and Dentistry (LCMD), institution under study, the DME was established in 2011. It oversees undergraduate and postgraduate education, continuing professional development, and dental education. The department is responsible for curriculum planning, design, implementation, and monitoring. It also supports educational innovation through instructional techniques and student skill development. The DME collaborates in research programme evaluation and quality assurance of assessments, aligning with local, regional, and international medical councils and accreditation bodies (LCMD, 2023). To enhance the department’s practices, an action research project was conducted to explore faculty perspectives on the DME’s role. Action research involves a cyclical process of collaboration for improving traditional procedures and is effective for identifying issues and generating workable solutions (Meyer, 2000). This study focuses on faculty expectations from the DME at LCMD and their suggestions for future endeavors.

Successful change involves consulting stakeholders to elucidate the need for improvement, considering their input in planning, and involving them as team members with full ownership (Lindberg, 1998). Understanding faculty perceptions is crucial for sustainable change, helping align faculty expectations with the department’s scope and filling any gaps (Khalid, 2013).

D. Need for Change

There is a practical-knowledge gap in the literature regarding the effectiveness of DMEs. While many studies focus on theoretical aspects and expected roles, there is a need for practical investigations into current practices (Al Shawwa, 2012; AlSheikh et al., 2022; Al-Wardy, 2008; Batool et al., 2018; Davis et al., 2005; Gruppen, 2008; Khalid, 2013; Kiguli-Malwadde et al., 2015). This study aims to address this gap by evaluating existing practices and identifying areas for improvement.

E. Research Questions

The study will address the following research questions:

1. What is the faculty’s perception of the roles of the medical education department?
2. What are the positive and negative experiences of working with a medical education department?
3. How should the medical education department function in the future?

II. METHODS

This study adopts a qualitative approach which aligns with the study’s aim at addressing and improving current practices in the Department of Medical Education (DME). The latter requires a comprehensive understanding of the research context and culture to tailor recommendations effectively. Participatory epistemology was adopted emphasising that knowledge is co-constructed through cooperation rather than imparted by researchers (Torre, 2009). This approach values participants’ lived experiences and insights, aiming to produce context-specific and practical knowledge to address real-world issues. This collaborative method, particularly relevant in medical education, involves continuous interaction between researchers, academics, students, and administrators, fostering an environment where knowledge evolves through ongoing dialogue and mutual learning (Peralta, 2017).

The study employs an action research approach, which involves the researcher in a structured process of planning, implementing, and reflecting on actions to bring about positive changes in a specific context (Meyer, 2000). Action research is well-suited for exploring and improving practices within the DME, as it emphasises collaboration, reflection, and iterative cycles to understand and enhance real-world practices (Soh et al., 2011). This methodology is increasingly used in health and education settings due to its applicability, stakeholder involvement, and focus on continuous development.

Action research in this study involves two main stages. Stage 1 consists of focus group discussions with faculty members to gather their opinions and recommendations for improvement. Focus groups facilitate the exchange and development of ideas among participants, generating diverse viewpoints essential for the study’s goals (Cleary et al., 2014). Stage 2 involves collecting and analysing the potential solutions identified in the focus groups for feasibility, with recommendations shared with stakeholders for review and further action.

Figure 1. Five stages of action research (Everd, 1978)

A voluntary sampling technique was used to recruit participants. All faculty members were informed about the study’s objectives and invited to participate via email, resulting in 14 respondents. These participants were divided into two focus groups. Each focus group (n=7) included a mix of male and female participants with varying teaching experiences, ensuring a balanced representation of perspectives.

The first discussion took place in person, while the second was conducted online via Zoom. Each session lasted between 60 and 80 minutes, allowing for thorough exploration of the topics without causing participant fatigue (Tang et al., 1995). The discussions were guided by a set of open-ended questions designed to elicit detailed responses regarding the roles, practices, and improvement suggestions for the DME.

Transcripts of the discussions were analysed using thematic analysis (TA), using Braun & Clarke (2012). TA’s flexibility and accessibility make it suitable for novice researchers and for studies aiming to generate reports based on participants’ perceptions and viewpoints. The analysis followed Braun and Clarke’s (2006) six-phase framework, involving familiarisation with the data, generating initial codes, theme development, refining themes, defining themes and producing the report. This approach ensured a systematic and thorough examination of the data, leading to a comprehensive understanding of the issues and potential solutions within the DME.

A. Researcher Position and Ethical Considerations

Ethical approval was obtained from both Liaquat College of Medicine and Dentistry with the reference number IRB/M-000037/22 and the University of Dundee with reference number SMED REC 22/64. Participants were provided with an information sheet and consent form, ensuring informed consent, confidentiality, and anonymity (Illing, 2013). Data was securely stored, and pseudonyms were used to protect participants’ identities.

III. RESULTS

Two focus groups were conducted including 14 participants, 7 in each discussion. Thereafter transcripts were analysed using thematic analysis. Codes lead to themes, then further refinement was done, until finally reduced to 4 themes and 14 subthemes.

Figure 2. Mind map of themes and sub-themes

When presenting participants’ quotes “p5FG1” refers to participant number 5 in first focus group discussion.

A. Theme 1: Department Role and Activities

The Medical Education Department should encompass all important responsibilities such as teaching, research, and service providing, as well as supporting staff career development. However, the balance of these activities may vary within departments. When discussed the current state and impact of the medical education department in the college, the participants appreciated its role and activities. Hence two themes were generated.

1. Positive impact:

Participants highlighted the positive impact of the Medical Education Department and echoed department’s responsibility in improving teaching skills, supporting innovative approaches, encouraging interdisciplinary collaboration, and establishing a friendly and inclusive atmosphere for faculty members.

“The department’s current situation is pretty impressive. It has made great progress in improving medical education quality.” – p5FG1

“The department has played a critical role in raising medical education standards.” – p6FG2

2. Collaborative role:

Participants stressed the need for more communication and collaboration with other departments.

“While there have been some collaborative initiatives, I believe there is still potential for development.” – p6FG1

Especially, Collaborative opportunities for curriculum development among faculty members will not only bring diverse expertise, comprehensive approach, innovation, and creativity but will also enhance their engagement and sense of ownership.

“They should hold brainstorming sessions, curriculum mapping exercises, and curriculum review meetings to discuss ideas and viewpoints.” – p2FG2

B. Theme 2: Faculty Development

Faculty development initiatives planned by the college’s medical education department seem satisfactory. However, faculty members stressed the need to include innovative and trendy topics i.e., creative pedagogy, technology informed teaching practices and leadership and communication skills for the workshops.

1. Need for training for professional excellence:

The faculty believes that they have a legitimate need for pedagogical training.

“As I have decided to pursue my carrier as a medical teacher and for that yes I need to develop some pedagogical knowledge and skills.” – p3FG1

“We’re eager to succeed in our professions, these training can positively impact our carriers.” – p5FG2

2. Nature and scope of activities:

Participants highlighted the need to introduce new and updated topics in relevance faculty development activities (FDA) with emphasis on participants’ engagement and interactivity.

“But sometimes I feel that these workshops should also consider our educational needs like research and leadership skills.” – p4FG1

“More interactive and active learning techniques would help us understand the content and would be more beneficial in its application.” – p7FG1

3. Motivation to participate:

Most participants thought that faculty members’ contributions to these faculty development events should be acknowledged in some way, hence motivating them to participate.

“Like for young doctors like me, who are struggling to find some balance between family and work, the institute must consider some incentives or recognitions in any form. That I think can keep us motivated.” – p1FG1

4. Roadblocks to faculty development:

Despite the advantages of faculty development workshops mentioned, participants still highlighted some barriers to their development i.e., duration, challenging commitments.

“After the hectic clinical schedule, I sometimes literally drag myself for the workshops. I would suggest planning short duration workshops.” – p6FG1

“After fulfilling my teaching and clinical commitments, despite understanding its (FDA) importance, I hardly wish to spare any time for it.” – p3FG2

5. Challenges to the adaptation to new practices:

Adaptation to new practices can occur at various levels like content, pedagogical and assessment adaptations. Participants focused on pedagogical training, especially for the introduction of new integrated curriculum. One of the members responded as follows.

“…then there is the issue of matching our existing resources to the new curriculum’s requirements. This requires reconsideration of our lesson ideas, assessments, and even classroom layouts.” – p4FG2

C. Theme 3: Inadequate Contributions Towards Research

MEDs play an important role in creating a culture of research (i.e. prevailing attitudes, values, and practices regarding research activities) by innovating, developing new methodologies to medical education, and disseminating their findings (Al-Wardy, 2008). However, the participants seem quite unsatisfied with the current research culture of the institute.

