Submitted: 3 April 2024
Accepted: 22 July 2024
Published online: 1 October, TAPS 2024, 9(4), 33-39
https://doi.org/10.29060/TAPS.2024-9-4/OA3282

Meltem Saygılı¹, Aysun Kandemir Türe¹ & Şirin Özkan²

¹Department of Health Management, Kırıkkale University, Kırıkkale, Türkiye; ²Department of Medical Services and Techniques, Vocational School of Health Services, Uludag University, Türkiye

Abstract

Introduction: Many societal changes threaten the sustainability of health systems. Entrepreneurs play a significant role in creating sustainable innovations necessary for development and structural change. This study aimed to evaluate how university students studying health sciences perceive individual entrepreneurship during the COVID-19 pandemic and to explore the impact of COVID-19-related hopelessness on their perception of entrepreneurship.

Methods: Six hundred eighty-one undergraduate students from the faculty of health sciences in Türkiye, participated in the study. The Individual Entrepreneurship Perception Scale and Beck Hopelessness Scale were used to collect data.

Results: The results revealed that the students’ perception of individual entrepreneurship was high, while their hopelessness levels were moderate. In addition, a moderate negative relationship was found between the students’ hopelessness levels and their perception of individual entrepreneurship. The regression analysis showed that the students’ hopelessness levels and sub-dimensions (hope, loss of motivation, and future expectation) accounted for 26.3% of the total variance in individual entrepreneurship perception. Increased hopelessness regarding the sub-dimensions of hope, loss of motivation, and expectations for the future decreased their individual entrepreneurship perceptions.

Conclusions: These findings suggest that individual entrepreneurship perception among health sciences students could be negatively impacted during extraordinary periods related to health crises like pandemics. Developing hope, motivation, and expectations for the future is crucial to enhancing individual entrepreneurship perception among health sciences students.

Keywords: Individual Entrepreneurship Perception, Hopelessness, Health Sciences, University Students, COVID-19 Pandemic

Practice Highlights

• University education plays a critical role in developing students’ perceptions of entrepreneurship.
• Students’ perceptions of entrepreneurship are affected by changing environmental conditions.
• The COVID-19 pandemic has led to a significant increase in awareness of Healthcare Entrepreneurship.
• The COVID-19 pandemic has negatively affected students’ expectations and hopes for the future.
• Health sciences students experienced the psychological effects of the pandemic more intensely.

I. INTRODUCTION

Entrepreneurs are described as individuals who “implement bold new ideas from the outset, taking on the risks of the business or venture that enables innovation to happen” (Suryavanshi et al., 2020). Entrepreneurship education seeks to provide students with in-depth knowledge, motivation, and skills to increase entrepreneurial intentions’ success in various settings (Sampene et al., 2023). In developing economies such as Türkiye, government efforts to improve unemployment conditions are directed towards developing students’ positive attitudes towards entrepreneurship and increasing their interest in self-employment.

Universities are crucial in developing students’ entrepreneurial intentions (Bagheri, 2018). It is critical to examine and develop the entrepreneurial potential of university students trained to fulfill important roles in the field of health services in the future. This is because students and newly graduated healthcare professionals with entrepreneurial skills are now needed to develop innovative healthcare delivery models that can improve the quality of healthcare services, improve treatment outcomes, and reduce the cost of care (Fashami et al., 2021; Mohamed et al., 2023). It is stated that healthcare is one of the main industrial areas where user entrepreneurship takes place worldwide (Schiavone et al., 2020) and the pandemic environment brings unique opportunities for entrepreneurs, especially in healthcare. However, research shows that fear and worry due to the COVID-19 pandemic are making the future workforce anxious and hopeless about their professional futures (Duplaga & Grysztar, 2021; Tao et al., 2023). In such an environment, it is predicted that university students, especially those who are trained to work in health service delivery, may act in different ways in their decisions about their professional future.

Because an individual’s perception of current conditions can significantly, positively, or negatively affect the formation of entrepreneurial intentions and the likelihood of starting an enterprise (Krichen & Chaabouni, 2022). Considering the increasing entrepreneurship opportunities in healthcare and the negative effects of the COVID-19 pandemic on healthcare services, it has become important to address the entrepreneurship perceptions of students who will serve in this field in the future and to evaluate the hopelessness experienced. When the literature was examined, no other research addressing entrepreneurship in the context of hopelessness was found. Therefore, we believe that our research findings will make a valuable contribution to filling this gap in the literature.

A. Universities, Health Sciences Education and Entrepreneurship

Recent years have focused on the role of universities in industrial competitiveness and their impact on social change (Hart & Rodgers, 2023), and universities in teaching and initiating entrepreneurship have emerged as leading actors. Recent research examining students’ attitudes toward entrepreneurship reveals that universities have a critical role in developing entrepreneurial spirit and perceptions of entrepreneurship in students (Krichen & Chaabouni, 2022; Liao et al., 2022; Sampene et al., 2023). Moreover, university students now value real experience more and prefer universities that offer entrepreneurship opportunities and experiences (Taneja et al., 2024).

Universities providing education in healthcare have traditionally emphasised vocational training and unfortunately, there are very few university programs with curricula that focus on innovation and entrepreneurship in healthcare (Suryavanshi et al., 2020). Consequently, most newly graduated physicians and other healthcare professionals start their careers without the knowledge, experience, and courage to integrate their medical knowledge with the healthcare business world, and thus are unable to commercialise new healthcare delivery methods (Boore & Porter, 2011).

B. Hopelessness Experienced by Students Due to the COVID-19 Pandemic and Perception of Individual Entrepreneurship

Students are one of the groups that experience the psychological effects of the pandemic most intensely (Marahwa et al., 2022). Studies conducted with students during the pandemic period showed that students experienced higher levels of anxiety and depressive symptoms due to uncertainties about the future and the negative effects of the pandemic on their educational lives (Alnıaçık et al., 2021; Hajinasab et al., 2022; Kaplan Serin & Doğan, 2023; Zhang et al., 2021). Moreover, it was also determined that students’ hopelessness levels were higher in the first wave of the pandemic and during the quarantine period and decreased with normalisation (Tao et al., 2023). In addition, it has been found that students who are educated in the field of health and have clinical experience are more anxious and hopeless than undergraduate students who are educated outside the field of health (Pretorius, 2021). Although entrepreneurship is a future-oriented orientation and is perceived as the ability to turn negative situations into opportunities, it is estimated that the psychological effects of COVID-19 may negatively affect entrepreneurial intention in students. Therefore, this study aims to examine the effect of hopelessness experienced by health sciences faculty students during the COVID-19 pandemic on their perception of individual entrepreneurship.

II. METHODS

A. Sampling and Participants and Data Collection

The study was conducted with university students studying at the Faculty of Health Sciences in Türkiye. The faculty consists of six departments, namely Physiotherapy and Rehabilitation, Health Management, Social Work, Nutrition and Dietetics, Child Development and Nursing, and has 2335 students. The sample size required for the study was calculated using the formula (n=[z²xp(1-p)/d²]/1+[z²xp(1-p)/d²N]) and it was determined that a minimum of 337 participants would be sufficient with a 5% error level and 95% confidence level. Participants were selected using a simple random sampling technique and volunteerism was taken as a basis in obtaining the data. The study was conducted between April and May 2022 and 681 valid questionnaires were returned from the participating students.

Data were collected using the socio-demographic information form, Individual Entrepreneurship Perception Scale, and Beck Hopelessness Scale. The Individual Entrepreneurship Perception Scale is a 5-point Likert scale consisting of 31 items and six sub-dimensions: planning, locus of control, self-confidence, communication, motivation, and self-discipline. This scale was developed by Incik and Uzun in 2017 to assess university students’ perceptions of entrepreneurship. The reliability coefficients (Cronbach’s Alpha) of the sub-dimensions of the Individual Entrepreneurship Perception Scale and the total scale were found to be 0.80, 0.84, 0.75, 0.75, 0.75, 0.72, 0.75, 0.60 and 0.92, respectively (Incik & Uzun, 2017). For this study, it was determined that the Cronbach Alpha values of the Individual Entrepreneurship Perception Scale ranged between 0.69 and 0.93 (Table 2).

The Hopelessness Scale was initially developed by Beck et al. in 1974 and subsequently adapted into Turkish by Durak and Palabıyıkoğlu in 1994. This scale comprises 20 items divided into three sub-dimensions: expectations for the future, loss of motivation, and hope. Each question in the scale requires a ‘yes’ or ‘no’ response, and the maximum achievable score is 20. An increase in the overall score denotes a higher level of hopelessness. The reliability coefficients for the sub-dimensions of the scale were calculated to be 0.78, 0.72, and 0.72, respectively (Durak & Palabıyıkoğlu, 1994). Table 2 presents the Cronbach’s alpha coefficients for the sub-dimensions and the scale, which were found to be 0.75, 0.77, 0.74, and 0.88, respectively.

B. Statistical Analysis

The statistical analyses used were performed in SPSS v23.0. Descriptive analyses such as percentage, mean, standard deviation, reliability analysis (Cronbach’s Alpha), and normality tests were performed to obtain the results. To test the normal distribution, kurtosis, and skewness values were calculated for each scale’s sub-dimensions and total scores. It was determined that the values obtained were in the range of -1.5 to +1.5 and the data showed a normal distribution (Tabachnick & Fidell, 2013). The results of the analysis are presented in Table 2. In addition, multiple linear regression analysis was used to investigate the relationship between hopelessness and students’ perception of individual entrepreneurship.

III. RESULTS

The study involved students with an average age of 21.3 years, ranging from 18 to 44 years old. 86% of the participants were female students, and the majority (52.3%) reported a grade point average of 3 or above (with a scale of 0 to 4). 68.3% of the students lived in the city center with their families. Among the students’ mothers, 37.7% had a primary school graduate degree, and 81.4% were not working. On the other hand, 32.2% of the students’ fathers had a high school graduate degree, and 78.4% were actively working. Most of the students (68.3%) stayed in dormitories. Regarding career plans after graduation, most students expressed their interest in working in a health institution (public or private). At the same time, only 15.6% said they wanted to start their own business. 15% of the students were still undecided about their work plans (Table 1).

Submitted: 21 February 2024
Accepted: 16 July 2024
Published online: 1 October, TAPS 2024, 9(4), 26-32
https://doi.org/10.29060/TAPS.2024-9-4/OA3255

Aletheia Chia¹, Menghao Duan¹ & Sashikumar Ganapathy^2,3

¹Paediatric Medicine, KK Women’s and Children’s Hospital, Singapore; ²Department of Emergency Medicine, KK Women’s and Children’s Hospital, Singapore; ³Paediatric Academic Clinical Programme, Duke-NUS Medical School, Singapore

Abstract

Introduction: Mentoring is an essential component of post-graduate medical training programs worldwide, with potential benefits for both mentors and mentees. While factors associated with mentorship success have been described, studies have focused on intrapersonal characteristics and are largely based in Western academic programs. Mentorship occurs in a broader environmental milieu, and in an Asian context, cultural factors such as respect for authority, hierarchy and collectivism are likely to affect mentoring relationships. We aim to explore the lived experience of mentors within an Asian postgraduate medical training program, and thus identify challenges and develop best practices for effective mentoring.

Methods: 14 faculty mentors from a post-graduate paediatric residency program were interviewed between October 2021 to September 2022. Data was collected through semi-structured one-on-one interviews, with participants chosen via purposeful sampling. Qualitative analysis was done via a systematic process for phenomenological inquiry, with interviews thematically coded separately by 2 independent reviewers and checked for consistency.

Results: 4 main thematic concepts were identified: “professional, but also personal”, “respect and hierarchy”, “harmony and avoidance of open conflict” and the “importance of trust and establishing a familial relationship”. Mentors also highlighted the value of structure in Asian mentoring relationships.

Conclusion: Cultural factors, which are deeply rooted in social norms and values, play an important role in shaping mentoring relationships in an Asian context. Mentoring programs should be tailored to leverage on the unique cultural norms and values of the region in order to promote career growth and personal development of trainees and mentors.

Keywords:           Medical Education, Graduate Medical Education, Professional Development

Practice Highlights

• Cultural factors are key in shaping Asian mentoring relationships.
• This includes being ‘professional, but also personal’, ‘respect and hierarchy’, ‘harmony and avoidance of open conflict’ and the “importance of trust and establishing a familial relationship’.
• Mentoring programs should be tailored to leverage on the unique local cultural norms and values.

I. INTRODUCTION

Mentoring is an essential component of post-graduate medical training programs worldwide. Mentorship is a reciprocal, interdependent relationship between a mentor (often a faculty member who is senior and experienced) and a mentee (beginner or protégé in the field) (Sambunjak et al., 2006). Benefits for mentees include aiding career preparation, development of clinical and communication skills, independence, and preventing burnout (Flint et al., 2009; Ramanan et al., 2006; Spickard et al., 2002). Mentors derive satisfaction from aiding the next generation, motivation for ongoing learning and institutional recognition (Burgess et al., 2018).

Variables associated with mentoring success have been described. Key components identified by mentors and mentees are communication and accessibility, caring personal relationship, mutual respect and trust, exchange of knowledge, independence and collaboration, and role modelling (Eller et al., 2014). Personality differences, lack of commitment, conflict of interests and mentor’s lack of experience can contribute to unsuccessful mentoring relationships (Straus et al., 2013).

However, mentorship occurs in a broader environmental milieu. Sambunjak (2015) described an ecological model of mentoring in academic medicine, with a first societal level of cultural, economic and political factors; a second institutional level of system- and organisation-related factors, and a third level of intrapersonal and interpersonal characteristics. Studies on mentorship have mainly focused on the latter and are situated in Western academic programs. In an Asian context, cultural factors such as respect for authority, hierarchy and collectivism may affect mentoring relationships (Chin & Kameoka, 2019). Trainees may show more deference to their mentors, and mentors may be more directive than collaborative. An Asian study surveying Doha’s postgraduate paediatric program found 75% mentees unsatisfied in their mentoring relationship (Khair et al., 2015).

We aim to explore the lived experience of mentors within an Asian postgraduate medical training program, and thus identify the challenges faced by trainees and mentors and develop best practices for effective mentoring.

II. METHODS

A. Study Design

This qualitative study is based on an interpretive phenomenological approach of participants’ lived experiences in their mentoring relationships. Through close examination of individual experiences, phenomenological analysis seeks to capture the meaning and common features, or essences, of an experience (Starks & Trinidad, 2007).

Semi-structured interviews were conducted. The interview guide was designed to follow a pre-determined structure whilst allowing for flexibility in probing. It was based on insights from literature on key socio-cultural determinants of successful mentoring relationships. Data was collected until saturation, with no new themes emerging.

B. Setting

We studied a paediatric residency program of a tertiary academic centre in Singapore, with 47 residents and 180 faculty members.

A formal mentorship program (Figure 1) has been in place since 2010. Residents indicate preferred faculty mentors at the start of residency, and are advised to consider specialty of interest, characteristics, and gender. Matches are subject to availability, review by the residency program, and mentor acceptance. Residents have one formal mentor throughout the 6 years unless the mentorship is terminated by mutual agreement between mentor and mentee.

Figure 1. Mentorship program structure, with suggested meeting timings and requisite forms. Meetings are required minimally 6-monthly and are scheduled on an ad-hoc basis by the mentor and mentee.

C. Participants

Purposive sampling to identify mentors in the residency program who would provide comprehensive and relevant insights. Considerations included age, gender, race, and years of mentorship and faculty experience. Study members and their mentors were excluded.

Study information sheets were provided to participants with assurance of confidentiality, and written informed consent obtained from each participant. The study was approved by the SingHealth Institution Review Board.

D. Analysis

Qualitative analysis was done via a systematic process for phenomenological inquiry (Creswell & Creswell, 2022), whereby statements were analysed and categorised into clusters of meaning that represent phenomenon of interest. Transcripts were interpreted independently by 2 reviewers (AC, MD) and reviewed by a 3rd study member (SG). Iterative data analysis and collection was performed, with coding done after each interview to identify new themes and inform further interviews.

III. RESULTS

We interviewed 14 mentors from October 2021 to September 2022. 8 were male and 6 were female. 12 were Chinese, 1 Indian, and 1 of other ethnicity. This was representative of faculty demographics. Mentors had two to eleven years of mentorship experience within the program, and one to five existing and prior mentees.

Mentors described their lived experiences in their mentoring journey, providing insights into key values and their relationships’ evolution. 4 main thematic concepts were identified: “professional, but also personal”, “respect and hierarchy”, “avoidance of open conflict” and the “importance of trust”. Mentors also highlighted the value of structure in Asian mentoring relationships.