“Well! I think this needs attention, as the research resources are not adequate.” – p5FG1

1. Workload balance:

Faculty find it difficult to balance between clinical and teaching responsibilities while conducting research work. Research work needs more commitment.

“The rigorous clinical workload leaves us with little time and energy to devote to research. Balancing clinical commitments and research can be difficult.” – p6FG2

2. Training and skills:

They also feel the need for research support offices to help and motivate the researchers and teach them research skills like conducting sound literature search strategies, data collection, analysis etc.

“I can see that faculty members who do not obtain proper research training usually have to struggle to initiate and carry out research projects.” – p7FG1

3. Limited resources:

Resources include financial as well as research resources. They feel that restricted financial and research resources (databases, journals, and libraries) are big impediments to the development of research culture in their institute.

“Faculty and students encounter problems performing strong investigations and generating significant findings without access to advanced laboratory equipment, research databases, and specialised research rooms.” – p4FG2

4. Motivation for research:

The institutional culture of a medical college can influence the emphasis and support for research efforts. If the college does not emphasise research or does not have a supportive research culture, faculty members may not receive appropriate recognition, incentives, or resources to engage in research. This can demotivate staff and result in low quality of research work. For instance, one of the participants said:

“Be it any field, lack of incentives, awards, and acknowledgment for research accomplishments might discourage academics and students from actively participating in research activities.” – p7FG2

D. Theme 4: Student Support Services

Planning and providing instructional activities that encourage students’ involvement in learning is another duty of the Medical Education Department. Yusoff. et. al (2014) argued that, to guarantee that medical students are engaged in their study, it is necessary to prepare and teach them to do so. Thus, at both the personal and professional levels, student development activities are essential and fundamental part of nurturing and preparing students for learning in the medical field.

1. Academic support:

The faculty agreed that students needed help and direction in their academic endeavours and appreciate the students’ services of the department.

“The current state of advising services, in my opinion, is fairly good. The department includes resolute advisers and mentors who help students with many aspects of their academic and personal lives. They are easily accessible and eager to respond to students’ problems and questions.” – p1FG1

2. Advisory of study:

The conversation emphasised the significance of addressing students’ emotional and mental health.

“There is a need for improved mental health support. Additional information and guidance on managing stress, building resilience, and obtaining counselling services would be great.” – p5FG2

The importance of educating medical students for their future careers options was underlined by the faculty.

3. Communication and feedback:

Establishing a successful mentoring programme requires thorough programme evaluation. As the programme’s focus, students’ expectations must be considered while evaluating the programme’s effectiveness in terms of its outcomes (Jayalakshmi et. al., 2011). Participants strongly felt that there is a need for a formalised feedback process to collect student perspectives and issues.

“Clearer communication lines, faster response times, and more proactive guidance suited to students’ specific needs and objectives would be advantageous.” – p4FG1

IV. DISCUSSION

A. Staff Perception of the Roles of the Medical Education Department

Staff generally perceive the Medical Education Department (MED) positively, particularly regarding its support for faculty development and student services. Faculty members appreciate the department’s commitment to assisting in teaching initiatives by offering tools, courses, and training opportunities, which help them enhance their teaching skills and stay current with pedagogical practices. This support contributes to providing high-quality education to students, contrasting findings by Latif & Wajid (2018), who reported difficulties in establishing DMEs due to a lack of consensus on their roles. Participants noted that MED encourages conference attendance and fosters professional development, benefiting both individual careers and institutional networking, research collaboration, and communication skills (Kamal et al., 2022). Additionally, MED’s role in organising extracurricular activities and mentorship programmes maximises students’ educational experiences, promoting personal development and teamwork (Yusoff et al., 2014). Khalid (2013) and Kiguli-Malwadde et al. (2015) found faculty viewing MED as a positive change and an agent of educational innovation. Rahman et al. (2019) reported faculty transfer knowledge from MED activities and use them in pedagogical and assessment techniques, hence classified them as beneficial activities. However, it was reported in other studies that faculty felt threatened by MED’s activities, perceiving them as taking over the curriculum (Batool, 2018).

Despite these positives, there is limited awareness among administration and students about MED’s role, leading to under-utilisation of its resources and lack of collaboration. Hence DMEs should actively promote their services through newsletters, workshops, and engagement with student and faculty organisations. Raising awareness ensures that MED’s resources and support reach those who can benefit, and therefore improve the educational experience for all involved stakeholders (Rahman et al., 2019; Khalid, 2013).

B. Staff Positive and Negative Experiences While Working with a Medical Education Department

Faculty members at LCMD view faculty development activities positively, appreciating their focus on teaching methods, assessment techniques, and curriculum development. Junior faculty members, in particular, value these activities as they transition from students to competent instructors, developing teaching abilities, communication skills, and interdepartmental collaboration through these programmes (Thorndyke et al., 2006; Whitcomb, 2004).

However, barriers include time constraints due to faculty members’ multiple responsibilities, passive learning methods in workshops, and a lack of incentives for participation. Studies in India found similar limitations, with debates on the effectiveness of incentives for attending workshops (Adkoli & Sood, 2009; Singh et al., 2008; Srinivas & Adkoli, 2009). While some argue for monetary incentives, others caution against misaligned motivations and ethical issues (Jessani et al., 2020).

Participants expressed dissatisfaction with research activities, with the limited research funding, lack of institutional support, and insufficient collaboration. Medical education research is essential for understanding teaching and learning in medicine, fostering innovation, and developing critical thinking skills (Magan, 2018; Susiani et al., 2018). Challenges include securing funding, lack of resources, and institutional prioritisation of clinical skills over educational research (Ghaffar et al., 2013; Sabzwari et al., 2009).

Regarding student services, faculty members are satisfied with advisory and mentoring activities but suggest improvements. Effective mentoring involves role modeling, career development advice, and direct interaction, evaluated through student feedback (Nimmons et al., 2019). The Kirkpatrick model offers a framework for assessing mentoring programme effectiveness, though evaluations should extend to the organisational level (Nimmons et al., 2019; Smidt et al., 2009).

C. How Should the Medical Education Department Function in the Future?

To address time constraints, MED should offer flexible scheduling for faculty development activities, including evening and weekend classes, and online resources. Integrating these activities into ongoing events and establishing mentorship programmes can further support faculty development. Journal clubs can promote knowledge exchange and research interest, addressing time constraints through peer group discussions (Bhattacharya, 2017; Linzer et al., 1988).

Active learning methods, such as workshops, case studies, and role-play, should be incorporated into faculty development programmes, underpinned by Knowles’ adult learning theory principles to promote internal motivation and self-directed learning (Kaufman, 2003; Norcini et al., 2005; Steinert et al., 2000). Monetary incentives and recognition for contributions should be allocated to motivate participation, with a framework for regular evaluation of teachers’ performance (Adkoli & Sood, 2009; Shah et al., 2018; Srinivas & Adkoli, 2009).

Customised workshops, though challenging, can be facilitated through self-assessed pathways like the COINNS model, identifying key issues and opportunities for professional development (Swanwick & McKimm, 2010). Research training, financial support, and acknowledgment for research accomplishments are crucial for fostering a research culture. Creating research support offices can streamline research processes, mentor researchers, uncover funding opportunities, and support collaborative research (Albanese et al., 2001; Eder & Pierce, 2011; Gisondi et al., 2022).

For student support, more academic services like stress management and study skills activities are needed. Ensuring student engagement and development through well-planned instructional activities can improve outcomes (Prebble et al., 2004; Yusoff et al., 2014). Resilience workshops and cognitive-behavioral training can address the mental and physical health pressures faced by medical students (Rogers, 2016).

V. CONCLUSION

This action research study highlights several key findings and recommendations based on faculty perceptions of their medical education department’s practices and policies. Faculty members expressed a positive attitude towards current policies, indicating a strong foundation for further advancements. However, the need for greater collaboration through multidisciplinary projects and cross-departmental connections was emphasised to enhance overall efficacy.

While existing faculty development programmes meet some demands, a stronger focus on motivational rewards is necessary to maintain participation and commitment. Incentives or acknowledgment for outstanding achievements can renew faculty devotion to departmental goals. Faculty development should also include interactive workshops on advanced pedagogical methods, technological integration, interdisciplinary teaching partnerships, and assessment strategies. These workshops ensure that faculty stay updated with educational advancements, benefiting both teachers and students.

Concerns about workload and its impact on research and scholarship were noted. Addressing the lack of research-related training and resources is crucial to fostering an academic culture of inquiry. Providing skill-enhancement programmes and seeking additional funding can empower faculty to pursue research initiatives.

Lastly, while faculty are satisfied with academic mentoring and support services, the student feedback system needs improvement. A more organised and proactive mechanism is required to effectively capture student insights and ensure continuous improvement.

A. Study Recommendations

Study recommends encouraging regular interactions with other departments via interdisciplinary/ multidisciplinary workshops; providing innovative pedagogical techniques; fostering Financial and Non-Financial Incentives. The latter could be planned by implementing a merit-based system, which rewards exceptional contributions with stipends, bonuses, and research funding. Recognising outstanding faculty annually for their achievements is a key in inspiring others and igniting their motivation. Moreover, aiming at improving DME practices, institutional research profile should be strengthened by organising research activities focused on grant writing, research publication, data analysis.

B. Study Limitations

Being localised to a single institute limits data generalisability. The findings are specific to unique context and may not apply to other institutions (Braydon-Miller et al., 2003). Voluntary faculty participation introduces selection bias, as the sample may not represent all faculty viewpoints (Gill, 2020; Berndt, 2020). Additionally, the study focused on faculty opinions, potentially missing insights from other stakeholders such as students, graduates, and recruiters, which could provide a more comprehensive understanding of the department’s strengths and areas for improvement.

Notes on Contributors

Dr Juveria Arjumand contributed to conceived the study, drafted the study proposal, conducted online Zoom focus group discussion, analysed the data as per her master proposal, and prepared the manuscript for submission.

Dr Syed Muhammad Azfar obtained ethical approval and assisted in conducting focus group discussion and data collection.

Dr Rubaba Azim assisted in conducting focus group discussions and data collection.

Dr Rania Alkhadragy reviewed the study proposal, planned for study design, followed data collection and analysis, gave critical review and edited the final version of the manuscript.

All authors read and approved the final manuscript.

Ethical Approval

Ethical approval was issued from Liaquat College of Medicine and Dentistry with the reference number IRB/M-000037/22 and from University of Dundee with the reference number SMED REC 22/64.

Data Availability

All relevant data are within the manuscript. Data has sensitive information form participants’ quotes that should not be publicly available.

Acknowledgement

We would like to thank all the faculty members at LCMD who participated in the study.

Funding

The author did not receive any funding to conduct this study.

Declaration of Interest

All authors have no conflict of interest.

References

Adkoli, B. V., & Sood, R. (2009). Faculty development and medical education units in India: A survey. National Medical Journal of India, 22(1), 28-32. https://pubmed.ncbi.nlm.nih.gov/19761158/

Al Shawwa, L. A. (2012). The establishment and roles of the medical education department in the faculty of medicine, King Abdul Aziz University, Jeddah Saudi Arabia. Oman Medical Journal, 27(1), 4. https://doi.org/10.5001/omj.2012.02

Albanese, M. A., Dottl, S., & Nowacek, G. A. (2001). Offices of research in medical education: Accomplishments and added value contributions. Teaching and Learning in Medicine, 13(4), 258-267. https://doi.org/10.1207/s15328015tlm1304_08

Ali, S. M., & Shamim, M. S. (2014). Way forward for departments of medical education in Pakistan. Journal Pakistan Medical Association, 64(7), 732-733. https://doi.org/10.12669/pjms.314.8575

AlSheikh, M. H., Zaini, R., Abdalla, M. E., & Magzoub, M. E. (2022). The wicked role of the medical education department. Health Professions Education, 8(1), 3-8. https://doi.org/10.55890/2452-3011.1014

Al-Wardy, N. M. (2008). Medical education units: History, functions, and organisation. Sultan Qaboos University Medical Journal, 8(2), 149.

Anwar, M. I., & Humayun, A. (2015). Faculty development – Looking through different lenses. Pakistan Armed Forces Medical Journal, 65(1), 110-117. https://pafmj.org/PAFMJ/article/view/701

Batool, S., Raza, M. A., & Khan, R. A. (2018). Roles of medical education department: What are expectations of the faculty? Pakistan Journal of Medical Sciences, 34(4), 864. https://doi.org/10.12669/pjms.344.14609

Berndt, A. E. (2020). Sampling methods. Journal of Human Lactation, 36(2), 224-226. https://doi.org/10.1177/0890334420906850

Bhattacharya, S. (2017). Journal club and post-graduate medical education. Indian Journal of Plastic Surgery, 50(3), 302-305. https://doi.org/10.4103/ijps.ijps_222_17

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

Braun, V., & Clarke, V. (2012). Thematic analysis. In H. Cooper (Ed.), APA handbook of research methods in psychology (Vol. 2, pp. 57-71). American Psychological Association. https://psycnet.apa.org/doi/10.1037/13620-004

Brydon-Miller, M., Greenwood, D., & Maguire, P. (2003). Why action research? Action Research, 1(1), 9-28. https://doi.org/10.1177/14767503030011002

Cleary, M., Horsfall, J., & Hayter, M. (2014). Data collection and sampling in qualitative research: Does size matter? Journal of Advanced Nursing, 70(3), 473-475. https://doi.org/10.1111/jan.12163

Davis, M. H., Karunathilake, I., & Harden, R. M. (2005). AMEE education guide no. 28: The development and role of departments of medical education. Medical Teacher, 27(8), 665-675. https://doi.org/10.1080/01421590500398788

Eder, M., & Pierce, J. R. (2011). Innovations in faculty development: Study of a research assistance unit designed to assist clinician-educators with research. Southern Medical Journal, 104(9), 647-650. https://doi.org/10.1097/smj.0b013e3182294e82

Evered, R. D., & Susman, G. I. (1978). An assessment of the scientific merits of action research. Administrative Science Quarterly, 23(4), 582-603. https://doi.org/10.2307/2392581

Ghaffar, A., Zaidi, S., Qureshi, H., & Hafeez, A. (2013). Medical education and research in Pakistan. The Lancet, 381(9885), 2234-2236. https://doi.org/10.1016/s0140-6736(13)60146-4

Gill, S. L. (2020). Qualitative sampling methods. Journal of Human Lactation, 36(4), 579-581. https://doi.org/10.1177/0890334420949218

Gisondi, M. A., Michael, S., Li-Sauerwine, S., Brazil, V., Caretta-Weyer, H. A., Issenberg, B., … & Chan, T. M. (2022). The purpose, design, and promise of medical education research labs. Academic Medicine, 97(9), 1281-1288. https://doi.org/10.1097/acm.0000000000004746

Gruppen, L. (2008). Creating and sustaining centres for medical education research and development. Medical Education, 42(2), 121-123. https://doi.org/10.1111/j.1365-2923.2007.02931.x

Gruppen, L. D. (2004). The department of medical education at the University of Michigan Medical School: A case study in medical education research productivity. Academic Medicine, 79(10), 997-1002. https://doi.org/10.1097/00001888-200410000-00023

Illing, J. (2013). Thinking about research: Theoretical perspectives, ethics, and scholarship. In T. Swanwick (Ed.), Understanding medical education: Evidence, theory, and practice (2nd ed., pp. 331-348). Chichester: Wiley Blackwell. https://doi.org/10.1002/9781118472361.ch24

 Jessani, N. S., Valmeekanathan, A., Babcock, C. M., & Ling, B. (2020). Academic incentives for enhancing faculty engagement with decision-makers – Considerations and recommendations from one School of Public Health. Humanities and Social Sciences Communications, 7(1), 1-13. https://doi.org/10.1057/s41599-020-00629-1

Kamal, M., Bhargava, S., & Katyal, S. (2022). Role of conferences and continuing medical education (CME) in post-graduate anaesthesia education. Indian Journal of Anaesthesia, 66(1), 82. https://doi.org/10.4103/ija.ija_1102_21

Kaufman, D. M. (2003). Applying educational theory in practice. British Medical Journal, 326(7382), 213-216. https://doi.org/10.1136/bmj.326.7382.213

Khalid, T. (2013). Faculty perceptions about roles and functions of a department of medical education. Journal of College of Physicians and Surgeons Pakistan, 23(1), 56-61. https://pesquisa.bvsalud.org/portal/resource/pt/emr-140581