A. Professional, but also Personal

All mentors agreed that the relationship was predominantly professional, with their key role being that of professional and career guidance. They described their roles as:

“Guidance through difficult decisions or challenges” (#1), “leaning the real world of medicine” (#2), “driving professional development” (#12) and providing “timely and wise advice to support the journey” (#13)

Relationships “predominantly focused on professional or educational aspects… as that’s what it was meant to be” (#10), and were “mainly limited to career-related matters (#11)”.

However, many also identified personal connection as key. While the focus was primarily professional, awareness of personal or emotional aspects aided in understanding their mentors to further professional development and psycho-emotional growth. This included sharing of family lives, and emotional difficulties faced at work.

As the journey progresses it becomes a lot more about the psycho-emotional aspect, and about their mental health and personal well-being. (#1)

A lot of time is spent discussing family issues. If we knew more about the personal life of our mentee it’s so much easier to tailor the advice based on the individual’s unique circumstances. (#3)

A minority of mentors kept their relationship strictly professional and preferred not to talk about aspects outside of work, as it was ‘easier’ (#10) and shared concerns of ‘overstepping certain norms’ (#11).

B. Respect and Hierarchy

Respect was a key factor brought up when exploring the socio-cultural aspects of mentoring in our Asian community. Mentors varied in their opinion as to the extent that this resulted in a hierarchical relationship, and if this had a negative or positive impact on the relationship.

All agreed that respect is a key value in mentoring relationships:

Culturally there’s a large part to play as we’re taught to respect our elders. (#1)

Respecting elders – definitely it’s more prominent in our Asian culture. (#2)

Many mentors highlighted that this resulted in a hierarchical relationship. This manifested in the way senior doctors were addressed strictly by title, polite communication, and consideration of what would be ‘proper’ to discuss or ask a mentor to do.

The hierarchical kind of mindset is still very strong, and is something that is not necessarily healthy. (#4)

You would always see your mentor as someone higher than you. It’s similar to the way in our Asian context we see our parents. a certain sense of distance (#11).

The way medicine is a 师傅徒弟 kind of thing (‘master and disciple’) (#13)

Many shared that this could be a barrier to open communication with juniors wanting to “respect and agree” with their mentors (#14), slowing the growth of some relationships.

No matter how much honesty and trust there is. If they want to say something that their mentor is not happy to hear, or strikes them as being a bit rude or disrespectful – they won’t say it. (#1)

Our culture does say to respect your senior, don’t argue and don’t disagree with your senior. Sometimes they’re not very vocal, ‘ok sir ok sir’. And then later you find out they have certain issues. (#9)

One mentor felt that hierarchy did not play a large part in his mentoring relationships. This was possibly personality related, describing himself as naturally “quite informal”.

Mentors also highlighted factors that mitigated the hierarchical nature of their relationship. This included time, and setting clear boundaries and goals of the relationship.

When we give… a clear boundary and aim with no go zones, then culture may not necessarily be that important anymore (#10)

A minority of mentors felt that hierarchy and respect was not a limiting factor in their relationships:

If the primary aim is having someone to offer you guidance and a different point of view, even if the mentee sees you as someone who is not equal, you can still have that effectiveness. (#11)

C. Harmony, Avoiding Open Conflict and Confrontation

Another socio-cultural concept highlighted was the avoidance of confrontation. While some of this was linked to avoiding disagreements given the hierarchical nature of the relationship, avoiding open conflict and striving for harmony was also a key factor.

Rather than openly bringing up something, to avoid being confrontational we have evolved other means of trying to work our way through that conflict. There is a conscious and deliberate effort to avoid open and confrontational conflict. (#3)

When I was in the UK, they really questioned their mentors quite a lot – almost like a quarrel. That kind of questioning style may not be that well received in our own culture. (#2)

When mentees had differing opinions from their mentors “they would rather not talk about the topic again, or just ask someone else” in order to preserve the relationship (#1).

Within our program, this resulted in difficulties in exiting the relationship to avoid “offending” the mentor:

When the mentor-mentee relationship is breaking down, culturally it can be more difficult for mentees to request to swap. That’s very detrimental to both the mentor and the mentee in the long run. (#1)

This also manifested in avoiding overly ‘emotional’ discussions, with discussion often being more “superficial”, “reserved” (#7) and “factual” (#5) in nature.

Conversely, one mentee shared that younger mentees being of a “younger generation” were more open to speaking their mind, and that this would continue to evolve.

D. Importance of Trust and Establishing a Familial Relationship

In exploring key values for successful mentoring relationships, many highlighted the importance of trust and building up an established relationship.

Chemistry and compatibility when starting out was key. Mentors often felt more comfortable if there was a pre-existing relationship they had their mentors and had “shared commonalities and chemistry”. Honesty and trust were key in enabling the relationship to progress. This included respecting each other’s confidentiality. Relationships without trust was difficult as mentors “had to keep guessing what they want”, and “whatever you plan may not be the real goals of what they actually want” (#2). Over time, establishing the relationship made it easier to confide in each other, overcoming boundaries brought on by hierarchy.

It’s about forming relationships before you can start reflecting with the person. Over time we get to know each other, and seeing that what is shared is truly kept private and confidential. Once we have trust among each other it (reservations) doesn’t become a barrier. (#7)

There must be a certain comfort and trust level before one readily does share vulnerabilities. (#2)

This can be enabled by being approachable, and creating safe environments where mentors can share their difficulties without consequence. However, this could be compromised if mentors have to take up a supervisory role or be involved in remediation processes.

Mentors who developed close and trusting relationships with their mentees described it as familial in nature. This could be as a big brother or sister who would give advice to their younger siblings in non-threatening and neutral ways. It was also described by one mentor as parental in nature.

One interviewer highlighted that whilst Asian cultural factors may limit mentoring, there were also potential benefits:

We must find the best of both worlds. The independence that the Western systems have is good, but Asians tend to be better at teamwork and team spirit. (#13)

E. Value of Structure in an Asian Mentorship Relationship

Many mentors highlighted the value of having a framework for their mentoring relationship. Formalisation of the relationship and having a structure provided a foundation for discussions and enabled them to set boundaries. This prevented it from becoming awkward or “random and situation-based” (#15), and also helped faculty who were “still learning the whole journey of mentoring” (#7).

When we don’t know what to talk about it becomes quite awkward and uncomfortable. But if in the Asian context the mentor brings to it some structure, and they respect that structure, that structure is helpful. (#10)

A minority of mentors felt having a framework was too rigid or unnecessary.

The structure must be there to guide the mentors, but the mentors chosen must also be of a certain maturity so they can find their own way. We must not be too prescriptive or rigid. (#13)

IV. DISCUSSION

In this study, we explored the lived experiences of mentors within an Asian paediatric postgraduate training program. Existing studies have explored characteristics of effective and ineffective mentor relationships, but less is known about the impact of sociocultural factors. Key thematic concepts identified such as “respect and hierarchy” and “avoidance of open conflict” highlighted the importance of cultural factors in shaping mentoring relationships in an Asian context. These are deeply rooted in social norms and values of the region.

Hierarchy is a fundamental aspect of many Asian cultures, where individuals are expected to show respect and deference to their ‘elders’ or those in positions of authority. This was also observed in other Asian communities. A study in postgraduate medicine in Japan found that mentees had an inner desire to “respect the mentor’s ideas”, with both mentees and mentors embracing “paternalistic mentoring” (Obara et al., 2021). In our interviews, this was most apparent in the way mentees addressed their mentors: by title and respectfully. On a deeper level, this was a barrier to open communication. Open sharing was identified as crucial for a constructive mentoring relationship (Burgess et al., 2018), with the lack of it a cause of failed mentoring relationships (Straus et al., 2013).  The willingness to share personal experiences by both mentors and mentees is key for effective mentoring and career growth. Additionally, this is not conducive to fostering creativity and innovation, which are increasingly important in the medical profession.

Communication was also affected by avoidance of open conflict and confrontation. Asian cultures have been described as collectivist, where the needs of the group take precedence over that of the individual, and intragroup harmony is paramount (Chin & Kameoka, 2019). In mentoring relationships, this translates to prioritising a successful and harmonious relationship over personal goals. Indirect communication styles are also more common in many Asian cultures. This has been described as high-context communication, whereby “most of the information is either in the physical context or internalised in the person, while very little is in the coded, explicit, transmitted part of the message” (Hall, 1976). Relying on indirect language nonverbal cues rather than explicitly stating one’s thoughts and feelings can hinder open communication.

Hierarchy and a lack of open communication may result in mentors taking on the role of advisors or coaches rather than true mentors. While there is no universal definition of mentorship, key features are that of a long-term dyadic relationship that encompasses educational, training and professional aspects that is personal and reciprocal (Sambunjak & Marusic, 2009). This is in contrast to tutors or coaches that primarily exhibit educational functions, or counsellors that exhibit personal functions. If the mentor-mentee relationship if influenced by hierarchical norms, mentors may be seen as figures of authority rather than partners in development. Cultural respect for authority figures and an emphasis on conformity may also discourage mentees from questioning or having open conversations with their mentors, limiting mutual learning.

Challenges with hierarchy and communication can be overcome with the aid of a structured program, and eventually establishment of trust and ‘familial’ relationships.  A structured program can guide mentors and mentees in having open communication. In an Asian context, mentors may initially play a more authoritative role in guiding and directing their mentees with the aid of a structured guide, from which more two-way communication may open up as the relationship becomes more established. Whilst desirable mentors have characteristically been described as not “bossy” or authoritative (Sambunjak & Marusic, 2009), a study of Japanese physician-scientist mentor-mentees viewed more paternalistic mentoring as favourable (Obara et al., 2021).  However, this will need to be individualised, as a highly directive mentoring style may not be well-suited to those who prefer a more collaborative and participatory mentoring relationship. Communication and learning styles may also continue to evolve with as incoming trainee physicians belong increasingly to Generation Z (1997-2012) instead of Generation Y/Millennials (1981-1996). A study of the mentorship experiences of Gen Z women medical students by Li et al (2024) described how current society had afforded them more opportunities for empowerment and expression, and emphasised the importance of tailored mentorship that considered the mentee’s identify and intersectionality.

Having mutual respect and trust were also key. The mentee and mentor having a pre-existing relationship and familiarity helped, and was more common in our context given that mentees could indicate their mentor of interest. Mutual respect and having a personal connection were also identified as key components in effective mentoring relationships by Eller (2014) and Straus (2013).

Whilst we had initially hypothesised that Asian sociocultural concepts would limit mentorship relationships to be largely professional, mentors shared that mutual respect, trust, and time enabled the relationship to also extend to sharing of personal matters and psychosocial wellbeing. Successful relationships were even described as ‘familial’, with a sense of fulfilment from both parties. A family-like relationship and a sense of loyalty to the mentor and organisation was also described in Japanese mentoring relationships (Obara et al., 2021). Such relationships may be more common in more collectivist cultures. These can be furthered by fostering a sense of community amongst mentees and mentors, such as through group activities, peer support, and shared learning experiences.

A. Limitations

This study was conducted in one of the two paediatric training centres in Singapore. Future studies should expand to other postgraduate programs to improve applicability of the results.

The investigators were participants in the program as mentees or mentors, with potential for bias in analysis. To minimise this, transcripts were analysed independently by two investigators followed by review by the third investigator. While our study focused on the lived experience of mentors, examining the perspective of mentees would be able to provide a more balanced and comprehensive understanding of mentoring relationships and highlight gaps where they can be better supported, and should be considered in future studies.

Our study did not delve into gender dynamics. Female medical trainees may face unique challenges, and male mentors may be stereotypically less nurturing and more process-oriented. Existing studies are varied: a survey of American cardiologists found sex concordance to be beneficial (Abudayyeh et al., 2020), whereas Jackson (2003) did not find same-gender matching to be important in an US academic program. In our initial interviews, gender did not come up as a significant factor and was hence not a focus subsequently. The role of gender in our program may have been minimised by a balanced gender ratio, with 59% of faculty female.

B. Future Research and Practical Implications

Given the significant influence of sociocultural factors on mentoring relationships, mentoring programs should be tailored to reflect the unique cultural norms and values of the region. In Asian cultures, this would include methods to reduce hierarchy, ensuring accessibility to mentors, and having a structured program. Training on mentorship for mentors and mentees would be beneficial to promote characteristics of effective mentoring relationships, and should include a focus on culturally sensitive mentoring with a recognition of how culturally-shaped beliefs can affect mentorship. This is particularly important in multicultural societies where cross-cultural mentorship is more common.

V. CONCLUSION

Cultural factors play an important role in shaping mentoring relationships in an Asian context. Whilst such these may be limiting to a degree, these can be also be leveraged on to further effective mentoring programs. Mentoring programs should be tailored to reflect the unique cultural norms and values of the region to promote career growth and personal development of trainees and mentors.

Notes on Contributors

AC, MD and SG contributed to study conception and design. Participant interviews were conducted by AC. Analysis and thematic interpretation were done by AC, MD with review by SG. All authors were involved in drafting the manuscript and reviewing it critically, and all read and approved the final manuscript.

Ethical Approval

The study was approved by the SingHealth Institution Review Board (IRB number 2021/2542).

Data Availability

The data of this qualitative study are not publicly available due to confidentiality agreements with the participants. 

Funding

No funding was received for conducting this study. 

Declaration of Interest

The authors declare that they have no competing interests.  

References

Abudayyeh, I., Tandon, A., Wittekind, S. G., Rzeszut, A. K., Sivaram, C. A., Freeman, A. M., & Madhur, M. S. (2020). Landscape of mentorship and its effects on success in cardiology. JACC: Basic to Translational Science, 5(12), 1181-1186. https://doi.org/10.1016/j.jacbts.2020.09.014

Burgess, A., van Diggele, C., & Mellis, C. (2018). Mentorship in the health professions: A review. The Clinical Teacher, 15(3), 197-202. https://doi.org/10.1111/tct.12756

Chin, D., & Kameoka, V. A. (2019). Mentoring Asian American scholars: Stereotypes and cultural values. American Journal of Orthopsychiatry, 89(3), 337-342. https://doi.org/10.1037/ort0000 411

Creswell, J. W., & Creswell, J. D. (2022). Research design: Qualitative, quantitative, and mixed methods approaches. SAGE Publications.

Eller, L. S., Lev, E. L., & Feurer, A. (2014). Key components of an effective mentoring relationship: A qualitative study. Nurse Education Today, 34(5), 815-820. https://doi.org/10.1016/j.nedt. 2013.07.020

Flint, J. H., Jahangir, A. A., Browner, B. D., & Mehta, S. (2009). The value of mentorship in orthopaedic surgery resident education: The residents’ perspective. The Journal of Bone and Joint Surgery, 91(4), 1017-1022. https://doi.org/10.2106/JBJS.H.00934

Hall, E. T. (1976). Beyond culture. Anchor Press/Double Day.

Jackson, V. A., Palepu, A., Szalacha, L., Caswell, C., Carr, P. L., & Inui, T. (2003). “Having the right chemistry”: A qualitative study of mentoring in academic medicine. Academic Medicine, 78(3), 328-334. https://doi.org/10.1097/00001888-200303000-00020

Khair, A. M., Abdulrahman, H. M., & Hammadi, A. A. (2015). Mentorship in pediatric Arab board postgraduate residency training program: Qatar experience. Innovations in Global Health Professions Education. https://doi.org/10.20421/ighpe2015.6

Li, C., Veinot, P., Mylopoulos, M., Leung, F. H., & Law, M. (2024). The new mentee: Exploring Gen Z women medical students’ mentorship needs and experiences. The Clinical Teacher, 21(3), e13697. https://doi.org/10.1111/tct.13697

Obara, H., Saiki, T., Imafuku, R., Fujisaki, K., & Suzuki, Y. (2021). Influence of national culture on mentoring relationship: A qualitative study of Japanese physician-scientists. BMC Medical Education, 21(1), 300. https://doi.org/10.1186/s12909-021-02744-2

Ramanan, R. A., Taylor, W. C., Davis, R. B., & Phillips, R. S. (2006). Mentoring matters: Mentoring and career preparation in internal medicine residency training. Journal of General Intermal Medicine, 21(4), 340-345. https://doi.org/10.1111/j.1525-1497.20 06.00346.x

Sambunjak, D. (2015). Understanding wider environmental influences on mentoring: Towards an ecological model of mentoring in academic medicine. Acta Medica Academica, 44(1), 47-57. https://doi.org/10.5644/ama2006-124.126

Sambunjak, D., & Marusic, A. (2009). Mentoring: What’s in a name? JAMA, 302(23), 2591-2592. https://doi.org/10.1001/jama. 2009.1858

Sambunjak, D., Straus, S. E., & Marusic, A. (2006). Mentoring in academic medicine: A systematic review. JAMA, 296(9), 1103-1115. https://doi.org/10.1001/jama.296.9.1103

Spickard, A., Gabbe, S. G., & Christensen, J. F. (2002). Mid-career burnout in generalist and specialist physicians. JAMA, 288(12), 1447-1450. https://doi.org/10.1001/jama.288.12.1447

Starks, H., & Trinidad, S. B. (2007). Choose your method: A comparison of phenomenology, discourse analysis, and grounded theory. Qualitative Health Research, 17(10), 1372-1380. https://doi.org/10.1177/1049732307307031

Straus, S. E., Johnson, M. O., Marquez, C., & Feldman, M. D. (2013). Characteristics of successful and failed mentoring relationships: A qualitative study across two academic health centers. Academic Medicine, 88(1), 82-89. https://doi.org/10.1097/ACM.0b013e31827647a0

*Dr Aletheia Chia
Department of Paediat,
KK Women’s and Children’s Hospital
100 Bukit Timah Road
Singapore 229899
Email: aletheia.chia@mohh.com.sg

Submitted: 8 January 2024
Accepted: 2 July 2024
Published online: 1 October, TAPS 2024, 9(4), 14-25
https://doi.org/10.29060/TAPS.2024-9-4/OA3212

Hema Suryavanshi¹, Santosh R Patil², Kaladhar Reddy Aileni³ & Mohmed Isaqali Karobari⁴

¹Department of Oral Pathology and Microbiology, Chhattisgarh Dental College & Research Institute, India; ²Department of Oral Medicine and Radiology, Chhattisgarh Dental College & Research Institute, India; ³Department of Preventive Dentistry, College of Dentistry, Jouf University, Kingdom of Saudi Arabia; ⁴Dental Research Unit, Centre for Global Health Research, Saveetha Institute of Medical and Technical Sciences, India

Abstract

Introduction: Oral health education is essential for adolescents, yet traditional methods face challenges in engaging this demographic. This study evaluates the effectiveness of a multimedia-based dental education program among high school students. This study was carried out to assess the impact of a comprehensive multimedia-based dental education program on oral health knowledge and practices among high school students.