Khan, A. W., Sethi, A., Wajid, G., & Yasmeen, R. (2020). Challenges towards quality assurance of basic medical education in Pakistan. Pakistan Journal of Medical Sciences, 36(2), 4. https://doi.org/10.12669/pjms.36.2.1319

Kiguli-Malwadde, E., Talib, Z. M., Wohltjen, H., Connors, S. C., Gandari, J., Banda, S. S., & Van Schalkwyk, S. C. (2015). Medical education departments: A study of four medical schools in Sub-Saharan Africa. British Medical Council medical education, 15(1), 1-9. https://doi.org/10.1186/s12909-015-0398-y

Latif, M. Z., & Wajid, G. (2018). Reforming medical education in Pakistan through strengthening departments of medical education. Pakistan Journal of Medical Sciences, 34(6), 1439. https://doi.org/10.12669/pjms.346.15942

Liaquat College of Medicine and Dentistry [LCMD]. (2023). Department of health professions education. Retrieved January 22, 2023, from https://www.lcmd.edu.pk/dhpe

Lindberg, M. A. (1998). The process of change: Stories of the journey. Academic Medicine, 73(9), S4-S10. https://doi.org/10.1097/00001888-199809000-00029

 Linzer, M., Brown, J., Frazier, L., Delong, E., & Siegel, W. (1988). Impact of a medical journal club on house-staff reading habits, knowledge, and critical appraisal skills. A randomized control trials. The Journal of the American Medical Association, 260(17), 2537-2541. https://doi.org/10.1001/jama.260.17.2537

Magan, D. (2018). Importance of research in medical education. Journal of Medical Education, 17(3). https://brieflands.com/articles/jme-105647

Meyer, J. (2000). Using qualitative methods in health-related action research. British Medical Journal, 320(7228), 178-181. https://doi.org/10.7748/nop.12.1.22.s12

Nasim, M. (2011). Medical education needs to change in Pakistan. Journal of the Pakistan Medical Association, 61(8), 808. https://europepmc.org/article/med/22356007

Nimmons, D., Giny, S., & Rosenthal, J. (2019). Medical student mentoring programs: Current insights. Advances in Medical Education and Practice, 10, 113-123. https://doi.org/10.2147/amep.s154974

Norcini, J., Burdick, W., & Morahan, P. (2005). The FAIMER Institute: Creating international networks of medical educators. Medical Teacher, 27(3), 214-218. https://doi.org/10.1080/01421590500126379

Peralta, K. J. (2017). Toward a deeper appreciation of participatory epistemology in community-based participatory research. PRISM: A Journal of Regional Engagement, 6(1), 4. https://encompass.eku.edu/prism/vol6/iss1/4/

Prebble, T., Hargraves, H., Leach, L., Naidoo, K., Suddaby, G., & Zepke, N. (2004). Impact of student support services and academic development programmes on student outcomes in undergraduate tertiary study: A synthesis of the research: Report to the Ministry of Education. Wellington: Ministry of Education. https://rb.gy/fd8mpf

Rahman, S., Talukder, M. H. K., & Alam, K. K. (2019). Activities of Medical Education Unit (MEU) in medical colleges of Bangladesh and some challenges faced. Bangladesh Journal of Medical Education, 10(2), 12-18. https://doi.org/10.3329/bjme.v10i2.44637

Rogers, D. (2016). Which educational interventions improve healthcare professionals’ resilience? Medical Teacher, 38(12), 1236-1241. https://doi.org/10.1080/0142159x.2016.1210111

Sabzwari, S., Kauser, S., & Khuwaja, A. K. (2009). Experiences, attitudes and barriers towards research amongst junior faculty of Pakistani medical universities. BMC Medical Education, 9(1), 1-7. https://doi.org/10.1186/1472-6920-9-68

Shah, N., Tabassum, A., & Shah, N. (2018). A needs assessment for faculty development at two medical colleges of Dow University of Health Sciences, Karachi. Pakistan Journal of Medical Sciences, 34(6), 1386. https://doi.org/10.12669/pjms.346.16302

Siddiqui, F. G., & Shaikh, N. A. (2014). Challenges and issues in medical education in Pakistan. Journal of Liaquat University of Medical Health Sciences, 13(3), 91-92.

Singh, T., Bansal, P., & Sharma, M. (2008). A need and necessity for faculty development: The role of medical education units in the Indian context. South East Asian Journal of Medical Education, 2(1), 2-6. https://doi.org/10.4038/seajme.v2i1.484

Smidt, A., Balandin, S., Sigafoos, J., & Reed, V. A. (2009). The Kirkpatrick model: A useful tool for evaluating training outcomes. Journal of Intellectual and Developmental Disability, 34(3), 266-274. https://doi.org/10.1080/13668250903093125

Soh, K. L., Davidson, P. M., Leslie, G., & Rahman, A. B. A. (2011). Action research studies in the intensive care setting: A systematic review. International Journal of Nursing Studies, 48(2), 258-268. https://doi.org/10.1016/j.ijnurstu.2010.09.014

Srinivas, D. K., & Adkoli, B. V. (2009). Faculty development in medical education in India: The need of the day. Al Ameen Journal of Medical Sciences, 2(1), 6-13. https://www.cabidigitallibrary.org/doi/full/10.5555/20103114268

Steinert, Y., Cruess, S., Cruess, R., & Snell, L. (2005). Faculty development for teaching and evaluating professionalism: From programme design to curriculum change. Medical Education, 39(2), 127-136. https://doi.org/10.1111/j.1365-2929.2004.02069.x

Susiani, T. S., Salimi, M., & Hidayah, R. (2018). Research based learning (RBL): How to improve critical thinking skills? Social Human Science Web of Conferences, 42, 00042. https://doi.org/10.1051/shsconf/20184200042

Tang, K. C., Davis, A., Sullivan, S., & Fisher, J. (1995). A review of 5 existing guidelines for planning focus groups in GP research. Australian Family Physician, 24(2), 184-186. https://europepmc.org/article/med/7880138

Thorndyke, L. E., Gusic, M. E., George, J. H., Quillen, D. A., & Milner, R. J. (2006). Empowering junior faculty: Penn State’s faculty development and mentoring program. Academic Medicine, 81(7), 668-673. https://doi.org/10.1097/01.acm.0000232424.88922.df

Torre, M. E. (2009). Participatory action research and critical race theory: Fueling spaces for nos-otras to research. The Urban Review, 41, 106-120. https://doi.org/10.1007/s11256-008-0097-7

Varpio, L., Bidlake, E., Humphrey-Murto, S., Sutherland, S., & Hamstra, S. J. (2014). Key considerations for the success of medical education research and innovation units in Canada: Unit director perceptions. Advances in Health Sciences Education, 19(3), 361-377. https://doi.org/10.1007/s10459-013-9479-z

Whitcomb, M. E., & Cohen, J. J. (2004). The future of primary care medicine. New England Journal of Medicine, 351(7), 710-712.

Wolcott, L. L., & Betts, K. S. (1999). What’s in it for me? Incentives for faculty participation in distance education. Journal of Distance Education, 14(2), 34-49. https://www.ijede.ca/index.php/jde/article/download/156/340?inline=1

Yusoff, M. S. B., Rahim, A. F. A., & Jaafar, R. (2014). Medical education department roles and initiatives towards achieving APEX agenda. Education in Medicine Journal, 6(2), e1-e7. https://doi.org/10.5959/eimj.v6i2.261

Yusoff, M. S. B., Rahim, A. F. A., Noor, A. R., Yaacob, N., & Hussin, Z. (2010). Evaluation of medical students’ perception towards the Big Sib Programme in the School of Medical Sciences, USM. Education in Medicine Journal, 2(1), e2-e11.

*Dr Rania Alkhadragy
University of Dundee,
Nethergate Dundee,
Scotland, United Kingdom
Email: ryalkhadragy@dundee.ac.uk

Submitted: 28 January 2025
Accepted: 16 June 2025
Published online: 6 January, TAPS 2026, 11(1), 22-31
https://doi.org/10.29060/TAPS.2026-11-1/OA3633

Hannah Woodall^1,2, Linda Furness^1,2, Robert Heffernan^1,2, Kay Brumpton¹, Janani Pinidiyapathirage^1,2 & Brendan Carrigan^1,2

¹Rural Clinical School, Griffith University, Toowoomba, Australia; ²Rural Medical Education Australia, Toowoomba, Australia

Abstract

Introduction: Reflection offers many benefits for medical students, improving self-awareness and integration of theory into real situations. However, like any skill, reflection must be learned and practiced. Reflective learning is also influenced by the workplace, particularly in students’ clinical training years. This study explored the factors perceived by educators to influence reflective learning amongst medical students undertaking a rural longitudinal integrated clerkship (LIC).

Methods: All educators within the LIC program were invited to participate. Educators come from both a medical and nursing background. Two focus groups (FG) were conducted. FG were facilitated by experienced researchers. Transcripts were analysed by two researchers using Braun and Clark’s approach to thematic analysis.

Results: Eleven educators participated in two focus groups (six medical educators; five nursing educators). Educators perceived that reflective learning was influenced at three levels: student, educator and institution. These findings aligned with workplace learning theory. Educator and institutional influences were identified as “affordances” which support or hinder reflection. Supportive affordances included labelling of reflection, multidisciplinary collaborative learning, and the longitudinal nature of the rural model. Hindering affordances included using artificial reflective assessments. Educators also identified characteristics of the individual student which may contribute to student decision-making about reflection.

Conclusion: This study provides a deeper understanding about educator experiences of reflective learning within LIC settings. The findings provide insights into the ways in which educators, educational institutions and student workplace settings may support or hinder reflective practice. This study also highlighted the potential for the LIC model to support reflective practice.

Keywords:           Reflective Practice, Undergraduate Medical Education, Rural Medical Education, Longitudinal Integrated Clerkship, Workplace Learning

Practice Highlights

• Educator factors including labelling and positive modelling of reflection may support reflective learning in clinical settings. Modelling of negative attitudes to reflection may hinder reflection in such settings.
• Institutional factors including the LIC model, allowing time for reflective activities and prioritising activities which promote genuine reflection may support reflection in clinical placements. Conversely, allowing limited time for reflection and focussing on written reflective activities may hinder reflection in these same settings.
• Despite educator and institutional factors, students must still choose to engage in reflection.

I. INTRODUCTION

Reflection is a vital skill for medical students, particularly as they transition from theoretical learning environments into clinical settings (Greenhill et al., 2017). In clinical settings, students must learn to translate theory into practice and integrate ethics, communication, professionalism, and culture into real-life situations (Malau-Aduli et al., 2020; Schön, 1995). Reflection supports students to make this transition and become reflective practitioners.

The relationship between reflection and learning is well established (Sandars, 2009). Dewey (1910) proposed that knowledge is created through reflection on experience, through which learners resolve doubt and make sense of situations. This early work has been reshaped, and advanced, with reflection recently defined as: “a metacognitive process that occurs before, during and after situations with the purpose of developing greater understanding of both the self and the situation so that future encounters with the situation are informed from previous encounters” (Sandars, 2009).

This definition proposes a broad understanding of reflection as “thinking about thinking” (metacognition) which occurs at all stages of an experience (before, during and after) (Flavell, 1979; Sandars, 2009). This definition recognises that reflection considers the situation, empirical knowledge and the drivers of the actions of “self” (Sandars, 2009). Such reflection allows past experience to shape future encounters (Kolb, 2014). Through reflection, students actively consider their experiences and examine their skills, beliefs, or assumptions to make sense of complex situations (Bradbury et al., 2010; Chambers et al., 2011; Fernandez et al., 2015; Sandars, 2009). This process moves beyond introspective reflection, instead requiring students to participate in “critical reflection”, whereby learners critically and intentionally consider their experience, knowledge and practice to shape and improve future encounters (Ash & Clayton, 2009).

Reflection is not an automatic or passive process, but requires time, willingness, and skills (Ash and Clayton, 2009; Chambers et al., 2011). Current reflective learning education has been criticised for its reliance on formulaic and written reflections, which may lead to contrived, inauthentic attempts (de la Croix & Veen, 2018). Similarly, while reflective models and frameworks (e.g. Boud, Driscoll or Gibbs) provide useful tools, a narrow focus on reflective models or assessment matrices can paradoxically reduce opportunities for authentic reflection (Boud et al., 1985; Dewey, 1910; Driscoll, 1994; Gathu, 2022; Gibbs, 1988). Evidence increasingly supports diverse reflective methods to enable learners to identify their own personal systems for reflection (de la Croix & Veen, 2018; MacAskill et al., 2023).

Student reflective learning is also impacted by the transition from university-based to workplace-based learning that occurs as students move into clinical settings. Workplace learning is a cooperative process between workplace and learner (Billett, 2001, 2016). In this duality, the workplace or clinical placement offers “affordances” such as formal training, mentoring or the underlying values and culture of the organisation, which may enable or hinder learning (Billett, 2001, 2016). However for meaningful learning to occur, a learner must elect to engage with these workplace opportunities (Billett, 2001). Engagement decisions may be shaped by many factors, including knowledge, values and motivations (Billett, 2001). Where these factors align with what the workplace affords, skill development and mastery will be promoted (Billett, 2001).

Our study was conducted within the context of a rural Longitudinal Integrated Clerkship (LIC) for medical students in Queensland, Australia. Rural longitudinal placements have been reported to foster reflective practice amongst students (Bates et al., 2013; Daly et al., 2013; Gaufberg et al., 2014; Greenhill & Poncelet, 2013; Nyaradi et al., 2025). However, educators in our program have expressed concerns that student reflections were often superficial and may not foster lifelong reflective practice. Given these concerns, a greater understanding of educator perspectives on student reflection is needed.

The student perspective in this context has been explored previously and identified that students valued scaffolding of reflective activities to assist them in learning to reflect, particularly at the beginning of their placement or where they were unsure what to reflect on in a specific situation (MacAskill et al., 2024). However, to gain a more comprehensive view of the placement setting, the perspectives of educators must be considered. Educators bring experience drawn from multiple student cohorts and observe student educational, clinical and interpersonal interactions over the course of a year (Hirsh et al., 2007; Norris et al., 2009). In the rural LIC context, these insights are gained not only through their formal work as educators but also through their roles as health professionals co-located with the students in small rural hospitals. This external perspective provided by educators offers valuable insights into the development of reflective practices and abilities of the students during their clinical placement. This study aimed to identify the factors that educators perceive as influencing reflective learning within a rural LIC program. Additionally, it explores effective methods for supporting student reflection and facilitating the development of authentic reflective practice.

II. METHODS

A. Setting

This study explored reflective learning in the Griffith University “Longlook” program, a rural LIC in south-east Queensland, Australia. Medical students in the Griffith Medical program, a four-year postgraduate medical degree, can elect to participate in Longlook for one or both of their clinical years (years three and four). Longlook students are placed in rural locations for one or two years and meet learning goals across multiple disciplines within a longitudinal placement rather than through isolated blocks (Fuller et al., 2021). Students live in communal accommodation within these rural locations.

The Longlook model affords students continuity of relationships with supervising clinicians and patients (Fuller et al., 2021; The Consortium of Longitudinal Integrated Clerkships [CLIC], 2020; Worley et al., 2016). Approximately 50 students participate in this program each year at one of eight rural clinical training sites (Carrigan et al., 2023).

Longlook is unique in being delivered in partnership with a rural not-for profit organisation, Rural Medical Education Australia (RMEA). Students are supported by generalist educators from both a medical and nursing background who are co-located with students in the hospital sites. Longlook medical educators are rural generalists, who are trained as general practitioners and also provide care within emergency medicine and/or obstetrics, anaesthetics or other hospital services within their local setting (Department of Health and Aged Care [DHAC], 2021). Longlook clinical nurse educators have advanced training to work in rural generalist hospitals and support education delivery within the LIC. Both nursing and medical educators attend monthly training sessions with the students at a central location throughout the academic year in addition to supporting medical students at their respective local sites.

Griffith University medical students are taught and practice reflective practice framed through the MaRIS model. MaRIS applies contemplative pedagogy to medical student teaching to foster a culture of affective reflection (Chan et al., 2020). The year 3 and 4 curricula include two forms of reflective assessment. The first is a written reflection on the student’s topic of choice, completed by all students in both year levels. The second is a series of case presentations (twenty-four in year 3 and six in year 4) which include reflection on the case as well as consideration of ethical, legal, professional or other non-biomedical issues.