Methods: A total of 228 students were recruited and randomly assigned to experimental (n=114) and control (n=114) groups. The experimental group received a four-week multimedia program, while the control group followed the standard curriculum. Outcome measures included oral health knowledge scores, brushing frequency, flossing habits, dietary choices, and observational assessments. Statistical analysis employed descriptive statistics, paired t-tests, and analysis of covariance (ANCOVA).

Results: The multimedia-based program led to a significant increase in oral health knowledge scores in the experimental group compared to the control group (Mean Change: 14.6, p < 0.001). Moreover, the experimental group demonstrated higher brushing frequency (p < 0.001), increased flossing habits (p < 0.001), and improved dietary choices (p < 0.05). Observational assessments showed higher adherence to oral hygiene practices in the experimental group (p < 0.001).

Conclusion: The multimedia-based dental education program effectively improved oral health knowledge and practices among high school students. This approach holds promise for scalable and engaging oral health education strategies.

Keywords:           Multimedia-based Education, Oral Health, Adolescents, Dental Education, Health Promotion, Preventive Dentistry

Practice Highlights

• Integrated multimedia elements enhanced participant engagement, utilising videos, e-learning modules, and pamphlets.
• Positive shifts in oral health practices observed, with increased brushing and flossing frequencies in the experimental group.

I. INTRODUCTION

Oral health education serves as a cornerstone in empowering adolescents with the knowledge and skills necessary to maintain optimal oral hygiene. By educating young individuals about the importance of regular brushing, flossing, and dental check-ups, as well as the impact of dietary choices on oral health, preventive practices can be instilled early on. This not only helps in preventing common dental problems like cavities and gum disease but also promotes overall health and quality of life (Nakre & Harikiran, 2013).

Furthermore, addressing oral health education during adolescence is strategic as it provides an opportunity to intervene during a critical developmental stage. By targeting adolescents with effective educational interventions, it becomes possible to shape behavior and instill healthy habits that can last a lifetime. This proactive approach not only benefits the individual’s oral health but also reduces the burden on healthcare systems by minimising the need for costly and invasive dental treatments later in life (Tadin et al., 2022).

The increasing prevalence of dental problems presents a significant public health challenge, as untreated oral diseases can lead to pain, discomfort, and even serious complications such as tooth loss, systemic infections, and impaired overall health (Texas Dental Association, 2008). Moreover, dental problems impose a substantial economic burden on healthcare systems, with costs associated with treatment, emergency care, and lost productivity. In light of these challenges, effective educational interventions are crucial for curbing the burden of oral diseases (Ghoneim et al., 2022). Oral health education programs aim to raise awareness about the importance of oral hygiene, preventive measures, and regular dental check-ups. By providing individuals with the knowledge and skills necessary to maintain good oral health practices, these interventions can empower them to take proactive steps to prevent dental problems and minimise their impact (Kassebaum et al., 2017). This study addresses this need by investigating the impact of a multimedia-based dental education program on the oral health knowledge and practices of high school students.

Adolescence represents a critical period for establishing lifelong health behaviors, and oral health is no exception (National Institutes of Health, 2021). Unfortunately, global studies indicate a concerning prevalence of dental issues among adolescents, including dental caries, gingivitis, and poor oral hygiene practices (Agbelusi & Jeboda., 2006, Zhang et al., 2021). Such issues not only impact immediate health but can also lead to long-term consequences, emphasising the urgency of effective oral health education.

Traditional oral health education methods often face challenges in engaging and effectively conveying information to adolescents. Conventional classroom lectures and textbook-based approaches may struggle to capture the attention of this demographic, potentially limiting the efficacy of such interventions. However, there is evidence to suggest that traditional oral health education has been effective in improving oral health knowledge (Angelopoulou et al., 2015), reducing plaque accumulation, and promoting oral health in adolescents (Gousalya et al., 2022). On the other hand, it is important to note that traditional models of oral health education have been criticised for their didactic delivery and failure to acknowledge the individual context and motivations of the recipients (Ford & Farah., 2012).

As technology becomes increasingly integrated into daily life, leveraging multimedia platforms for health education emerges as a promising strategy to enhance engagement and knowledge retention (George et al., 2014).

The primary objective of this study was to assess the effectiveness of a comprehensive multimedia-based dental education program in improving oral health knowledge and promoting positive oral hygiene practices among high school students. By employing a well-structured intervention and rigorous evaluation, this research aims to contribute valuable insights that can inform the design and implementation of future oral health education initiatives.

The significance of this study lies in its potential to inform evidence-based oral health education strategies for adolescents, especially in regions facing resource constraints. If successful, the multimedia-based approach could serve as a scalable and cost-effective model for widespread implementation in school settings. Ultimately, the outcomes may contribute not only to the improvement of oral health outcomes among adolescents in the study setting but also to the development of best practices with broader implications for global oral health promotion.

II. METHODS

A. Intervention

A comprehensive multimedia-based dental education program was developed by a team of experienced dental educators, multimedia designers, and content developers. The program included visually engaging educational videos covering various aspects of oral health, interactive e-learning modules to reinforce key concepts, and informative pamphlets providing supplementary written material.

Throughout the intervention period, the research team closely monitored the attendance and participation of students in both the experimental and control groups. Attendance records, completion rates of e-learning modules, and participation levels in interactive sessions were meticulously documented to assess the program’s adherence.

1) Program feedback and modification: Continuous feedback sessions were held with both students and educators to evaluate the effectiveness of the multimedia-based dental education program. Adjustments and modifications were made in real-time based on feedback received, ensuring the program remained dynamic and responsive to the specific needs and preferences of the participants.

2) Quality assurance: To maintain consistency and quality across program delivery, educators underwent training sessions, and periodic evaluations were conducted to assess their adherence to the prescribed curriculum and teaching methodologies.

B. Study Design

A randomised controlled trial was conducted involving 228 high school students, aged 14 to 18, recruited from four local high schools in Burhanpur, India, after obtaining permission from the school authorities. Institutional Review Board (IRB) approval with approval number GGSCDS&RC/2022/IEC/168 was obtained prior to the start of this study. Students and their parents/guardians were provided with detailed information about the study, and informed consent was obtained from all participants. The study was conducted between January 2022 and December 2023.

A sample size calculation was conducted prior to the initiation of the study to ensure adequate statistical power. Based on previous literature and anticipated effect sizes, the calculation indicated that a sample size of 228 participants would provide sufficient power to detect significant differences in oral health knowledge and practices between the experimental and control groups. Factors such as an alpha level of 0.05, a power of 0.80, and an effect size estimate derived from similar interventions were taken into consideration during the calculation. This approach ensured that the study was adequately powered to detect meaningful differences in the outcomes of interest.

Random assignment of participants to the experimental and control groups was performed using a computer-generated randomisation sequence. The sequence was generated by an independent researcher not directly involved in the implementation of the study. Participants were assigned to the experimental or control group based on their identification numbers, ensuring an equal chance of allocation to either group. This randomisation process helped minimise selection bias and ensure that any differences observed between the groups could be attributed to the intervention rather than systematic differences in participant characteristics.

Given that participants were recruited from multiple local high schools in Burhanpur, India, cluster randomisation was employed to minimise contamination between groups. High schools were considered as clusters, and randomisation was carried out at the school level to prevent potential contamination of intervention effects between students within the same school. This approach helped maintain the integrity of the study design and reduce the risk of cross-group contamination, thereby enhancing the internal validity of the findings.

To address potential biases related to academic performance, we collected demographic information from all participants, including indicators of academic achievement. This information allowed us to assess any confounding variables during data analysis. Additionally, randomisation was employed to ensure that participants with varying academic backgrounds were equally distributed between the experimental and control groups, minimising the impact of academic performance on study outcomes.

1) Experimental group (n=114): Prior to the intervention, informed consent was obtained from both students and their parents/guardians. The multimedia-based dental education program was delivered to the experimental group during regular school hours. The intervention spanned four weeks, with carefully structured sessions designed to cover topics such as oral anatomy, proper brushing and flossing techniques, the impact of diet on oral health, and the importance of regular dental check-ups. Each week, students participated in interactive discussions, watched educational videos, completed e-learning modules, and received informational pamphlets to reinforce the acquired knowledge. To ensure engagement and understanding, the program incorporated quizzes, group activities, and open discussions facilitated by trained dental educators.

2) Control group (n=114): The control group received the standard oral health education provided as part of the existing school curriculum. The standard curriculum included traditional classroom lectures, textbook readings, and basic demonstrations of oral hygiene practices. No additional multimedia resources were introduced to the control group to maintain a clear distinction from the experimental group.

C. Development of Survey Instrument

The survey instrument utilised for baseline assessment underwent a rigorous validation process to ensure its reliability and validity in measuring participants’ oral health knowledge. The validation process included several key steps aimed at enhancing the quality and accuracy of the survey instrument.

The survey items were delved based on an extensive review of existing literature on oral health knowledge among adolescents. Content experts in the fields of dentistry, public health, and education were consulted to ensure that the survey items adequately covered essential concepts related to oral health.

Prior to the commencement of the main study, a pilot test of the survey instrument was conducted with a small group of high school students similar to the study population. Feedback from the pilot test participants was carefully analysed, and adjustments were made to the wording and clarity of the survey items based on their input.

The survey instrument underwent thorough review by a panel of experts comprising professionals from diverse backgrounds, including dentistry, education, and survey design. The expert panel assessed the relevance, comprehensibility, and appropriateness of the survey items for the target population, providing valuable feedback for further refinement.

D. Outcome Measurements and Analysis

In this study, a comprehensive set of outcome measures was employed to assess the impact of the intervention on participants’ oral health knowledge and practices. The study commenced with a baseline assessment, during which demographic data, oral health history, and participants’ knowledge of oral health practices were collected. Throughout the four-week intervention period, participants’ oral health practices were evaluated weekly through self-reports and observations, ensuring continuous monitoring of their adherence and engagement with the program. Following the intervention, a post-intervention assessment was conducted, and participants’ oral health practices were monitored for an additional two weeks to assess the sustainability of behavior changes beyond the intervention period.

1) Pre-intervention assessment: Before the initiation of the intervention, a thorough baseline assessment of participants’ oral health knowledge was conducted using validated surveys (Appendix A). These surveys covered a wide spectrum of oral health concepts, including the anatomy of teeth and gums, the significance of fluoride, and common dental diseases. Individual knowledge scores were calculated, establishing a baseline measure for each participant, with the maximum score for the knowledge assessment set at 100 (Appendix B).

2) Post-intervention assessment: Following the four-week intervention period, participants from both the experimental and control groups underwent a post-intervention survey (Appendix C). This survey mirrored the pre-intervention assessment and allowed for a direct comparison of changes in knowledge. Individual knowledge scores were recalculated, and the difference between pre- and post-intervention scores was used to quantify the impact of the educational program.

3) Brushing frequency: Participants’ brushing habits were assessed through a combination of self-reporting and observation. Each participant maintained a detailed log, recording the frequency and duration of their toothbrushing activities. Trained researchers also conducted periodic observations to validate self-reported data, enhancing the reliability of the findings.

4) Flossing habits: Similar to brushing, participants self-reported their flossing habits, detailing the frequency and thoroughness of their flossing routine. Periodic checks were conducted to corroborate self-reported data, ensuring the accuracy of the information gathered.

5) Dietary choices: The study assessed participants’ dietary habits related to oral health, including the consumption of sugary snacks and beverages. Dietary logs and self-reporting were used, and nutritional assessments were conducted to evaluate participants’ awareness of the relationship between diet and oral health.

Trained researchers conducted periodic observations to assess participants’ oral health practices in a naturalistic setting. This included direct observations of toothbrushing and flossing routines, as well as an assessment of participants’ adherence to recommended oral hygiene practices.

Throughout the study, continuous monitoring and quality checks were implemented to ensure the accuracy and reliability of the outcome measures. Any deviations or unexpected trends in the data were promptly investigated, and corrective actions were taken as needed. This approach ensured the robustness of the study’s outcome assessments.

Descriptive statistics were employed for demographic data. Paired t-tests were used to compare pre- and post-intervention knowledge scores. Analysis of covariance (ANCOVA) was conducted to assess the impact of the intervention on oral health practices, controlling for baseline differences. IBM SPSS Statistics software (version 22.0) was utilised for data analysis, with a predetermined significance level set at p < 0.05.

III. RESULTS

The demographic characteristics table illustrates a well-balanced study population, with both the experimental and control groups having similar age distributions (16.2 ± 1.0 vs. 16.1 ± 0.9) and gender representation (Male/Female: 56/58 vs. 55/59). Baseline knowledge scores align closely, with mean scores of 45.2 (experimental) and 44.8 (control) and standard deviations of 8.3 and 8.1, respectively (Table 1).

Submitted: 16 December 2022
Accepted: 25 June 2024
Published online: 1 October, TAPS 2024, 9(4), 6-13
https://doi.org/10.29060/TAPS.2024-9-4/OA2928

Pooja Sachdeva & Derrick Chen-Wee Aw

Department of General Medicine, Sengkang General Hospital, Singapore

Abstract

Introduction: Case write-ups and reflective journals have been used as assessment tools of learning in clinical rotations in Yong Loo Lin school of medicine. It is timely to review the current process of conducting these assessments and effectiveness as an assessment tool. This study aims to understand faculty outlook towards these assessments.

Methods: This is a study that involves a survey-based questionnaire with both closed and open-ended questions, sent out to faculty marking the students’ assignments. This survey was anonymous & voluntary and was disseminated by administrative assistants. The purpose of this survey was to collect the feedback from faculty about current process with intentions of improving the effectiveness of these assessments. The suggestions for improvement were incorporated in the survey and faculty was invited to comment over these suggestions and provide further suggestions if any.

Results: Fifty-two responses from faculty were collected and analysed. Ninety percent of respondents thinks that this is an effective tool to assess and promote self-directed learning. Qualitative feedback was received about need of improvement in a) alignment of the submissions timings with rotation postings b) marking rubric to incorporate factors such as case complexity and weightage to different components of case write-ups, c) timely feedback to students, and d) follow up on action plans.

Conclusion: Case write-ups and reflective journals are still effective learning and assessment tools. They promote self-directed learning and clinical analysis in students. Feedback and action plans are the backbone of these assessments and optimal utilisation of these is recommended.

Keywords:           Undergraduate Medical Education, Case Write-ups, Medical Assessments, Reflective Journals

Practice Highlights

• Case write-ups promote critical analysis & clinical judgement and reflection develops metacognition.
• Students should be guided and encouraged to choose cases to promote self-directed learning.
• Marking rubrics need revising and faculty development on how to utilise them.
• Timing of submission needs to be improved to facilitate feedback and follow-up.
• Direct and timely feedback to students and follow up on actions plans improve utility.

Table 1. Comparison of Mini CEX and case write-ups as assessment tools

*For direct feedback, assessor needs to have follow up communication with the student.