B. Research Team

The research team has broad experience across medical education and clinical practice. HW is an academic GP. KB, BC and RH are clinicians and medical educators who have been involved in the development and implementation of the Longlook program. BC and RH lead the 3^rd and 4^th year student programs. LF is an occupational therapist with expertise in education and reflective learning within the allied health context. JP is an experienced health researcher and RMEA director of research. The research team reflected upon the assumptions brought to the study, namely that reflective learning is important but existing approaches do not appear to engage students in genuine reflection. The background of research team members allows an active interpretation of the results based on experience within medical education and clinical practice (Olmos-Vega et al., 2023).

C. Participants

All educators within the Longlook program were invited to participate (eight medical educators, six nursing educators). Participants were not recruited from outside of this program due to the challenges of comparing this unique context with other education settings.

D. Study Design

A constructivist case study research paradigm was used to ensure methodological congruence and forefront the experiences and voices of the research participants. Constructivist perspectives reflected the desire to explore the participants’ constructions of their lived experiences as educators (Shannon-Baker, 2023). The case study approach enabled the team to understand and describe the experiences of educators within the setting of a rural LIC by purposively selecting educators within the program (Hall et al., 2008). In accordance with the constructivist approach, semi-structured focus groups were used to capture educators’ collective experiences and enable rich data generation based on interactions between participants (Gill & Baillie, 2018).

Two focus groups were conducted between August and December 2022. The potential for power differentials between medical and nursing educators led to the decision to separate focus groups, ensuring that the perspectives of both groups could be explored freely. The medical educator (ME) focus group was conducted by a ME, while the clinical nurse educator (NE) focus group was facilitated by a clinical nurse educator. Focus groups lasted approximately one hour and were conducted in person during student teaching days. Informed written consent was obtained from all participants prior to the focus group. The focus groups explored educator views on reflective learning activities, an evaluation of current reflective methods, and how reflective learning could be improved. The interview guide is attached in Appendix 1.

Focus group data recordings were transcribed using Sonix™ and uploaded to NVivo™ for coding. Braun and Clarke’s 6-step approach to thematic analysis was adopted to generate codes and themes inductively from the transcribed data, aligning with the qualitative approach to data generation and in keeping with the constructivist paradigm underpinning the research design (Braun & Clarke, 2006). Two researchers (HW and LF) worked independently on analysis before coming together to define and decide on the most significant themes, applying the principals of thematic analysis in a non-linear and iterative way.

The research team sought to ensure the trustworthiness of the data through acknowledging their own background and assumptions, providing thick descriptions of the data and its context, and through independent analysis by team members from different backgrounds (Ahmed, 2024).

E. Ethics

Ethical approval was obtained from the Griffith University Human Research Ethics Committee (GU 2021/376).

III. RESULTS

Eleven educators were recruited to participate in this study, including six with a medical background, and five with a nursing background. Factors perceived by educators to impact student reflective practice occurred at three levels: student, educator and institution.

A. Student Factors

The student’s pre-clinical life experience and innate ability to reflect appeared to impact their ability to engage in reflective practice. Educators perceived that some students were already skilled in reflection, while for others it was a new and challenging concept. They also perceived that student’s life experience and self-awareness impacted on their ability to reflect.

“You’re teaching, for some people, something that they’re doing already and then for others, … you are actually trying to teach, you know, an unnatural kind of process.” ME3

“Everybody has really different life experiences and the way that they bring those life experiences to the way that they either talk to somebody or treat a patient or think about, diagnose, diagnostics or anything like that, you know, all of those life experiences will contribute to that in some way. So I guess it’s just also that self-awareness of who you are and where you came from and how that’s influencing the way that you are interacting and thinking about other people as well.” NE4

“An increasing number of students that come rural, actually, it is a practice for them, and they will actually journal and reflect on their day most days… I don’t know whether something that they’re, they’ve been taught to do in years one and two, or whether it’s something that they’ve it’s just been a practice of theirs from something else” NE5

Educators perceived clinical exposure as significantly impacting the quality of student reflections, with students new to the placement reflecting on the newness of their experience, while students who had been on the placement for several weeks or months reflected on their capabilities and strategies for improving their practice. Educators witnessed the evolution of student’s reflective skills and described deepening complexity of reflections, incorporating the socio-cultural context of rural healthcare, during the LIC program.

“At the beginning, the reflection was just, this is all new and different. And now the reflection is more about what was done well and how they contributed and how they could do better or could do things differently.” ME1

“By the end of it, they’ve learnt so much that the reflective practice is actually more where they’re thinking…They’re now more thinking about reflecting on their practice and how they’re going to be a better doctor.” NE2

“I think with the rural generalist model, when people are learning in these kind of, in rural towns, that application to a bigger context is a bit probably easier for them to learn and to see. So we probably do have an opportunity to actually get them to understand that more and reflect on that more.” ME6

Educators also described informal reflection occurring outside of the clinical environment. The immersion in a rural LIC setting and shared accommodation was felt to provide greater informal opportunities for reflection.

“I think about the students in the accommodation building this year and I think about the students in the accommodation building last year, and last year there was lots of reflective practice, just informally, in the accommodation building. This year, it was very limited, and that’s, you know, different personalities” ME1

“I wonder within the rural context whether our students are naturally doing it [reflecting] at night when they go home and talk to each other a little bit anyway.” ME6 

B. Educator Factors

Educators recognised the importance of role modelling and their own reflective practice to support student reflection. The approach and attitude of medical educators towards reflection was felt to be particularly significant. Educators linked this with the “hidden curriculum”; the informal learning that occurs through witnessing attitudes and behaviours of educators and supervisors (Hafferty & O’Donnell, 2014).

“I wonder if the groaning about, and negativity to reflective practice is in the hidden curriculum in that as a profession, we groan and have a negative attitude to reflective practice.” ME2

“I’m not sure whether we as doctors do as much active reflecting as we probably should as well and show how important that is.” ME6

“It [reflection] probably also needs to be better embraced amongst the medical community itself. Because, yeah, because there’s a lot of doctors out there that’ll think it’s a bit airy fairy or bit of a waste of time. And I suppose when you’re trying to be a doctor, a doctor’s opinion is going to have a higher standing than a nurse’s opinion” NE4

Educators also acknowledged that reflection is not always labelled when it occurs, which may impact student reflective activities.

“I hear lots of philosophical conversations coming from my colleagues with medical students… I’ve never heard any of them termed as reflection.” ME3 

“You asked if we use the word reflection, and I think we all try and shy away from it.” ME5 

Educators reported that educators and students engaging in collaborative reflection provided a positive influence, as an example of educators modelling reflection.

“One thing I try and do with the students is every week we catch up and I ask them all the question, “What was the most interesting thing you saw this week?” …. I always try and do one as well to model firstly that I’m still learning. This was interesting to me because I missed the diagnosis, actually, and I need to work on that or for whatever reason and be part of the collective “we’re all learning together” ME5 

Collaborative reflection as part of multidisciplinary educator teams was also considered significant. Educators from different disciplines are involved in the Longlook program, with educators proposing that different disciplines may bring different reflective skills. Nurse educators identified that they may be able to contribute more to this aspect of student learning and wondered if medical educators may benefit from professional development in this area.

“Perhaps the nurse educators are better positioned to talk to them about reflective practice …Because perhaps the medical educators don’t do it well, either.” NE5 

“If there are some struggling, because [medical educator] doesn’t have the time. Maybe I could just work with them… What’s been going on? Have that sort of informal thing just to prompt them to reflect a little bit more” NE4

“Maybe …some professional development for the medical educators as well, just to see how comfortable they are with it” NE5

Participants identified that this process of learning together requires a safe learning environment in which trust and vulnerability from both sides allows educators and students to learn to reflect together. 

 “Because they’re [students] so used to being such high performers, being in a position where you’re not performing so well definitely puts them in a vulnerable position…” NE1 

“I think that depends on trust. That’s probably the key thing. And the relationship that exists, so it wouldn’t be a natural thing at the start of a year to do it with an educator.” ME3 

C. Institutional Factors

Finally, educators identified organisational factors related to the university curriculum which impacted student reflective learning. Time constraints within the medical school program meant that reflective activities were omitted when time was tight.

“When you’ve only got like two hours to get through six people [presenting case-based discussions], you may not be able to sort of expand on some of those reflections, as interesting as they might be to discuss as a group.” NE1 

Educators felt that students required institutions, assessors and educators to set clear expectations for reflection.

“We could probably do a better job of actually setting that standard with orientation” ME2

“Do it [reflective teaching] as a sort of combined nurse-educator to the students reflective practice session. “This is what we’re going to expect for the year.” Maybe then they’ll start off a little bit better instead of gradually getting better if they know what we are expecting. NE3

Educators also expressed concern that assessing reflection may create an engineered environment that may reduce the opportunities for deep reflective learning.