**it can be made objective with descriptors provided in the, marking template for each domain that is being assessed.

Evidence has shown that case write-ups do provide assessors the ability to understand students’ learning and analytical skill (McLeod, 1989) and unlike Mini CEX, it involves reflections by students that deepen learning and memory (Fortson & Sisk, 2007). Similarly, Bjerkvik & Hilli (2019) emphasised that reflective journals promote deeper understanding, critical analysis, metacognition and promotes self-development. Onishi (2008) noted that case presentations during clinical rotations promote the assessor’s understanding of student learning which is consistent with our faculty response as most of our faculty (n=47, 90%) agree that case write-ups are important tools to assess learning. However, since these are not observed assessments at the bedside and require submission, there is no face-to-face contact with the student to give instant feedback and discuss action plans, if any. The discussion of feedback and action plan requires separate communication such as a meeting or phone calls or emails between the assessor and student. If appropriate feedback is not provided or communicated, it is a lost opportunity for improvement in students’ learning.

Results from our survey have highlighted a few areas that needed the attention in optimal utilisation of these assessments. First is, the choice of cases, either by faculty or by students is not uniform. The case selection by students promotes self-directed learning. Presently, students are given a list of cases that may help them select one, but the enlisted cases may not be encountered during their rotation. In such situations, faculty suggesting the choice of cases can provide directions to students. Lee et al. (2010) demonstrated that students who were encouraged to choose their cases based on their knowledge gaps, learning strategies, and study time, were more inclined towards self-directed learning. Self-directed learning has been a cornerstone of adult learning, and it provides learners autonomy and control over their learning and prepares them for lifelong self-management outside educational institutions (Goldman, 2009; Lee et al., 2010). Understandably, students’ choice of cases is influenced by the curriculum, tutorials, and objectives of a particular rotation. Case write-ups and Reflective Journals in our context included both inpatient and outpatient encounters hence providing the choice for both acutely sick vs stable chronic patients. Since the students were encouraged to choose their cases for these assessments on their own, it provided them the opportunity to meet their personal goals and learning deficits. However, if asked for guidance, slightly more than half the faculty (56%, n=29) would assign the cases themselves, and of note, such selection of cases, in various forms of frequency and complexity, did affect the marking by faculty by a considerable amount (about 30 to 45%). Nonetheless, the reflective journals involve writing about one’s learning evolution about a case from preset knowledge to acquired knowledge after encounter. Hence, both these written assignments, case write-ups and reflective journals on any encounter tend to improve learning by making students do literature search and individualise this current evidence-based management search in context of the chosen patient. It still serves the purpose of learning, although personal selection of patients encourages students to work on their own interest, at their own pace and promotes deeper understanding tailored to one’s own pre-existing gaps or deficiencies in knowledge. The authors think that faculty assigning cases will inadvertently compromise the extent of self-directed learning to a significant degree and adjusting the marking based on the frequency and complexity is a qualitative component that warrants further investigation. We recommend the school generate a simple set of guidelines to help students to make an informed and wise selection of suitable cases for their written assignments. Focus group discussions with tutors who regularly mark students on such assignments may provide useful directions in the guidelines’ construction.

Results of this survey also raised the inconsistency in faculty use of marking rubrics. McLeod (1989) raised the major concerns about the variability of criteria and standards of evaluation of these written assessments.

Kogan & Shea (2003) addressed these concerns and assessed the evaluation of write-ups against a pre-set evaluation form that increased the validity and reliability of scoring these write ups. Peggy (2014) also highlighted the use of standardised scoring rubric for case write-ups to reduce the interrater variability and improve the reliability of these assessments. Hence, the scoring rubrics must have descriptors for faculty to mark the students against their performances and it not only makes the assessment fair, but also contributes to individualised and appropriate feedback for students for further improvement in respective domains (Cyr et al., 2014; Kogan & Shea, 2005). Thus, the author recommends that universities or schools must emphasise on faculty training and thereby its use in marking these assignments.

This also brought about the feedback, provided by faculty in this survey about components of this rubric. Reflective journals and case reports assess similar yet different components of learning. While case reports accounts more for critical analysis, clinical judgement, evidence-based management for a particular patient, the reflective journals assess the student’s ability to assimilate an encounter with new acquired knowledge and reflect on their individual learning and growth (Sandars, 2009). Hence, rubric should be tailored to these assessments’ subcomponents accordingly. A small fraction of faculty (12%, n=6) in our survey responded that the discussion and analysis of information by students influenced their marking of the write-up as it provided them invaluable insight into students’ clinical reasoning. In line with this, half of the faculty (53%, n=27) recommended that analytic skills be ranked higher in weightage as compared to data collection on patient history and examination. Hence, marking rubric should emphasise more on clinical judgement and critical analysis in case write-ups than components such as history taking and examination as latter can be assessed in detail with other assessments such as Mini CEX or OSCE examinations. At the same time, complexity of the case and atypical presentation must also account for separate marks to encourage students for choosing challenging and difficult cases. Similarly, for reflective journals rubrics must have weightage on self-reflection cycle, changes in attitudes and perception and how the encounters have changed one’s learning and future practice. The role of rubric in standardisation of these written assessments is paramount as former provides a structure of written submissions for students and reliable and valid scoring tool for faculty.

Results of our survey also highlighted pertinent inadequacy in these assessments that is inability to provide the face-to-face feedback to the students in timely fashion, contributed by timing of submissions of these assessments towards the end of rotation. There is ample literature to support that feedback is a backbone of any formative assessment (Clynes & Raftery, 2008; Nicol & Macfarlane‐Dick, 2006) as it promotes self-regulation of training and highlights the discrepancies in the trainee’s current vs expected learning outcome. Hence like every other assessment, the templates of case write-ups are imbued with spaces for feedback and action plans which the majority of faculty (60%, n=31) have personally communicated to the students. Face-to-face feedback has a higher impact on performance improvement than written indirectly communicated or no feedback as the former provides two-way engagement, however, this impact depends upon the supervisor’s training and content & organisation of feedback (Johnson et al., 2020; Pelgrim et al., 2012). The final stage of providing any feedback as per Pendleton’s rule (Pendleton, 1984). Pendleton’s rule is an agreement between the learner and assessor for a joint action plan for improvement. Presently, there is no timeline for students to submit these written assignments to their core supervisor, hence if these are submitted towards the end of the rotation, the opportunity for face-to-face feedback and discussion on action plans is underutilised. Hence, it would be worthwhile to align the submission with weeks of rotation so that timely and personal feedback can be provided and agreed action plans can be followed within the rotation.

This study highlighted that though an action plan was agreed upon, it was not actively followed up with students 90% (n=47) of the time – as such, the accountability of this assessment is reduced. The most common reason for the inability to follow up on action plans was coordination (having to schedule a meeting between the assessor and student when the student may have moved on to the next rotation). This can be modified if students are instructed to submit their assignments at least one or two weeks before the end of posting to allow ample time for both parties to schedule a meet-up. Alternatively, there could be an end-of-posting mandatory meet-up with the clinical supervisor to provide overall feedback for rotation and to discuss action plans. Additionally, the school could also mandate a follow-up meeting, over an interactive online platform if a face-to-face meeting is not feasible, for a supervisor to review the outcomes of the actions undertaken by the student. The school may even consider recruiting student mentors to follow up instead.

Overall, this survey has provided useful insight into these assessments’ conduct and has highlighted the factors that limit the utility of these written assessments. With the faculty agreeing that these assessments are still worthy educational and learning assessment tools, there is a need to improve marking standardisation of these assessments and like other assessments, formative feedback to students on gaps in knowledge must be provided. These assessments have been part of curriculum for decades and their role in students learning must be utilised to its full potential.

There are limitations in our study such as lower number of respondents and qualitative feedback. As survey is voluntary and anonymous, it is limited in its research capability for recommendations and qualitative feedback as latter is respondent dependent. Hence, further qualitative research such as focussed group discussions is required to understand the ways, these assessments can be utilised to their full potential as learning and assessment tools.

VI. CONCLUSION

In conclusion, written assignments are still worthy and useful tools to assess the learning of students during clinical rotations. It promotes self-directed learning by allowing students to select their case and provides the opportunity for the assessor to assess the knowledge gaps of students about case management. Since the case choice affects the marking by the assessor, authors recommend that students are given free reign, within a set of recommended guidelines.

Marking and scoring should be adjusted to include variables such as case selection and complexity in the marking rubric provided to the assessors, hence authors also recommend updating marking rubrics in consultation with faculty, with subsequent faculty development for compulsory use of this rubric.

For these assessments to be more effective, structured, timely and direct feedback should be given to students with action plans that must be followed. The hurdles in following up on action plans such as change of rotations can be dealt with by adjusting the timing of submission of these assessments during a posting and creating opportunities for follow-up. Hence, authors also recommend face-to-face feedback by ensuring adequate timing of assessments and appropriate follow up for action plans to maximise educational improvement opportunities.

Notes on Contributors

Dr. Pooja Sachdeva has contributed to the conceptual development of this study, survey questionnaire development, dissemination of the survey to faculty, data collection, and analysis. This manuscript has been written, read, and finally approved by her.

Dr. Derrick Aw has contributed to the conceptual development of this study, survey questionnaire development, and student and faculty engagement. This manuscript was read, edited, and finally approved by him.

Ethical Approval

The study was approved by the Singhealth Institutional Review Board (IRB) with reference no 2020/2688.

Data Availability

The data that supports the findings of this study are openly available in Figshare repository at https://doi.org/10.6084/m9.figshare.24471661.v1  (Sachdeva & Aw, 2023).

Acknowledgement

We acknowledge the contributions of Dr Shweta Rajkumar Singh for editing the final manuscript.

Funding

There is no funding received for the study.

Declaration of Interest

There are no conflicts of interest.

References

Bjerkvik, L. K., & Hilli, Y. (2019). Reflective writing in undergraduate clinical nursing education: A literature review. Nurse Education in Practice, 35, 32–41. https://doi.org/10.1016/j.nepr.2018.11.013

Boyd, E. M., & Fales, A. W. (1983). Reflective learning: Key to learning from experience. Journal of Humanistic Psychology, 23(2), 99–117. https://doi.org/10.1177/0022167883232011

Bussard, M. E. (2015). Clinical judgment in reflective journals of prelicensure nursing students. The Journal of Nursing Education, 54(1), 36–40. https://doi.org/10.3928/01484834-20141224-05 

Clynes, M., & Raftery, S. (2008). Feedback: An essential element of student learning in clinical practice. Nurse Education in Practice, 8(6), 405–411. https://doi.org/10.1016/j.nepr.2008.02.003

Cyr, P. R., Smith, K. A., Broyles, I. L., & Holt, C. T. (2014). Developing, evaluating and validating a scoring rubric for written case reports. International Journal of Medical Education, 5, 18–23. https://doi.org/10.5116/ijme.52c6.d7ef

Fortson, A. (n.d.). Reflective journaling as assessment and teaching. http://www.reap.ac.uk

Gibbs, G. (1998). Learning by Doing: A guide to teaching and learning methods. Oxford Brookes University.

Goldman, S. (2009). The educational kanban: Promoting effective self-directed adult learning in medical education. Academic Medicine, 84(7), 927–934. https://doi.org/10.1097/ACM.0b013e3181a8177b

Johnson, C. E., Weerasuria, M. P., & Keating, J. L. (2020). Effect of face-to-face verbal feedback compared with no or alternative feedback on the objective workplace task performance of health professionals: A systematic review and meta-analysis. BMJ Open, 10(3), e030672. https://doi.org/10.1136/bmjopen-2019-030672

Joshi, M., Singh, T., & Badyal, D. (2017). Acceptability and feasibility of mini-clinical evaluation exercise as a formative assessment tool for workplace-based assessment for surgical postgraduate students. Journal of Postgraduate Medicine, 63(2), 100–105. https://doi.org/10.4103/0022-3859.201411

Kogan, J. R., Bellini, L. M., & Shea, J. A. (2002). Implementation of the mini-CEX to evaluate medical students’ clinical skills. Academic Medicine, 77(11), 1156–1157. https://doi.org/10.1097/00001888-200211000-00021

Kogan, J. R., & Shea, J. A. (2003). An assessment measure to evaluate case write-ups in a medicine core clerkship. Medical Education, 37(11), 1035–1036. https://doi.org/10.1046/j.1365-2923.2003.01660.x

Kogan, J. R., & Shea, J. A. (2005). Psychometric characteristics of a write-up assessment form in a medicine core clerkship. Teaching and Learning in Medicine, 17(2), 101–106. https://doi.org/10.1207/s15328015tlm1702_2

Kunin, M., Julliard, K. N., & Rodriguez, T. E. (2014). Comparing face-to-face, synchronous, and asynchronous learning: Postgraduate dental resident preferences. Journal of Dental Education, 78(6), 856–866.

Larsen, D. P., London, D. A., & Emke, A. R. (2016). Using reflection to influence practice: Student perceptions of daily reflection in clinical education. Perspectives on Medical Education, 5(5), 285–291. https://doi.org/10.1007/s40037-016-0293-1

Lee, Y.-M., Mann, K. V., & Frank, B. W. (2010). What drives students’ self-directed learning in a hybrid PBL curriculum. Advances in Health Sciences Education: Theory and Practice, 15(3), 425–437. https://doi.org/10.1007/s10459-009-9210-2

McGlade, K., Cargo, C., Fogarty, D., Boohan, M., & McMullin, M. (2012). Handwritten undergraduate case reports. The Clinical Teacher, 9(2), 112–118. https://doi.org/10.1111/j.1743-498X.2011.00494.x

McLeod, P. J. (1987). Faculty assessments of case reports of medical students. Journal of Medical Education, 62(8), 673–677. https://doi.org/10.1097/00001888-198708000-00008

McLeod, P. J. (1989). Assessing the value of student case write-ups and write-up evaluations. Academic Medicine, 64(5), 273–274. https://doi.org/10.1097/00001888-198905000-00016

Mello, L. V., & Wattret, G. (2021). Developing transferable skills through embedding reflection in the science curriculum. Biophysical Reviews, 13(6), 897–903. https://doi.org/10.1007/s12551-021-00852-3

Miller, G. E. (1990). The assessment of clinical skills/competence/performance. Academic Medicine, 65(9), S63.

Mortaz Hejri, S., Jalili, M., Masoomi, R., Shirazi, M., Nedjat, S., & Norcini, J. (2020). The utility of mini-clinical evaluation exercise in undergraduate and postgraduate medical education: A BEME review: BEME Guide No. 59. Medical Teacher, 42(2), 125–142. https://doi.org/10.1080/0142159X.2019.1652732

Nicol, D. J., & Macfarlane-Dick, D. (2006). Formative assessment and self-regulated learning: A model and seven principles of good feedback practice. Studies in Higher Education, 31(2), 199–218. https://doi.org/10.1080/03075070600572090

Onishi, H. (2008). The role of case presentation for teaching and learning activities. The Kaohsiung Journal of Medical Sciences, 24(7), 356–360. https://doi.org/10.1016/s1607-551x(08)70132-3

Patrício, M. F., Julião, M., Fareleira, F., & Carneiro, A. V. (2013). Is the OSCE a feasible tool to assess competencies in undergraduate medical education? Medical Teacher, 35(6), 503–514. https://doi.org/10.3109/0142159X.2013.774330

Pelgrim, E. A. M., Kramer, A. W. M., Mokkink, H. G. A., & van der Vleuten, C. P. M. (2012). The process of feedback in workplace-based assessment: Organisation, delivery, continuity. Medical Education, 46(6), 604–612. https://doi.org/10.1111/j.1365-2923.2012.04266.x

Pendleton, D. (1984). The consultation: An approach to learning and teaching. Oxford University Press.

Sachdeva, P. & Aw D. C. W. (2023). Case write-ups survey responses [Dataset]. Figshare. https://doi.org/10.6084/m9.figshare.24471661.v1  

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

Schon, D. A. (1984). The reflective practitioner: How professionals think in action. Basic Books.

Stufflebeam, D. (2002). The CIPP model for evaluation. In The International Handbook of Educational Evaluation, 49, 279–317. https://doi.org/10.1007/0-306-47559-6_16

*Pooja Sachdeva
110 Sengkang East Way,
Singapore 544886
96170342
Email address: pooja.sachdeva@singhealth.com.sg

Submitted: 5 July 2023
Accepted: 12 December 2023
Published online: 2 July, TAPS 2024, 9(3), 1-14
https://doi.org/10.29060/TAPS.2024-9-3/OA3045

Dujeepa D Samarasekera¹, Shuh Shing Lee¹, Su Ping Yeo¹, Julie Chen², Ardi Findyartini^3,4, Nadia Greviana^3,4, Budi Wiweko^3,5, Vishna Devi Nadarajah⁶, Chandramani Thuraisingham⁷, Jen-Hung Yang^8,9, Lawrence Sherman¹⁰

¹Centre for Medical Education, Yong Loo Lin School of Medicine, National University of Singapore, Singapore; ²Department of Family Medicine and Primary Care/ Bau Institute of Medical and Health Sciences Education, LKS Faculty of Medicine, The University of Hong Kong, Hong Kong; ³Medical Education Center, Indonesia Medical Education & Research Institute (IMERI), Faculty of Medicine, Universitas Indonesia, Jakarta, Indonesia; ⁴Department of Medical Education, Faculty of Medicine, Universitas Indonesia, Jakarta, Indonesia; ⁵Department of Obstetrics and Gynaecology, Faculty of Medicine Universitas Indonesia/Cipto Mangunkusumo Hospital, Jakarta, Indonesia;  ⁶IMU Centre of Education and School of Medicine, International Medical University, Kuala Lumpur, Malaysia; ⁷Department of Family Medicine, School of Medicine, International Medical University, Kuala Lumpur, Malaysia; ⁸Medical Education and Humanities Research Center and Institute of Medicine, College of Medicine, Chung Shan Medical University, Taichung, Taiwan; ⁹Department of Dermatology, Chung Shan Medical University Hospital, Taichung, Taiwan; ¹⁰Meducate Global, LLC, Florida, USA

Abstract

Introduction: Continuing medical education and continuing professional development activities (CME/CPD) improve the practice of medical practitioners and allowing them to deliver quality clinical care. However, the systems that oversee CME/CPD as well as the processes around design, delivery, and accreditation vary widely across countries. This study explores the state of CME/CPD in the East and South East Asian region from the perspective of medical practitioners, and makes recommendations for improvement.

Methods: A multi-centre study was conducted across five institutions in Hong Kong, Indonesia, Malaysia, Singapore and Taiwan. The study instrument was a 28-item (27 five-point Likert scale and 1 open-ended items) validated questionnaire that focused on perceptions of the current content, processes and gaps in CME/CPD and further contextualised by educational experts from each participating site. Descriptive analysis was undertaken for quantitative data while the data from open-ended item was categorised into similar categories.

Results: A total of 867 medical practitioners participated in the study. For perceptions on current CME/CPD programme, 75.34% to 88.00% of respondents agreed that CME/CPD increased their skills and competence in providing quality clinical care. For the domain on pharmaceutical industry-supported CME/CPD, the issue of commercial influence was apparent with only 30.24%-56.92% of respondents believing that the CME/CPD in their institution was free from commercial bias. Key areas for improvement for future CME/CPD included 1) content and mode of delivery, 2) independence and funding, 3) administration, 4) location and accessibility and 5) policy and collaboration.

Conclusion: Accessible, practice-relevant content using diverse learning modalities offered by unbiased content providers and subject to transparent and rigorous accreditation processes with minimal administrative hassle are the main considerations for CME/CPD participants.

Keywords:        Medical Education, Health Profession Education, Continuing Professional Development, Continuing Medical Education, Accreditation

Practice Highlights

• Identifying professional practice gaps of clinicians should be the first step.
• The state of CME/CPD varies among countries and addressing relevant needs is crucial.
• Clinicians agreed that CME/CPD improves their skills and knowledge but lacked time to participate.
• Potential improvements include relevant content free from commercial bias and delivery mode.
• Systematic governance and aligned regulations by physician credentialing agencies is recommended.

I. INTRODUCTION

Lifelong learning is an essential skill for all healthcare professionals. This is particularly true when new models of healthcare delivery are being implemented and there is increased focus on outcomes and values such as shorter hospital stay, greater accountability and transparency and emphasis on patient engagement (Sachdeva, 2016; Vinas et al., 2020). Recent literature highlights that continuing medical education and continuing professional development programs (CME/CPD) are crucial in providing current contextually relevant educational and developmental activities in maintaining knowledge, skills, and performance for clinicians and have proven to be effective (Cervero & Gaines, 2015; Drude et al., 2019; Forsetlund et al., 2009). CME is defined as “educational activities which serve to maintain, develop, or increase the knowledge, skills, and professional performance and relationships that a physician uses to provide services for patients, the public, or the profession” (Accreditation Council for Continuing Medical Education, n.d.), while CPD is usually a broader and more inclusive term referring to the combination of formal CME and other activities type that are designed to assist healthcare professionals to acquire skills and knowledge essential for their professional growth (Sherman & Chappell, 2018). Critical systematic reviews of the literature have shown that CME/CPD improves practice and support professional activities of medical practitioners to deliver best patient care (Cervero & Gaines, 2015; Sachdeva, 2016).

Although CME/CPD has undergone enormous changes and growth over the past 25 years, the advancement in CPD still considerably lag behind as compared to undergraduate and graduate medical education (Sachdeva et al., 2016). Goals and objectives in CME/CPD are often poorly defined and there is a paucity of the curricular structure for medical practitioners (Sachdeva, 2016). Despite consistent evidence sharing that formal CME/CPD activities, such as conferences and workshops, have little or no long-lasting effect on medical practitioners, many CME/CPD providers continue to include these approaches as their major educational offerings while clinicians continue to attend to improve their practice (Mann, 2002). Additionally, there are environments where CME/CPD is not mandatory, and in some instances, non-existent (Sherman & Nishigori, 2020).

Despite CME/CPD’s importance, the state of CME/CPD varies widely across regions and countries. Unlike Europe and the United States, there is no parallel accreditation system for CME/CPD in Asia. CME/CPD does not follow a standard process in all countries and the requirements are also different. A short summary of the CME/CPD system in the countries which are studied in this article is provided in Appendix 1. However, there is still a lack of empirical data in understanding the CME/CPD in Asia. Only one study was conducted in Japan to assess the state of CPD in the country and to identify the gaps in the understanding of the medical practitioners’ needs (Sherman & Nishigori, 2020). Hence, this study aims to explore the state of CME/CPD in the East and South East Asian region from the perspective of medical practitioners, and make recommendations for improvement.

A. Theoretical Framework

Researchers have been proposing few theoretical frameworks which are related to CME/CPD. For this study, we will be using the Process of Change and Learning framework by Fox et al. (1989) to provide an overarching view on the process of change and learning among medical practitioners. This will be further enhanced by using adult learning theory (Knowles, 1989).

No discussion of practice informing theory in CME could exclude the work of Fox et al. (1989), who studied the process of change and learning in the lives of medical practitioners. They interviewed more than 350 medical practitioners to find out the types of learning activities that clinicians undertake and the important factors in the process of learning and change. The framework is illustrated in Figure 1.

Figure 1. Theoretical Framework related to CME/CPD using the process of change and learning (Fox et al., 1989) and adult learning theory (Knowles, 1989)

This framework clearly illustrated how change and learning occurs through several processes and how these changes were influenced by three forces. The actual process of change involves three iterative steps – preparing for the change, making the change, and sustaining or implementing the change in practice.

Through validated studies, we understand that there are three forces to prepare for the change, mainly personal, professional and social forces. Professional forces were found to be the most frequently motivated change. Personal forces, such as the desire for personal well-being, were infrequent and usually not the sole force for change. More often they were combined with professional forces, e.g. the desire to further one’s career. Social forces were also cited, usually combined with professional forces, e.g. relationships with colleagues.

Once the image of change has been developed, medical practitioners will evaluate the discrepancy between what new knowledge and skills are needed to achieve the change and estimate their current capacities. As shown in Figure 1, the perceived discrepancy is positively correlated with the effort that a medical practitioner will put in in learning. Therefore, the next step may involve attending a formal CME event if the discrepancy is high – to understand what is required and to assess or verify one’s own capabilities.

Although the Process of Change and Learning Framework provides us a big picture on how medical practitioners engaged in change and learning, it is insufficient to understand the humanist approach in understanding learning for human growth. It is widely recognised that autonomy and self-directed learning are the developmental nature for human desire to learn (Personal Forces). This behaviour is usually motivated by a mixture of external and internal motivation. This is important for the development of individuals toward autonomy, the self-directed learning, reflective practice and critical reflection, experiential learning, and transformative learning.

II. METHODS

This is a multi-centred study which employed a survey using a validated questionnaire and the section below will describe the data collection process, sampling of participants and data analysis coupled with a qualitative data gathering focus group with educational experts from each place participating. Five sites were involved in this study: Hong Kong, Indonesia, Malaysia, Singapore and Taiwan. Ethical approval was obtained from the respective Institutional Review Board [Reference Number: DSRB-2019-0449 (Singapore), UW 19-840 (HKU/HA HKW IRB) (Hong Kong), KET-1035/UN2.F1/ETIK/PPMetc.00.02/2019 (Indonesia), (CCH-IRB-200425) (Taiwan), IMU 467/2019 (Malaysia)].

The same questionnaire that was used and validated previously in Japan was modified for use in this region (Nishigori and Sherman, 2018). The questionnaire is a self-administered, 28-item test comprising 27 single or multiple-choice questions and an open-ended question for comments. Respondents were asked to rate on a 5-point Likert scale (Strongly Disagree to Strongly Agree) for some of the questions. Demographic questions were included at the start of the survey (e.g. specialty, years of practice, prior participation in CME/CPD activities) followed by the following domains:

• Perceptions and satisfaction of clinicians with regard to current CME/CPD available for them
• Adequacy of the current CME/CPD available
• Impacts of CME/CPD in content coverage, evaluation, and development of learning
• Gaps in CME/CPD
• Future areas to focus on

The items were finalised following a group of experts’ meeting held in Singapore (March 2019) whereby the representatives (medical educationalists and medical practitioners) from participating sites discussed and went through the questions thoroughly. The meeting was moderated by an expert with over 28 years of experience in CME/CPD, and who designed the original study questionnaire. To add more local context and ensure that respondents were able to answer accurately, the questionnaire was translated into the native language and terms by the representatives in some locations.

Medical practitioners were invited to participate in the study.  The study was conducted from July 2019 until May 2020. Voluntary, convenience, and snowball sampling was used and the representatives either disseminate the questionnaire link to their mailing list or through the various national organisation/institutions (Table 1) who then informed their members/faculty, in accordance with the ethics protocol guidelines. Reminders were sent until the response rate no longer increased. Implied consent was obtained from the participants when they proceeded to complete the survey after reading the information about the study on the first page.

Submitted: 2 September 2023
Accepted: 9 January 2024
Published online: 2 July, TAPS 2024, 9(3), 15-21
https://doi.org/10.29060/TAPS.2024-9-3/OA3129

Uzma Khan

Department of Clinical Sciences, College of Medicine, Al Rayan Colleges, Saudi Arabia

Abstract

Objectives: To compare the cut scores and pass/fail rates achieved by arbitrary 60% method and Hofstee method in an undergraduate year 4 end semester objective structured clinical examination (OSCE) and check the possibility of using Hofstee method of standard setting in future exams.

Method: 102 medical students of year 4 underwent a 10 station OSCE exam conducted in a state of art simulation lab in 3 cycles. The cut scores were calculated using arbitrary method aiming at 60% of task achievement and by Hofstee method. The student’s obtained scores were compared for cut scores and pass rates for individual stations and the entire exam.

Results: The arbitrary and Hofstee methods of standard setting leads to different cut scores. For the individual stations it was 60% vs 65-70% and for the overall score it was 60% vs 70%. The percentage of students failing the exam is 13.7% based on arbitrary scores and is 29.4% when Hofstee cut score is applied.

Conclusions: The two methods lead to different cut scores and students’ failure rates. Overall, Hofstee method is more appropriate for assessing competencies in an OSCE exam in medical schools as it leads to calculation of cut scores based on the difficulty level of the station/exam and the examiners expected level of performance by the students.

Keywords:          Objective Structured Clinical Examination, Standard Setting, Hofstee Method, Arbitrary Method

Practice Highlights

• Standard settings of OSCE identifies objective, reliable and valid cutoff scores.
• Arbitrary method scrutinises the test content and nominates the percentage of items to be answered correctly.
• Hofstee method is calculative and avoids illogical very high and low scores.
• A retrospective descriptive study design assessing applicability of Hofstee method in low stake exam in a private medical school in Saudi Arabia.
• Students’ failure rate increased with applying Hofstee standard settings in OSCE.

Figure 1. Calculation of final cut score based on examiners provided four Hofstee values

Arbitrary cut score of 60% is applied to students achieved scores and the pass/fail percentage is calculated and recorded in table 2.

III. RESULTS

The OSCE went on without any significant issues. The data provided by the Exam and evaluation Unit (EEU) according to their software showed that the mean score was 75% with a standard deviation of 3.99% and an alpha coefficient of 1.03. Station wise descriptive results show a range in mean scores from 61 to 84%, illustrating a range in station difficulty. The detailed analysis of each station is shown in table 1.

Table 2. Station wise descriptive statistics, the two cut scores and students pass rates according to cut scores

The mean score for the station reflects its level of difficulty ranging from 61.17% to 83.3%. The cut score of the individual stations for the Hofstee method was higher than the cut score for the arbitrary method. So is the difference in pass rates, pass rates achieved with arbitrary cut scores are higher than with Hofstee method, as shown in Table 3.

Table 3. Comparison of overall cut scores and pass rates

Using Hofstee method and cut of score of 14 out of 20 passing rates achieved is 72 out of 102 which in percentage makes 70.5%. When compared with arbitrary method and cut score of 12 out of 20, students pass rate increased to 88 out of 102 leading to 86% overall. This study points out a higher pass rate for the students by arbitrary method, which creates a doubt on the competency of passing students.

IV. DISCUSSION

In this research, the results of end semester OSCE exam are compared by two methods, arbitrary fixed 60% standard setting method used at our college for the last 4 years and a compromise Hofstee method, which is applied for the very first time.

According to our study, the failure rate has increased from 13.7% to 29.4%, and has almost doubled. In fact, this increase is higher than what had been usually observed previously. This gives the impression that the students who have not yet achieved the required competency would have been allowed to pass. The same observation was made by Dudas et all who did apply Hofstee standard setting to a historic cohort of 116 Johns Hopkins University School of Medicine students from the academic year 2012–2013 to assess the potential impact on grade distributions (Dudas & Barone 2014).

According to the results of a study conducted by Doaa Kamal in Suez Canal University, Egypt in 2020 where four standard methods, the modified Cohen’s, borderline regression, Hofstee methods, and the fixed 60% arbitrary method were compared in determining the passing score in ophthalmology OSCE exam, it was concluded that 60% fixed arbitrary method resulted in a marked difference in failure and pass rates among students and Hofstee method yielded low pass rates which is consistent with my research (Kamal et al., 2020).

Since our exam was dealing with the assessment of multiple competencies, so Hofstee method is more likely to produce a standard appropriate with the purpose of assessment. Secondly the cut scores were calculated by the academic staff who were very much familiar with the OSCE as an assessment tool, the curriculum and the students as well. They were all content experts, fair and open-minded. Some of them were teaching in Taibah university the same content so they were well aware of the acceptable students’ performance. The examiners were meeting the criteria set by Downing et al., so their decision regarding the cut scores and estimation of number of failing students was accepted (Downing et al., 2006).   

Schindler et al in his research paper has applied Hofstee cut off scores and found that it can even be used for a multi assessment surgical clerkship and for assigning grades as well and concluded that this method has all the characteristics of an appropriate standard setting method (Schindler et al., 2007).

V. CONCLUSION

Since different competencies reflect the different level of difficulties, the cut scores need to be set for each station dealing with that competency. The arbitrary 60 % method is not appropriate to the purpose of an OSCE exam, but a cut off score calculated by using data from experts’ judgments provides a reasonable result with acceptable failing rates. Thorough and thoughtful preparation on the judges’ part is deemed important. The data gathered from this exam can be reviewed and acted in accordance with to create a standard each academic year.

Notes on Contributors

The author herself contributed to the design of the research, carried out the data acquisition and analysis, interpreted the data and prepared the manuscript.

Ethical Approval

Approval was obtained from the Institutional Research Ethics Committee (IREC) for the collection and publication of student data with approval No. HA-03-M-122-046. Informed consent is taken from the students and special permission from the dean of the college is obtained for the use of students result for this research purpose.

Data Availability

The data generated and analysed in this study are included in this published article. The raw data set analysed can be provided by the author if special interest in it is shown.

Acknowledgement

I would like to thank Dr. Yasir Naseem Khan from the department of basic medical sciences, Al-Rayan college of medicine for useful suggestions and guidance at the final stage of the project.

I would also like to thank the Dean and the Exam and evaluation Unit (EEU) of the Al-Rayan college of medicine for their support.

Funding

The study does not require any funding.

Declaration of Interest

The author declares that she has no competing interests.