“I do worry that in assessment that people will just write the minimum of what they have to do because they don’t see it as a priority.” ME6 

“I think the main thing about doing it as a formal assessment is that it’s hard to actually sit down and put it in writing in a formal way that the university wants to hear, basically, though. Doing it as a practice is a good thing, but having to write it like an assignment makes it hard work.” NE2

“It should be sort of mandated that in some capacity they do it, but maybe not so much in a “you’ve got to do it and I’ve got to tick the box and say that, you know, you’ve passed or whatever” ME5

Educators instead suggested reflective activities to focus on real-world situations to encourage authentic reflection.

“Why are we doing this as a single one off reflective about a random event that may or may not be true and we just add reflection onto a true in situ real world case and assess it across an entire year” ME1

“Could they knock off one of the CEXs [clinical evaluation exercises] and have a reflective piece like that is just a reflection for each block that they do? NE3

IV. DISCUSSION

This study identified student, educator and institutional factors that were perceived by educators to enable or inhibit student reflective learning. Enabling factors included labelling of reflection, provision of a trusting environment, multidisciplinary collaborative reflective learning, allowing time for reflective activities and the longitudinal nature of the rural model. Inhibiting factors included the use of artificial reflective assessments. Two elements were identified which may either inhibit or enable reflective learning: student factors (both life experience and experience of reflection) and modelling. Students’ previous positive experiences of reflection or established life experience was perceived to enhance student reflection. Conversely, reflective activities may be inhibited by a student’s lack of experience or previous negative experiences of reflection. In addition, modelling could be inhibitory or enabling depending on whether positive or negative attitudes towards reflection were modelled to students.

A. Workplace Reflective Learning

Educator insights align with workplace learning theory which describes “affordances” through which workplaces support or hinder learning (Billett, 2001, 2016). The educator and institutional factors identified can be viewed as “affordances” for reflective learning. Educator modelling and labelling of reflective practice in the clinical setting provide opportunities for students to learn. Similarly, the development of a trusting environment, allowing time for reflection and encouraging real-world reflections provide opportunities for students to reflect.

However, workplace learning theory also recognises that, despite the number and quality of affordances, individuals have choice about whether to engage in learning activities (Billett, 2001, 2016). Educators identified student factors which may improve engagement with reflection. This study was conducted in a post-graduate medical program with students from diverse backgrounds and with different experiences and reflective skills. These elements may impact individual decisions to engage. This observation aligns with workplace learning theory’s identification that, even with the same affordances, learners may make different choices when it comes to engagement.

B. Educator Reflective Ability

Educators strongly focused on the impact of their own practice in these focus groups, identifying areas for improvement in their clinical and educator roles. Medical educators highlighted the impact of their own, often negative, views of reflection and failure to label reflective activities. Nurse educators realised that they may have a key role in reflective learning and identified practical strategies to increase their involvement.

These insights arose through profound reflective discussions during the focus groups. Educators reflected deeply on their own challenges, experiences and struggles with reflection. They reflected on the impact of their own practice and attitudes on their students. Educators then collectively discussed changes to future practice including modelling positive examples of reflection, labelling reflective activity or actively participating in student reflective activities. While this process occurred in an iterative and conversational manner, it clearly demonstrates reflective skills. However, this process was not labelled as reflection at any point in either group.

This demonstration of reflective ability is especially meaningful since educators, particularly medical educators, expressed concerns that they lacked reflective skills. The focus group discussions suggest that educators have reflective skills but may not be attuned to recognise reflection when it occurs.

C. The Rural LIC Model

The rural LIC model was identified as an affordance for reflective learning. The long-term student-educator and student-student relationships in the rural LIC setting were felt to enable the development of a trusting environment in which students and educators feel safe to reflect honestly. The rural longitudinal setting was also felt to enable greater opportunities for reflection through communal living arrangements. These benefits were seen as supporting reflection in medical students and align with previously reported benefits of the LIC model including relationship continuity, a holistic perspective on the patient and their experience, and self-awareness (Carrigan et al., 2023; Gaufberg et al., 2014; Mylopoulos et al., 2020; Purea et al., 2022).  

D. Limitations

This study considered the educator perspective only. A study exploring the student perspective in this setting has previously been published (MacAskill et al., 2024).

The limited sample size of this study was related to the limited pool of educators in this program. Limitations in numbers of rural medical educators is a widespread problem. Most medical educators are located in urban centres (McGrail et al., 2023). Given the unique context of this study (rural LIC), it was not possible to recruit more widely within different programs.

E. Future Research

The significance of the LIC model in this setting highlights an important lesson for medical education more broadly. This study demonstrates the importance of trust for reflection, and how these elements are facilitated through models such as the LIC. Further study is needed to explore how trust can be developed in the context of shorter-term student-educator relationships. This study also did not include a comparator group within a more traditional block-mode setting but this may be a useful area for future enquiry. Further studies to explore reflection within other LIC models and within other collaborative multidisciplinary learning environments would be useful to more fully understand the role of such models in reflective learning. Finally, further study to explore the drivers of student engagement in reflective learning would improve our understanding of why some students do not engage despite affordances.

F. Implications for Practice

This study was conducted to identify how reflective practice could be improved in this rural medical education setting. Educators identified that students who are not naturally reflective, lack life experience or exhibit limited self-awareness were less likely to engage in reflective practice. Engagement may also relate to educator factors such as the labelling of reflective activities and students experiencing modelling of positive attitudes towards reflection.

Educators identified that the relationships formed through the rural LIC model may support students to reflect but also noted that educators should ensure that they label reflection where it occurs, and model positive and authentic reflective practice to their students. This study also highlighted the potential strengths of different clinical disciplines and emphasised the benefits of multidisciplinary educator teams. Encouraging nurse and medical educators to teach and reflect together may improve reflective skills of the educator and student cohort.

V. CONCLUSION

This study sought the perspectives of educators on student reflective learning within a rural longitudinal integrated clerkship. Findings aligned with workplace learning theory, with “affordances” identified which facilitated or hindered reflective learning. These affordances predominantly related to educator factors including modelling and labelling of reflection, and institutional factors including the time allowed for reflection and the nature of reflective activities. Elements of a rural LIC model provide affordances to develop deeper reflective learning and highlight the extended opportunities provided by this model.

Notes on Contributors

Hannah Woodall designed the study with Robert Heffernan, Kay Brumpton, Janani Pinidiyapathirage and Brendan Carrigan. Hannah Woodall was responsible for data collection and worked with Linda Furness to analyse the data. Hannah Woodall was responsible for development and editing of the manuscript.

Linda Furness worked with Hannah Woodall to analyse the data and was involved in interpreting the results. Robert Heffernan was involved in conceptualisation of the study and interpretation of the data. Kay Brumpton was involved in study design and development of study materials. Kay Brumpton participated in making sense of the data, contributing theoretical background to the analysis. Janani Pinidiyapathirage was involved in development of the study protocol and materials and contributed to interpreting the data. Brendan Carrigan was involved in study development and interpretation of the collected data. All authors have read and approved the final manuscript.

Ethical Approval

Ethical approval for the study was obtained from the Griffith University Human Research Ethics Committee (GU 2021/376).

Data Availability

The datasets analysed during the current study are not publicly available due to participants’ potential identifiability due to the small dataset. Data is available from the corresponding author on reasonable request. 

Acknowledgement

The writers acknowledge Dr Claire D Nicholls (University of Southern Queensland) for her assistance in reviewing the research methods section of this manuscript.

Funding

The authors would like to acknowledge the funding received through the Rural Health Multidisciplinary Training (RHMT) program grant of the Australian Government that supported the salaries of HW, LF, RH, KB, JP and BC during this study.

Declaration of Interest

The authors declare that they have no competing interests.