References

Boulet, J. R., De Champlain, A. F., & McKinley, D. (2003). Setting defensible performance standards on OSCEs and standardised patient examinations. Medical Teacher, 25(3), 245-249. https://doi.org/10.1080/0142159031000100274

Cusimano, M. D. (1996). Standard setting in medical education. Academic Medicine, 71(10), S112-20. https://doi.org/10.1097/00001888-199610000-00062

Dent, J., Harden, R. M., & Hunt, D. (2021). A practical guide for Medical Teachers (6th ed.). Elsevier.

Downing, S. M., Tekian, A., & Yudkowsky, R. (2006). Procedures for establishing defensible absolute passing scores on performance examinations in health professions education. Teaching and Learning in Medicine, 18(1), 50-57. https://doi.org/10.1207/s15328015tlm1801_11

Dudas, R. A., & Barone, M. (2014). Setting standards to determine core clerkship grades in pediatrics. Academic Pediatrics, 14(3), 294-300. https://doi.org/10.1016/j.acap.2014.01.008

Dwivedi, N., Vijayashankar, N. P., Hansda, M., Ak, D., Nwachukwu, F., Curran, V., & Jillwin, J. (2020). Comparing standard setting methods for objective structured clinical examinations in a Caribbean medical school. Journal of Medical Education and Curricular Development, 7. https://doi.org/10.1177/2382120520981992

Gormley, G. (2011). Summative OSCEs in undergraduate medical education. The Ulster Medical Journal, 80(3), 127. 

Harden, R. M., & Gleeson, F. (1979). Assessment of clinical competence using an objective structured clinical examination (OSCE). Medical Education, 13(1), 39-54. https://doi.org/10.1111/j.1365-2923.1979.tb00918.x

Harden, R. M., Stevenson, M., Downie, W., & Wilson, G. M. (1975). Assessment of clinical competence using objective structured examination. The British Medical Journal, 1(5955), 447–451. https://doi.org/10.1136/bmj.1.5955.447

Hodges, B. (2003). OSCE! Variations on a theme by Harden. Medical Education, 37(12), 1134-1140. https://doi.org/10.1111/j.1365-2923.2003.01717.x

Hofstee, W. K. (1983). The case for compromise in educational selection and grading. On Educational Testing, 109-127. 

Humphrey‐Murto, S., & MacFadyen, J. C. (2002). Standard setting. Academic Medicine, 77(7), 729-732. https://doi.org/10.1097/00001888-200207000-00019

Impara, J. C., & Plake, B. S. (1997). Standard setting: An alternative approach. Journal of Educational Measurement, 34(4), 353-366. https://doi.org/10.1111/j.1745-3984.1997.tb00523.x

Kamal, D., Sallam, M. A., Gouda, E., & Fouad, S. (2020). Is there a “best” method for standard setting in OSCE exams? Comparison between four methods (a cross-sectional descriptive study). Journal of Medical Education, 19(1), Article e106600. https://doi.org/10.5812/jme.106600

Kaufman, D., Mann, K., Muijtjens, A., & Van Der Vleuten, C. P. (2000). A comparison of standard-setting procedures for an OSCE in undergraduate medical education. Academic Medicine, 75(3), 267-271. https://doi.org/10.1097/00001888-200003000-00018

Khan, K., Ramachandran, S., Gaunt, K., & Pushkar, P. (2013). The objective structured clinical examination (OSCE): AMEE Guide No. 81. Part I: An historical and theoretical perspective. Medical Teacher, 35(9), e1437-e1446. https://doi.org/10.3109/0142159x.2 013.818634

Khan, K., Gaunt, K., Ramachandran, S., & Pushkar, P. (2013). The objective structured clinical examination (OSCE): AMEE Guide No. 81. Part II: Organisation & administration. Medical Teacher, 35(9), e1447-e1463. https://doi.org/10.3109/0142159x. 2013.818635

McKinley, D., & Norcini, J. J. (2014). How to set standards on performance-based examinations: AMEE Guide No. 85. Medical Teacher, 36(2), 97-110. https://doi.org/10.3109/0142159x.2013.8 53119

Norcini, J. J., Anderson, M. B., Bollela, V. R., Burch, V., Costa, M. J., Duvivier, R., Galbraith, R. M., Hays, R., Kent, A., Perrott, V., & Roberts, T. (2011). Criteria for good assessment: Consensus statement and recommendations from the Ottawa 2010 Conference. Medical Teacher, 33(3), 206-214. https://doi.org/10.3109/0142159x.2011.551559

Pell, G., Fuller, R., Homer, M., & Roberts, T. (2010). How to measure the quality of the OSCE: A review of metrics – AMEE Guide No. 49. Medical Teacher, 32(10), 802-811. https://doi.org/10.3109/0142159x.2010.507716

Pugh, D., & Smee, S. (2013). Guidelines for the development of objective structured clinical examination (OSCE) cases. Ottawa: Medical Council of Canada. https://doi.org/10.13140/RG.2.1.462 2.0003

Schindler, N., Corcoran, J., & DaRosa, D. A. (2007). Description and impact of using a standard-setting method for determining pass/fail scores in a surgery clerkship. The American Journal of Surgery, 193(2), 252-257. https://doi.org/10.1016/j.amjsurg. 2006. 07.017

Smee, S., Coetzee, K., Bartman, I., Roy, M., & Monteiro, S. (2022). OSCE standard setting: Three borderline group methods. Medical Science Educator, 32(6), 1439-1445. https://doi.org/10.1007/s40670-022-01667-x

Zayyan, M. (2011). Objective structured clinical examination: The assessment of choice. Oman Medical Journal, 219-222. https://doi.org/10.5001/omj.2011.55

*Dr. Uzma Khan
Department of Clinical Sciences,
Al Rayan College of Medicine,
Al Rayan National Colleges
Madina Munawara, Saudi Arabia
Contact: +966542754680
Email: uziik2019@gmail.com, uk.yasser@amc.edu.sa

Submitted: 4 July 2023
Accepted: 9 January 2024
Published online: 2 July, TAPS 2024, 9(3), 22-31
https://doi.org/10.29060/TAPS.2024-9-3/OA3081

Jia Le Ivan Tan¹ & Sashikumar Ganapathy²

¹School of Biological Sciences, Nanyang Technological University, Singapore; ²Department of Emergency Medicine, KK Hospital, Singapore

Abstract

Introduction: Maintenance of procedural skills is crucial for paediatric emergency medicine (PEM) physicians to provide high-quality care. A study by Lin-Martore et al. (2021) in the US identified key themes in conceptualising procedural skill maintenance (PSM), its motivations, and barriers to maintenance. However, the difference in culture brings into question the validity of their findings in other contexts. To determine its applicability specifically in an Asian context, this study aims to replicate the study at KK’s Women and Children Hospital (KKH), focusing on PEM physicians. While the findings are limited to a single hospital, they provide valuable insights into challenges encountered by PEM physicians.

Methods: A general qualitative approach was used through semi-structured interviews. Participants were recruited through email. Interviews were conducted via Zoom and subsequently de-identified and transcribed. The data was coded manually through thematic analysis, identifying key themes.

Results: Fifteen PEM physicians were interviewed. Participants conceptualised PSM through technical aspects and measured competence through objective and subjective measures. General motivation themes found the (1) desire to provide optimal patient care, (2) procedural competence as part of the identity of a PEM physician who teaches and performs procedures, and (3) desire for choice when alternatives are present. Barriers included limited time, support, and opportunities.

Conclusion: The study found that the themes from the original study are applicable in KKH, featuring SDT concepts prominently. Practical recommendations for KKH were proposed. Future research can focus on the challenges and gaps in maintaining procedural skills and develop strategies to improve PSM in PEM physicians.

Keywords:          Procedural Skill Maintenance, Singapore, Emergency Medicine, Qualitative, Paediatric Medicine

Practice Highlights

• Comparisons with the original study in the US were made.
• Understanding of procedural skill maintenance (PSM) was assessed.
• Motivators of PSM are identified.
• Barriers to skill maintenance are constant across studies.
• Current healthcare standards are maintained but medical advancements are limited.

I. INTRODUCTION

Procedural skills are critical in the training and competency of healthcare professionals. Paediatric Emergency Medicine (PEM) physicians may need to perform a wide range of procedures, including intubation, cannulation, and other life-saving interventions and are often the primary care physician first contacting the patient. As such, maintaining the procedural skills of PEM physicians is critical to ensure patient safety and high-quality care. However, many critical procedures are not common and the wide variety of procedures that fall under their purview makes maintenance of such skills challenging (Cabalatungan et al., 2020). Hence, there is a need to investigate the current state of procedural skill maintenance (PSM) in physicians to evaluate current systems and implement new policies if necessary.

According to a study by Lin-Martore et al. (2021), three themes revolving around motivation for PSM have been identified based on self-determination theory components of autonomy, competence, and relatedness (Ryan & Deci, 2000): (1) desire for optimal patient care and fear of suboptimal performance, (2) procedural competence is part of a PEM physician’s identity who teach and perform procedures and (3) desire for accessibility and choice in PSM.

As the research was conducted in the US, it is important to determine if such findings are generalisable to and replicable within an Asian society that may have different values than Western, Educated, Industrialised, Rich, and Democratic (WEIRD) societies (Henrich et al., 2010; Jones, 2010; National Academies of Sciences et al., 2019).

This paper aims to replicate the research design by Lin-Martore et al. (2021). It examines the unique challenges of maintaining proficiency in a high-stress environment within the paediatric emergency department (PED) of KK’s Women and Children’s Hospital (KKH) in Singapore.

This study examines the following research questions: (1) To what extent do the three themes characterising motivation for PSM identified from the Lin-Martore study in the US apply to Singapore? (2) To what extent do the barriers to motivation and skill maintenance identified from the Lin-Martore study in the US apply to Singapore?

Additionally, this study aims to identify any gaps or challenges in the current skill maintenance process and make recommendations for improving the maintenance of procedural skills in PED physicians.

II. METHODS

To tackle this hypothesis, the study design involved conducting qualitative interviews with participants to elicit key themes through thematic analysis. The themes would then be compared to the original study to determine its validity and subsequently formulate applications for use in Singapore.

Participants were recruited using the Purposeful Sampling Method through an email invitation. The selection criteria required participants to be faculty currently working in the Emergency Department of KKH with varying years of experience. They must specialise in PEM and have been working in the Emergency Department of KKH for at least 2 years. Participants consented to participation and recordings. The research team consisted of an undergraduate student (IT) and a PEM senior consultant (SG) with 12 years of experience in PEM.

A. Interview Questions

Based on the original study, most of the interview questions were kept the same and revolved around the conceptualisation of PSM using SDT concepts of autonomy, relatedness, and competence together with its motivations and barriers (Bradbury-Jones et al., 2017; Kahlke, 2014). However, the original question regarding autonomy was replaced to determine the receptiveness of participants toward novel techniques when existing protocols are already enacted by one investigator (SG).

B. Interviews

One investigator (IT) conducted interviews and was involved in the development and refinement of the interview guide and review of the transcribed interviews. This addressed the potential for reduced participant candour due to established relationships and mitigated the potential for less explicit responses due to familiarity with certain jargon. Similar to the original study, 30 – 45-minute semi-structured interviews were conducted and recorded via video-conferencing software (Zoom Cloud Meetings) using a general qualitative approach from July 2022 to February 2023. Following this, they were de-identified and transcribed. No participant was interviewed more than once. Interviews were conducted until data saturation was achieved.

C. Thematic Analysis

The data underwent structural coding for categorisation based on research questions and topics by one investigator (IT). In line with thematic analysis, ideas from the initial study were used as a framework for identifying key ideas relating to concepts from SDT by both investigators (IT and SG). Additional ideas elicited from interviews were then integrated into the codebook. Key concepts and patterns were then identified by both investigators.

The data was manually coded using Microsoft Office. Having perspectives from a PEM physician and nonphysician in the research team provided greater theoretical analysis and practical applications of SDT in the context of KKH.

III. RESULTS

A. Participant Demographics

Fifteen PEM physicians with 6-32 years of experience were interviewed (Table 1). Participants worked shifts with and without learners, including medical students.

Table 1. Participant demographics (n=15)

Note: Shifts are 8 hours long.

B. Thematic Analysis

The themes were organised based on the research results and findings of the original study (Table 2).

Table 2. Major themes in procedural skill maintenance

C. Conceptualisation of Procedural Skill Maintenance (PSM)

1) PSM is understood through technical aspects: Participants intuitively understood PSM and operationalised it through technical aspects such as practicing the procedure, attending courses and refreshers, keeping up to date with literature, revisiting the content, and teaching others.

“There should be constant upgrading of yourself either by doing the procedure itself or also upgrading by constantly reading literature and updated books and materials to check new things.”

(interview 3)

“For my TNS, although I try to teach some of the new MOs that come, I have to read back or watch from previous videos to maintain my skills.”

(interview 5)

The ability to teach is based on the protégé effect where through teaching others, knowledge retention increases (Baugh & Scandura, 1999; Chase et al., 2009; Gates, 2019, p. 20). It also allows senior physicians to gauge their competence relative to others. This self-evaluation means that PSM is an abstract concept understood by physicians through a form of social comparison with others.

2) Measuring competence through objective and subjective measures: Physicians listed objective measures implemented for junior doctors such as having third-party physicians evaluate and provide immediate feedback on skills.

“All of us must go through a skill test in the sense that you have to do supervised procedures – X number in the first six months of joining. So, there is a senior who makes sure that you know what you’re doing and [according to] the correct method, process including you know consent taking and post-procedure care, etc. And once we are supervised, we are ticked off as competent by the senior staff.”

(interview 9)

Confidence and the ability to foresee problems and deal with them are subjective measures that highlight the difficulties in measuring competencies. Many physicians feel confident in their ability to perform a procedural skill if they can do it without hesitation and without committing mistakes.

“If you are quite confident, it is just as easy as using a spoon and fork. You don’t have to think much about it, and you do it at ease with all confidence. It’s like muscle memory plus decision-making.”

(interview 6)

“I think we always know what our backup plan is. So, if it’s incubation then I know if I need to, I can code, call for airway code. There’s another senior on shift who might be able to help. I can call the anaesthetist without even coding if I need to … I anticipate what’s the problem that’s going to happen.”

(interview 12)

D. General Motivation

On motivation, three themes were identified with the SDT components of autonomy, competence, and relatedness serving as tenets.

1) Desire to provide optimal patient care (competence):

“The satisfaction that you have done a good job and that has resulted in a good outcome, gives you the motivation, satisfaction to update, maintain, upskill your skills.”

(interview 1)

Providing optimal patient care is a key motivation. The idea of competence is highlighted through the need to feel capable and effective in providing patient care.

“As a doctor, you are responsible and accountable for your patients, right? You must treat your patient at your best, right? If you’re not maintaining your procedural skills, you cannot serve your patient to the best of your knowledge and skill.”

(interview 7)

The concept of duty was highlighted. Physicians felt responsible for providing optimal patient care as part of their values and the right thing to do.

2) Procedural competence as part of the identity of a PEM physician who teaches and performs procedures (competence and relatedness): Participants listed several key procedures as part of their repertoire. Essentially, these skills were part of their identity as a PEM physician, making the skills important to maintain.

“The fact that you are the consultant and you need to know everything …  you might be the only one who is the most senior to be able to do it. If nobody can get it done, then it comes down to you.”

(interview 11)

Being the sole physician available to perform a procedure confers responsibility. Hence, skill maintenance is paramount to clinical practice with responsibility acting as a motivator.

“Although we have a lot of experienced doctors who can do it, but for me as a senior, I think I have to learn so that I can supervise in the future.”

(interview 13)

Senior physicians often teach and supervise junior doctors, driving senior physicians to maintain their skills. As senior physicians, individuals may feel a sense of connection and responsibility to other physicians who look up to them as role models.

3) Desire for choice when alternatives are present (autonomy): Physicians highlighted a need to ascertain the suitability of certain procedures to the patient. This indicates a desire for choice and autonomy, for the physician to make their judgement on the situation.

“If there is a good alternative that’s already in place, unless there’s a departmental guideline to force us to change, then I don’t see the need to change that. It’s sort of stipulated by what they [the department] wants.”

(interview 11)

Regarding novel techniques, physicians tend to fall back on existing, proven techniques. Without adequate reason, physicians are less likely to experiment with new skills unless there is a need to such as inadequacy of existing skills or department policy.

E. Barriers to Maintenance of Procedural Skills

On barriers, the lack of opportunities, time, and support served as the greatest obstacles.

1) Lack of opportunities: This encompasses external constraints such as patient flow, allowing junior doctors to perform procedures, and limited course slots

“We need to prioritise who to see for us because if, for example, I just keep doing trauma, it takes me 30 minutes to one hour. Rather than seeing medical cases in which in one hour I can see three to four patients. So, I think it’s more of how busy the children’s emergency is.”

(interview 10)

Patient flow and load are factors physicians consider as constantly prioritising learning creates delays in patient care, especially seen in high patient volumes. Prioritising efficiency, physicians fall back on well-versed competent skills that are already well-maintained. 

“At this stage, we are not doing the procedure ourselves yeah so it’s mainly the junior so that would be the barrier for the senior doctors.”

(interview 8)

After senior physicians reach a certain level, there is a transition in roles from a participatory to a supervisory one. With less direct participation in procedures, there are reduced opportunities to practice.

“There are limited slots every 4 years for APLS so the interval of the course is every four years to maintain their accreditation… there is a wait time for it.”

(interview 2)

Accreditation is an objective measure to determine competency in a particular skill. However, limited slots and infrequent sessions create long wait times, leading to some disparity in skill across the faculty.

2) Lack of time:

“Time is the biggest factor for anybody. If things like practicing or attending courses are outside of the shift, it would be difficult because you have other things to do and the shifts usually are quite busy.”

(interview 1)

Time limits a physician’s ability to practice skills. Within typical working hours, they need to balance clinical hours with practicing skills not commonly used. Higher clinical hours would mean less time available for workshops or courses for skill maintenance.

3) Lack of support:

“I think our limitation is more because we are unable to spare the manpower for dedicated time for updates or refresher courses for the seniors or the permanent staff…

Ideally, we would do it more frequently but we have to balance it with the clinical needs.”

(interview 4)

Reduced manpower equates to reduced capacity to send physicians for workshops and courses at regular intervals without compromising on clinical care. As the number of patients remains high, the reduced manpower means that the department cannot afford to send them for courses as there would be insufficient physicians available, constituting a lack of support for PSM.

IV. DISCUSSION

A. Comparison to the Original Study

The purpose of this study is to replicate the findings of Lin-Martore (2021) to determine applicability in an Asian context. A summary comparing the themes in the current study and the original study has been created (Table 3).

Topic	Current Study Themes	Original Study Themes
Conceptualisation of PSM	PSM is understood through technical aspects	PSM lacks a clear definition
	Measuring competence through objective and subjective measures	Ambivalence regarding requirements and the importance of adapting any requirements to practise needs
Motivation	Desire to provide optimal patient care (competence)	Desire to provide optimal patient care and fear of unsuccessful performance (competence)
	Procedural competence as part of the identity of a PEM physician who teaches and performs procedures (competence and relatedness)	Procedural competence as part of the identity of a PEM physician who teaches and performs procedures (competence and relatedness)
	Desire for choice when alternatives are present (autonomy)	Desire for accessibility and choice in maintaining procedural skills (autonomy)
Barriers to PSM	Lack of opportunities, time, and support	Lack of opportunities, time, and support

Table 3. Comparison of major themes

Singapore and the US have different social settings, values, and tenets which may help explain some of the results presented in this study. Singaporean physicians use social comparison within the department for performance evaluation and decision-making. US physicians take a more individualistic approach to self-evaluation with physicians sourcing for courses and defining their own standards (Lin‐Martore et al., 2021).

Regarding the conceptualisation of PSM, the current study did not find that participants had difficulty defining PSM, contrasting with the original study where conceptualisations were intuitive but difficult to verbalise and define. The same tautology exists where being competent was defined as completing the skill, however, the need to know if one is competent before performing the skill is not as prominent in the current study. This is due to the availability of senior staff and specialties available to assist, creating a space that allows independent learning with minimal patient risk. Additionally, the ambivalence regarding requirements is not as present in the current study. Although junior doctors have requirements, autonomy among senior physicians is important and highly respected (Chen & Chung, 2002; Fischer, 2008).

Interestingly, many mentioned confidence as a primary factor determining competence. This contrasts with the original study where participants noted that confidence alone failed to demonstrate competency adequately. In an Asian society where collectivistic efforts are highly valued, being sufficiently confident in performance could be a more accurate representation of competence compared to Western societies.

Regarding motivation, the desire to provide optimal patient care is consistent between studies (Deber, 1994, p. 19; Eisenberg, 1985; Nease & Brooks, 1995). The current study did not find the fear of unsuccessful performance as prominent as that in the original study. A possible reason could lie in the culture of reliance on other specialties. Within KKH, there is a culture of learning, and rather than a complete handover of the patient to other specialties, PEM physicians tend to assist with complex procedures, promoting interdisciplinary learning across faculties. As such, rather than a fear of unsuccessful performance, this is perceived as an opportunity to learn new skills.

Procedural competence is a vital part of a PEM physician’s identity across studies. The additional responsibility of being a senior is a key theme in this study. Should seniors fail to upkeep their skills, there is a sense of shame especially when juniors seek aid. Additionally, the failure to upkeep skills also impedes patient care, violating their sense of competence. This holds the greater the seniority.

The desire for autonomy differs in scope across studies. In the original study, skill prioritisation depends on the availability of individuals who possess that skill. Should there be someone with greater experience in that one skill, participants would choose to practice other skills. In the current study, skill prioritisation is dependent on the reliability of the skill and the presence of alternative skills. Should there be an existing skill that is highly reliable, physicians are likely to prioritise it.

Regarding barriers to PSM, a lack of time, opportunities and support are consistent throughout the studies.

B. Challenges of Maintenance

In this paper, three challenges are identified from the barriers to PSM: practice constraint, advancement constraint, and knowledge constraint.

Practice constraint comes from the barriers of time and opportunity. PEM physicians often have busy work schedules, making it difficult to practice less common but critical procedures during shifts. Additionally, the rarity of critical procedures limits opportunities to use them. With non-use, skills and procedural knowledge decay at a faster rate than knowledge by a year after training (Perez et al., 2013, p. 20; Yang et al., 2012).

Advancement constraint arises from the barriers of support and time. Rapid advancements can make it difficult for physicians to keep up with the latest techniques and procedures. The tyranny of choice heightens the barrier to entry to these new techniques, especially when tried-and-tested techniques exist and have proven to be reliable. Without departmental support pushing for more experimentation, there is little incentive to develop novel techniques, impeding the advancement of medical knowledge.

Knowledge constraint arises from barriers of support and opportunities. Different healthcare institutions have different critical skills important to the faculty, causing a knowledge disparity between physicians across facilities (Mittiga et al., 2019). With new physicians, proper onboarding is critical in ensuring the same standard of care and level of specialised knowledge. As a result, teaching and maintaining the procedural skills of physicians is an ongoing challenge.

C. Applications in KKH

Firstly, the workflow in KKH targets practice constraints and knowledge constraints. The use of senior physicians as a safety net allows junior doctors to learn and practice procedures on the job (practice constraint) while resolving knowledge gaps as senior physicians provide timely, informative feedback for optimal learning (knowledge constraint) (K. Ericsson et al., 1993, p. 199). Providing the space for junior doctors to learn by trial leads to an increase in performance accuracy while still allowing a safe environment for senior physicians to intervene (Crowe et al., 2018; Docherty-Skippen et al., 2020; K. Ericsson et al., 1993; Firdaus, 2018; Trowbridge & Cason, 1932).

This is seen in how participants understand PSM through technical aspects such as the ability to teach and how competence is operationalised objectively (third-party rating) and subjectively (confidence). Teaching others requires identifying the learner’s weaknesses and assigning tasks that build on their pre-existing knowledge for optimal learning. Based on the Levels of Processing Framework, deeper engagement with the material also allows deeper retention of the material for the teacher (Craik & Lockhart, 1972).

Next, the nature of a physician’s career relies heavily on competence. Motivating factors such as the desire to provide the best patient care demonstrate advancement constraints as physicians desire to improve their own skill set. However, as a physician’s priority is patient care, there is little incentive to explore new treatment options with unknown reliability especially with established treatment options (K. Ericsson et al., 1993, p. 199). Participants are less motivated to explore regional blocks unless it is a department regulation. With more options, physicians tend to fall back on what has been tried and tested, enforcing a mental set as exploring new options that may not succeed could lead to damage to their reputation or hinder patient care.

Finally, the lack of time, manpower, and opportunities is a consistent problem. Most PEM physicians spend their hours tending to patients, leaving little time for courses within stipulated working hours. Attending courses creates a greater workload for other physicians due to a decreased doctor-patient ratio. Rosters to send physicians to courses in a staggered formation have been a common suggestion however, many recognise the difficulties of doing so with limited manpower. As external parties conduct some courses, there is a big pause between their conduct. In-house trainers allow for more frequent conduct due to accessibility. However, the lack of manpower reduces the number of accredited trainers that can facilitate such sessions.

In the short term, current attitudes towards PSM appear to be geared towards crisis management, dealing with the large influx of patients with low manpower. PEM physicians revise only the most essential skills, whittling away those that are less necessary and can be executed by specialists. In the long term, these attitudes could impede innovation as deliberate practice is inherently unenjoyable and requires effort over a long period (K. A. Ericsson, 2004). PEM physicians could display expert mastery over their skills however, they would face difficulties exhibiting eminent performance to make a unique contribution to the field.

D. Practical Recommendations

Hospital administrators can consider extending the practice of enforced protected learning time to all PED physicians, rather than just junior doctors. This protected time could drive autonomous learning through workshops or practice resources. It also enhances proficiency and confidence in real-life procedures while providing opportunities to try novel treatment options and determine their reliability in various contexts. Complementary to this would be promoting self-directed learning. Making available various educational resources such as online modules provide opportunities to enhance and maintain skills outside of formal training, fostering a culture of life-long learning.

Finally, current workflows should be evaluated with a shuffle in resource allocation to minimise unnecessary administrative work while optimising availability for procedural skill practice. This includes streamlining documentation workflows, re-distribution of non-clinical work, or promoting work-life integration. Support services such as wellness programs and counselling can be extended and promoted. Through this, focus and concentration can be redirected toward performance.

E. Limitations

This study was conducted at a single academic centre with policies, workflows, and culture that may not be generalisable to other academic healthcare institutions. The voluntary nature of participants means that the findings presented might not include all faculty. Future studies can consider a larger and more diverse sample from several hospitals to take this into account. Having a comparison group of Adult Emergency Medicine (AEM) physicians or non-emergency medicine departments could be included in future studies to elicit unique challenges faced by PEM physicians.

V. CONCLUSION

Overall, the themes from the original study largely translate to and are applicable in KKH. SDT concepts are highly applicable in characterising motivation for PSM. Although the scope of autonomy differs, the resultant finding from the current study still utilises its principles. Additionally, the barriers to motivation and skill maintenance hold, allowing for the formulation of practical recommendations to complement the existing framework in KKH.

While findings may not be fully generalisable, they highlight important areas for improvement. Subjective and objective measures of competence highlight the need for evaluating and maintaining competence between various healthcare institutions. Understanding these could allow for policy development to ensure high fidelity of procedural skills. Future research should explore strategies to overcome these barriers and promote effective PSM among PEM physicians.

Notes on Contributors

IT reviewed the literature, conducted, and transcribed interviews, and wrote the manuscript. SG advised the design of the study and interview methods, gave critical feedback on the writing of the manuscript, and sent out invitations to the study. Both authors designed the study, developed the methodological framework, analysed transcripts, and read and approved the final manuscript.

Ethical Approval

This study was approved by the Ethics Committee of SingHealth IRB (Ref: 2022/2228). All participants have given written consent for their data to be used in the research and for publication.

Data Availability

It is not possible to share data since we did not obtain consent from participants to share all data collected. 

Acknowledgments

We thank the Emergency Department of KK Hospital for their participation.

Funding

This study is not funded by any organisations.

Declaration of Interest

The authors have no potential conflicts to disclose.

References

Baugh, S. G., & Scandura, T. A. (1999). The effect of multiple mentors on protege attitudes toward the work setting. Journal of Social Behavior and Personality, 14(4), 503. 

Bradbury-Jones, C., Breckenridge, J., Clark, M. T., Herber, O. R., Wagstaff, C., & Taylor, J. (2017). The state of qualitative research in health and social science literature: a focused mapping review and synthesis. International Journal of Social Research Methodology, 20(6), 627–645. https://doi.org/10.1080/13645579. 2016.1270583

Cabalatungan, S. N., Thode, H. C., & Singer, A. J. (2020). Emergency medicine physicians infrequently perform pediatric critical procedures: a national perspective. Clinical and Experimental Emergency Medicine, 7(1), 52–60. https://doi.org/ 10.15441/ceem.19.004

Chase, C. C., Chin, D. B., Oppezzo, M. A., & Schwartz, D. L. (2009). Teachable agents and the protégé effect: increasing the effort towards learning. Journal of Science Education and Technology, 18(4), 334–352. https://doi.org/10.1007/s10956-009-9180-4

Chen, G.-M., & Chung, J. (2002). Seniority and superiority: a case analysis of decision making in a Taiwanese religious group. Communication Studies Faculty Publications, 11(1), 41-56. https://web.uri.edu/iaics/files/03-Guo-Ming-Chen-Jensen-Chung.pdf

Craik, F. I. M., & Lockhart, R. S. (1972). Levels of processing: a framework for memory research. Journal of Verbal Learning and Verbal Behavior, 11(6), 671–684. https://doi.org/10.1016/S0022-5371(72)80001-X

Crowe, S., Ewart, L., & Derman, S. (2018). The impact of simulation based education on nursing confidence, knowledge and patient outcomes on general medicine units. Nurse Education in Practice, 29, 70–75. https://doi.org/10.1016/j.nepr.2017.11.017

Deber, R. B. (1994). Physicians in health care management: 7. The patient-physician partnership: changing roles and the desire for information. CMAJ: Canadian Medical Association Journal, 151(2), 171–176.

Docherty-Skippen, S. M., Karrow, D., & Ahmed, G. (2020). Doing science: pre-service teachers’ attitudes and confidence teaching elementary science and technology. Brock Education: A Journal of Educational Research and Practice, 29(1), 24–34.

Eisenberg, J. M. (1985). Physician utilisation: the state of research about physicians’ practice patterns. Medical Care, 40(11), 1016-1035.

Ericsson, K. A. (2004). Deliberate practice and the acquisition and maintenance of expert performance in medicine and related domains. Academic Medicine, 79(10 Suppl), S70-S81. https://doi.org/10.1097/00001888-200410001-00022

Ericsson, K., Krampe, R., & Tesch-Roemer, C. (1993). The role of deliberate practice in the acquisition of expert performance. Psychological Review, 100(3), 363–406. https://doi.org/10.1037/ 0033-295X.100.3.363

Firdaus, A. R. (2018). Application of everyone is a teacher here learning model to improve self-confidence students. PrimaryEdu: Journal of Primary Education, 2(2), Article 2. https://doi.org/10.22 460/pej.v2i2.1007

Fischer, R. (2008). Rewarding seniority: Exploring cultural and organisational predictors of seniority allocations. The Journal of Social Psychology, 148(2), 167–186. https://doi.org/10.3200/SO CP.148.2.167-186

Gates, A. (2019). The protégé effect in the retention of underrepresented minority undergraduate teaching assistants in geoscience: preliminary indications from Newark, New Jersey. Journal of Geoscience Education, 67(4), 417–426. https://doi.org/ 10.1080/10899995.2019.1661760

Henrich, J., Heine, S. J., & Norenzayan, A. (2010). Beyond WEIRD: towards a broad-based behavioral science. Behavioral and Brain Sciences, 33(2–3), 111–135.  https://doi.org/10.1017/S0 140525X10000725

Jones, D. (2010). Psychology. A WEIRD view of human nature skews psychologists’ studies. Science, 328(5986), 1627. https://doi.org/10.1126/science.328.5986.1627

Kahlke, R. M. (2014). Generic qualitative approaches: pitfalls and benefits of methodological mixology. International Journal of Qualitative Methods, 13(1), 37–52. https://doi.org/10.1177/1609 40691401300119

Lin‐Martore, M., Kant, S., & O’Brien, B. C. (2021). Procedural skill maintenance: perspectives and motivations of pediatric emergency medicine faculty. AEM Education and Training, 5(4), Article e10696. https://doi.org/10.1002/aet2.10696

Mittiga, M. R., FitzGerald, M. R., & Kerrey, B. T. (2019). A survey assessment of perceived importance and methods of maintenance of critical procedural skills in pediatric emergency medicine. Pediatric Emergency Care, 35(8), 552–557. https://doi.org/10.1097/PEC.0000000000000991

National Academies of Sciences, E., Affairs, P., and G., Committee on Science, E., Information, B. on R. D. and, Sciences, D. on E. and P., Statistics, C. on A. and T., Analytics, B. on M. S. and, Studies, D. on E. and L., Board, N. and R. S., Education, D. of B. and S. S. and, Statistics, C. on N., Board on Behavioral, C., & Science, C. on R. and R. in. (2019). Replicability. In Reproducibility and Replicability in Science. National Academies Press (US). https://www.ncbi.nlm.nih.gov/books/NBK547524/