References

Ahmed, S. K. (2024). The pillars of trustworthiness in qualitative research. Journal of Medicine, Surgery, and Public Health, 2, Article 100051. https://doi.org/10.1016/j.glmedi.2024.100051

Ash, S. L. & Clayton, P.H. (2009). Generating, deepening, and documenting learning: The power of critical reflection in applied learning. Journal of Applied Learning in Higher Education, 1(1), 25-48. https://doi.org/10.57186/jalhe_2009_v1a2p25-48

Department of Health and Aged Care. (2021). National rural generalist pathway. Australian Government. https://www.health.gov.au/initiatives-and-programs/national-rural-generalist-pathway

Bates, J., Konkin, J., Suddards, C., Dobson, S., & Pratt, D. (2013). Student perceptions of assessment and feedback in longitudinal integrated clerkships. Medical Education, 47(4), 362-374. https://doi.org/10.1111/medu.12087

Billett, S. (2001). Learning through work: Workplace affordances and individual engagement. Journal of Workplace Learning, 13(5), 209-214. https://doi.org/10.1108/EUM0000000005548

Billett, S. (2016). Learning through health care work: Premises, contributions and practices. Medical Education, 50(1), 124-131. https://doi.org/10.1111/medu.12848

Boud, D., Keogh, R., & Walker, D. (Eds.). (1985). Reflection: Turning experience into learning. Taylor & Francis Group. https://lccn.loc.gov/84016507

Bradbury, H., Frost, N., Kilminster, S., & Zukas, M. (2010). Beyond reflective practice: New approaches to professional lifelong learning. Routledge. https://doi.org/10.4324/9780203873175

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

Carrigan, B., Bass, L., Pinidiyapathirage, J., Walters, S., Woodall, H., & Brumpton, K. (2023). Connectivity is the key to longer rural placement: Retaining students on rural longitudinal integrated clerkships. Medical Teacher, 46(2), 225-231. https://doi.org/10.1080/0142159X.2023.2243025

Chambers, S. L. K., Brosnan, C., & Hassell, A. B. (2011). Introducing medical students to reflective practice. Education for Primary Care, 22(2), 100-105. https://doi.org/10.1080/14739879.2011.11493975

Chan, K. D., Humphreys, L., Mey, A., Holland, C., Wu, C., & Rogers, G. D. (2020). Beyond communication training: The MaRIS model for developing medical students’ human capabilities and personal resilience. Medical Teacher, 42(2), 187-195. https://doi.org/10.1080/0142159x.2019.1670340

Daly, M., Roberts, C., Kumar, K., & Perkins, D. (2013). Longitudinal integrated rural placements: A social learning systems perspective. Medical Education, 47(4), 352-361. https://doi.org/10.1111/medu.12097

de la Croix, A., & Veen, M. (2018). The reflective zombie: Problematizing the conceptual framework of reflection in medical education. Perspectives on Medical Education, 7(6), 394-400. https://doi.org/10.1007/s40037-018-0479-9

Dewey, J. (1910). How we think. D C Heath. https://doi.org/10.1037/10903-000

Driscoll, M. P. (1994). Psychology of learning for instruction. Allyn & Bacon.

Fernandez, S. C., Chelliah, K. K., & Halim, L. (2015). A peek into oneself: Reflective writing amongst undergraduate medical imaging students. Reflective Practice, 16(1), 109-122. https://doi.org/10.1080/14623943.2014.982524

Flavell, J. H. (1979). Metacognition and cognitive monitoring: A new area of cognitive–developmental inquiry. American Psychologist, 34(10), 906. https://doi.org/10.1037/0003-066X.34.10.906

Fuller, L., Lawson, M., & Beattie, J. (2021). The impact of clerkship model and clinical setting on medical student’s participation in the clinical workplace: A comparison of rural LIC and rural block rotation experience. Medical Teacher, 43(3), 307-313. https://doi.org/10.1080/0142159x.2020.1839032

Gathu, C. (2022). Facilitators and barriers of reflective learning in postgraduate medical education: A narrative review. Journal of Medical Education and Curricular Development, 9. https://doi.org/10.1177/23821205221096106

Gaufberg, E., Hirsh, D., Krupat, E., Ogur, B., Pelletier, S., Reiff, D., & Bor, D. (2014). Into the future: Patient-centredness endures in longitudinal integrated clerkship graduates. Medical Education, 48(6), 572-582. https://doi.org/10.1111/medu.12413

Gibbs, G. (1988). Learning by doing: A guide to teaching and learning methods. Great Britain Further Education.

Gill, P., & Baillie, J. (2018). Interviews and focus groups in qualitative research: An update for the digital age. British Dental Journal, 225(7), 668-672. https://doi.org/10.1038/sj.bdj.2018.815

Greenhill, J., & Poncelet, A. N. (2013). Transformative learning through longitudinal integrated clerkships. Medical Education, 47(4), 336-339. https://doi.org/10.1111/medu.12139

Greenhill, J., Richards, J. N., Mahoney, S., Campbell, N., & Walters, L. (2017). Transformative learning in medical education: Context matters, a South Australian longitudinal study. Journal of Transformative Education, 16(1), 58-75. https://doi.org/10.1177/1541344617715710

Hafferty, F. W., & O’Donnell, J. F. (2014). The hidden curriculum in health professional education. Dartmouth College Press. https://muse.jhu.edu/book/36816.

Hall, S. L., Forrester, S., & Borsz, M. (2008). A constructivist case study examining the leadership development of undergraduate students in campus recreational sports. Journal of College Student Development, 49(2), 125-140. https://doi.org./10.1353/csd.2008.0010

Kolb, D. (2014). Experiential learning: Experience as the source of learning and development, second edition (2nd edition ed.). PH Professional Business.

MacAskill, W., Chua, W., Woodall, H., & Pinidiyapathirage, J. (2023). Beyond the written reflection: A systematic review and qualitative synthesis of creative approaches to reflective learning amongst medical students. Perspectives on Medical Education, 12(1), 361-371. https://doi.org/10.5334/pme.914

MacAskill, W., Woodall, H., Nicholls, C. D., Brumpton, K., & Pinidiyapathirage, J. (2024). Enhancing reflective practice using prompts in Online Submission of Case Reports (OSCAR): An exploratory study among medical students in rural longitudinal integrated clerkships. Perspectives on Medical Education, 13(1), 654-665. https://doi.org/10.5334/pme.1416

Malau-Aduli, B. S., Roche, P., Adu, M., Jones, K., Alele, F., & Drovandi, A. (2020). Perceptions and processes influencing the transition of medical students from pre-clinical to clinical training. BMC Medical Education, 20(1), 279. https://doi.org/10.1186/s12909-020-02186-2

McGrail, M. R., Doyle, Z., Fuller, L., Gupta, T. S., Shires, L., & Walters, L. (2023). The pathway to more rural doctors: The role of universities. Medical Journal of Australia, 219(S3), S8-S13. https://doi.org/10.5694/mja2.52021

Mylopoulos, M., Kulasegaram, K., Weyman, K., Bernstein, S., & Martimianakis, M. A. (2020). Same but different: Exploring mechanisms of learning in a longitudinal integrated clerkship. Academic Medicine, 95(3), 411-416. https://doi.org/10.1097/ACM.0000000000002960

Olmos-Vega, F. M., Stalmeijer, R. E., Varpio, L., & Kahlke, R. (2023). A practical guide to reflexivity in qualitative research: AMEE Guide No. 149. Medical Teacher, 45(3), 241-251. https://doi.org/10.1080/0142159X.2022.2057287

Purea, P., Brumpton, K., Kumar, K., & Pinidiyapathirage, J. (2022). Exploring the learning environment afforded by an Aboriginal community controlled health service in a rural longitudinal integrated clerkship. Education for Primary Care, 33(4), 214-220. https://doi.org/10.1080/14739879.2022.2054371

Sandars, J. (2009). The use of reflection in medical education: AMEE Guide No. 44. Medical Teacher, 31(8), 685-695. http://doi.org/10.1080/01421590903050374

Schön, D. A. (1995). Reflective practitioner: How professionals think in action. Taylor and Francis Group. https://doi.org/10.4324/9781315237473

Shannon-Baker, P. (2023). Philosophical underpinnings of mixed methods research in education. In R. J. Tierney, F. Rizvi, & K. Ercikan (Eds.), International encyclopaedia of education (4^th ed., pp. 380-389). Elsevier. https://doi.org/10.1016/B978-0-12-818630-5.11037-1

The Consortium of Longitudinal Integrated Clerkships. (2020). CLIC – The Consortium of Longitudinal Integrated Clerkships. CLIC. https://clicmeded.com

Worley, P., Couper, I., Strasser, R., Graves, L., Cummings, B. A., Woodman, R., Stagg, P., & Hirsh, D. (2016). A typology of longitudinal integrated clerkships. Medical Education, 50(9), 922-932. https://doi.org/10.1111/medu.13084

*Hannah Woodall
190 Hume Street, Toowoomba, QLD, 4350
Email: h.woodall@griffith.edu.au