Nease, R. F., & Brooks, W. B. (1995). Patient desire for information and decision making in health care decisions: the autonomy preference index and the health opinion survey. Journal of General Internal Medicine, 10(11), 593–600. https://doi.org/10.1007/BF02602742

Perez, R. S., Skinner, A., Weyhrauch, P., Niehaus, J., Lathan, C., Schwaitzberg, S. D., & Cao, C. G. L. (2013). Prevention of surgical skill decay. Military Medicine, 178(10 Suppl), 76–86. https://doi.org/10.7205/MILMED-D-13-00216

Ryan, R. M., & Deci, E. L. (2000). Self-determination theory and the facilitation of intrinsic motivation, social development, and well-being. The American Psychologist, 55(1), 68-78. https://doi,org/10.1037//0003-066x.55.1.68

Trowbridge, M. H., & Cason, H. (1932). An experimental study of Thorndike’s theory of learning. Journal of General Psychology, 7(2), 245–260. https://doi.org/10.1080/00221309.1932.9918465

Yang, C.-W., Yen, Z.-S., McGowan, J. E., Chen, H. C., Chiang, W.-C., Mancini, M. E., Soar, J., Lai, M.-S., & Ma, M. H.-M. (2012). A systematic review of retention of adult advanced life support knowledge and skills in healthcare providers. Resuscitation, 83(9), 1055–1060. https://doi.org/10.1016/j.resusci tation.2012.02.027

*Tan Jia Le Ivan
School of Biological Sciences
Nanyang Technological University
50 Nanyang Ave
Singapore 639798
Email address: B200021@e.ntu.edu.sg

Submitted: 1 September 2023
Accepted: 29 January 2024
Published online: 2 July, TAPS 2024, 9(3), 32-40
https://doi.org/10.29060/TAPS.2024-9-3/OA3127

Michiko Goto¹, Ryota Sakamoto², Hideki Wakabayashi³ & Yousuke Takemura⁴

¹Department of General Medicine, Mie University School of Medicine, Japan; ²Department of Medical Informatics, Mie University Hospital, Japan; ³Department of Community Medicine, Mie University School of Medicine, Japan; ⁴Department of General Medicine, Tokyo Women’s Medical University, Japan

Abstract

Introduction: From the late 1960s to the present, physicians’ dress codes have been actively studied in Western countries. Until the early 21st century, patients tended to prefer a conservative dress style, such as “shirt and tie or skirt” with white coats for physicians. However, as attitudes toward dress codes have changed, knowledge regarding this issue needs to be updated. A variety of colours of scrubs are currently commonly used by medical professionals, but it is not known whether all colours are acceptable to patients. The current study sought to investigate the acceptability of various dress codes for physicians from the patients’ perspective, to inform medical education.

Methods: Outpatients and their family members at a university hospital and a small-to-medium-sized hospital were surveyed. We inquired about which of the different styles of white coats and different colours of scrubs were most desirable for male and female physicians. We used Scheffe’s paired comparison method to determine rankings.

Results: Patients and their family members expected their physicians to wear white coats rather than scrubs. Furthermore, a more traditional and formal dress code was preferred. The least preferred colour of scrubs was yellow.

Conclusion: The current results indicated that patients’ preference for a traditional, conservative appearance has not changed over time. This finding does not match current perspectives on infection prevention. Both patient preferences and infection prevention are important for informing education and gaining patient trust.

Keywords:           White Coat, Scrub Colour, Physicians’ Appearance, Medical Education, Doctor-Patient Communication

Practice Highlights

• The physician’s traditional white coat may be associated with a sense of trust, and is most preferred by patients and their family members. This trend has not changed over time.
• Among the scrub colours, bright colours are not preferred, and black and red may have a negative meaning for patients and their family members.
• Regarding dress code education, patient/family perspectives, infection prevention, and sociocultural background should all be considered.

Figure 1. Scrubs in 15 different colours

1: black, 2: grey, 3: light blue, 4: light purple, 5: dark blue, 6: blue-green, 7: dark blue-green, 8: dark green, 9:  yellow, 10: orange, 11: brown, 12: pink, 13: dark pink, 14: red, 15: red-purple

Figure 2. Nine types of attire for mature and young male physicians, each in order of patient preference with scale chart of average degree of preference

*The yard stick values were Y_0.05=0.052 for young men and 0.054 for mature men

A total of 264 individuals reported 354 images showing unacceptable appearances, of which 40% showed the physician wearing scrubs (Table 1).

3) Young women: The descending order of preference for images of young women was as follows: ① white coat, ③ sandals, ② open-front white coat, ④ mask, ⑤ rolled-up sleeves, ⑥ scrubs + white coat, and ⑦ scrubs (Figure 3). Moreover, ① white coat and ③ sandals formed the top group; ② open-front white coat and ④ mask formed the middle group; and ⑤ rolled-up sleeves, ⑥ scrubs + white coat and ⑦ scrubs formed the lower group. There were no significant differences between the groups (Figure 3).

A total of 403 individuals reported 535 images showing unacceptable appearances, of which 57% featured rolled-up sleeves and 33% featured scrubs (Table 1).

Table 1. The characteristics of images that were identified as showing an unacceptable appearance by patients and their family members, and the percentage of respondents that deemed the image unacceptable

4) Mature women: The descending order of preference for images of mature women was as follows: ① white coat, ③ sandals, ④ mask, ② open-front white coat, ⑦ scrubs, ⑤ rolled-up sleeves, and ⑥ scrubs + white coat (Figure 3). There was no significant difference between the components ① white coat and ③ sandals in the top group. Moreover, ① white coat and ③ sandals were components of the top group, similar to the case for images of young women, and there was no significant difference between them (Figure 3).

Figure 3. Seven types of attire for mature and young female physicians, each in order of patient preference with scale chart of average preference

*The yard stick values are Y_0.05=0.054 for young women and 0.061 for mature women

A total of 172 individuals reported 222 images showing unacceptable appearances, of which 48% featured scrubs (Table 1).

We examined the trends by participants’ gender and age. The results revealed no differences between men and women and in each age group. However, participants over 70 years old tended to prefer tie + closed- and open-front white coat compared with participants under 70, and tended not to favour female doctors with rolled-up sleeves.

B. Question 2

1) Scrub colour: The colours and percentages of scrubs that were identified as unacceptable were, in descending order, as follows: 52%, yellow; 46%, red; 42%, dark pink; 33%, pink; 27%, black; 23%, orange; 20%, blue-green; 16%, grey; 17%, red-purple; 14% brown; 11%, dark blue-green; 8%, light blue; 7%, dark green; 6%, light purple; and 4%, dark blue (Figure 4).

Figure 4. Percentage of scrub colours not preferred by patients and their family members.

IV. DISCUSSION

Many patients and their family members expected their physicians to wear white coats rather than scrubs. On average, a traditional and formal dress style was most preferred by patients and their family members (buttoned white coat and tie for men, leather shoes, and buttoned white coat for women). In a 2010 study conducted in Japan by Yamada et al., the most favoured formality attire by patients was white coats (but skirts for women). Pronchik, who investigated the benefits of neckties prior to the BBE policy (King & Infection Prevention and Control Nurse, 2022), concluded that in an emergency room in the United States (US), patients preferred their physicians to wear ties, and patient satisfaction was high (Pronchik et al., 1998). The survey found that people in older age groups in particular preferred doctors to wear ties.

The results suggest that patients’ preferences regarding physicians’ appearance have not changed substantially. One study found that patients in the United Kingdom (UK) who were briefed on the BBE policy felt that conservatively dressed doctors looked more professional (Toquero et al., 2011).

The second-most preferred attire for male physicians was the Casey, followed by the white coat with rolled-up sleeves for younger men. However, this attire was not ranked highly for women or mature men. This indicates that patients perceived the Casey as a traditional style of dress for men, and that the preference was not necessarily based on the prevalence of the BBE concept or concerns about cleanliness. The pros and cons of rolling up the sleeves of white coats are often discussed in medical student dress guidance, including in a study by Bond (Bond et al., 2010). In the current study, rolled-up sleeves were not preferred by patients. However, it is known that the sleeves of white coats can become contaminated (Banu et al., 2012), and Wong et al. pointed out that the risk of contamination may be increased by pathogens in ties, cuffs, and pockets (Wong et al., 1991). The current results indicated that patients in their 70s and older were not comfortable with female doctors rolling up the sleeves of their white coats. Although this finding may be related to cultural factors, to the best of our knowledge, this phenomenon has not been previously reported in the literature. The results suggest that patients’ concepts of professionalism and infection prevention are not directly connected. When instructing students about dress code, they should be told that patients may not approve of rolling up their sleeves.

Men wearing masks were rated less favourably, while women wearing masks were not rated less favourably. For women, there may be something to compensate for the facial expressions hidden by masks. Because wearing a mask and other prophylactic devices has been essential for physicians since the beginning of the COVID-19 pandemic, the impressions of patients and family members should be examined in future studies.

Although scrubs are often rated as hygienic (Bond et al., 2010; Lightbody & Wilkie, 2013), the current survey revealed that scrubs were not rated as a preferred attire for physicians by patients and their family members. In the survey by Aitkin et al. mentioned above, scrubs also received the lowest ratings. However, previous studies in the US reported no influence of scrubs and other types of attire on patient satisfaction and perceptions of professionalism (Fischer et al., 2007; Li & Haber, 2005). Additionally, a recent survey in the UK reported a clear downward trend in resistance to scrubs, with a survey by Palazzo and Hocken reporting that white coats and ties are no longer expected by patients (Palazzo & Hocken, 2010). In a study in the US, patients undergoing surgery reported that scrubs were most favoured in outpatient settings (Edwards et al., 2012). These findings suggest that the resistance to scrubs in Japan may disappear in the near future.

Brightly coloured (yellow, red, and pink) and black scrubs were considered to be less acceptable than others, and those in pale and cold colours, such as dark blue and light blue, were preferred. This may have occurred because red and black are associated with negative emotions such as anger, anxiety and fear, whereas cold colours are associated with calm and quiet (Oyama et al., 1963). Some patients commented that black reminded them of death and red reminded them of blood. Bright colours may be irritating to patients. To the best of our knowledge, no previous studies have examined colour preferences for scrubs among patients, suggesting that these findings are novel.

In the 20th century, physicians in many countries were required to wear white coats (Gooden et al., 2001; Harnette, 2001). It is not surprising that preferences regarding physicians’ appearance have changed in the 21st century, as many people have started to become more familiar with the threat of infection and changes in the global medical environment. However, the concept of BBE is still not pervasive, and the appearance of attire required to be worn by physicians has not changed significantly. The current results are consistent with the findings of the largest study of this issue conducted in the UK (Jacob, 2007), which reported the following: “if there is deemed to be no significant infection risk from any given variation of workwear, our patients would like us to wear a shirt and tie.” Patients’ awareness regarding infection needs to be investigated, but patients will accept physicians’ suggestions if they understand the need for them (Collins et al., 2013).

Shelton et al. conducted an experiment in the UK to reduce cross-infection between doctors and patients, and reported that there was no significant difference in patient preferences between different types of attire before explaining the importance of clothing to patients; however, after the explanation, scrubs and short-sleeved shirts were most preferred (Shelton et al., 2010). When considering physicians’ dress code, we need to understand both the patient’s preferences and infection control factors. We propose that a dress code should be developed that does not compromise patients’ trust and confidence, but also takes safety into consideration.

A. Limitations

Although the types of clothing shown in the photos in the current study were based on a prior survey, it may not have been comprehensive. Moreover, using different models in the photographs may have influenced the results, and the potential effects of measurement bias cannot be excluded. It is unclear from the current findings why certain appearances were preferred or deemed unacceptable. Furthermore, the current study did not examine doctors’ preferences. Medical practitioners’ preferences need to be taken into account when making workplace attire choices in hospitals. Further research will be needed to identify the preferred attire for both patients and doctors.

V. CONCLUSION

The current findings indicated that patients exhibited a preference for physicians dressed in traditional attire. Even though times have changed, people may still associate trust, credibility, and respect with the formal appearance of their physicians. The current findings also suggested that patients were not aware of the BBE policy. The results of this study may be helpful for informing teaching approaches regarding the appearance of medical students and residents.

Notes on Contributors

MG developed the research idea and design with YT. The data collection was performed by MG. The data were analysed by RS. HW performed the data interpretation with MG. MG wrote the article with revision by HW. All the authors read and agreed with the final manuscript.

Ethical Approval

Verbal informed consent was obtained from all participants for publication and this procedure was approved by the Mie University Ethics Committee. The Ethical Review Committee of Mie University committee approved this study (No. 1237). All methods were performed in accordance with the relevant guidelines and regulations.

Data Availability

The data that support the findings of this RCT study are openly available at a Figshare repository, https://doi.org/10.6084/m9.figshare.23936379.v1

Acknowledgements

We would like to express our heartfelt gratitude to the models for their cooperation in creating the photograph stimuli, and to Goto F, Makita H, Yin M, Kasyo K, Sakaguchi R, Masukawa E, Tsunoda K, Shimada K, and Tanaka K, for collecting the data. We thank Benjamin Knight, MSc., from Edanz (https://edanz.com) for editing a draft of this manuscript. This paper has been preprinted. M Goto et al. What dress code do we teach students and residents? A survey of patients’ and their families’ preferences regarding physicians’ appearance. 23 Mar, 2022（Version 1）available at Research Square (https://doi.org/10.21203/rs.3.rs-1430222/v1).

Funding

This study was supported by research grants from the Kameyama City Department of Community Medicine [No. J12061L005] and the Tsu City Department of Community Medicine [No. J12061L008].

Declaration of Interest

No conflict of interest, financial or otherwise, exists.

References

Aitken, S. A., Tinning, C. G., Gupta, S., Medlock, G., Wood, A. M., & Aitken, M. A. (2014). The importance of the orthopaedic doctors’ appearance: A cross-regional questionnaire-based study. The Surgeon, 12(1), 40-46. https://doi.org/10.1016/j.surge.2013. 07.002

Au-Yeung, P. K. K. (2005). SARS changed medical dress code. BMJ, 330(7505), 1450. https://doi.org/10.1136/bmj.330.7505.14 50-b

Banu, A., Anand, M., & Nagi, N. (2012). White coats as a vehicle for bacterial dissemination. Journal of Clinical and Diagnostic Research, 6(8), 1381-1384. https://doi.org/10.7860/JCDR/2012/42 86.2364

Baxter, J. A., Dale, O., Morritt, A., & Pollock, J. C. (2010). Bare below the elbows: Professionalism vs infection risk. The Royal College of Surgeons of England Bulletin, 92(7), 248-251. https://doi.org/10.1308/147363510X510581

Blumhagen, D. W. (1979). The doctor’s white coat. The image of the physician in modern America. Annals of Internal Medicine, 91(1), 111-116. https://doi.org/10.7326/0003-4819-91-1-111

Bond, L., Clamp, P. J., Gray, K., & Van Dam, V. (2010). Patients’ perception of doctors clothing: Should we really be ‘bare below the elbow’? The Journal of Laryngology and Otology, 124(9), 963-966. https://doi.org/10.1017/s0022215110001167

Brandt, L. J. (2003). On the value of old dress code in the new millennium. Archives of Internal Medicine, 163(11), 1277-1281. https://doi.org/10.1001/archinte.163.11.1277

Collins, A. M., Connaughton, J., & Ridgway, P. F. (2013). Bare below the elbows: A comparative study of a tertiary and district general hospital. Irish Medical Journal, 106(9), 272-275. 

Edwards, R. D., Saladyga, A. T., Schriver, J. P., & Davis, K. G. (2012). Patient attitudes to surgeons’ attire in outpatient clinical setting: Substance over style. American Journal of Surgery, 204(5), 663-665. https://doi.org/10.1016/j.amjsurg.2009.09.001

Fischer, R. L., Hansen, C. E., Hunter, R. L., & Veloski, M. S. (2007). Does physician attire influence patient satisfaction in an outpatient obstetrics and gynecology setting? American Journal of Obstetrics and Gynecology, 196(2), e1-e5. https://doi.org/10.1016/ j.ajog.2006.09.043

Gherardi, G., Cameron, J., West, A., & Crossley, M. (2009). Are we dressed to impress? A descriptive survey assessing patient’s preference of doctors’ attire in the hospital setting. Clinal Medicine, 9(6), 519-524. https://doi.org/10.7861/clinmedicine.9-6-519

Gjerdingen, D. K., Simpson, D. E., & Titus, S. L. (1987).  Patients’ and physicians’ attitudes regarding the physician’s professional appearance. Archives of Internal Medicine, 147(7), 1209-1212.

Gledhill, J. A., Warner, J. P., & King, M. (1997). Psychiatrists and their patients: Views on forms of dress and address. The British Journal of Psychiatry, 171, 228-232. https://doi.org/10.1192/bjp. 171.3.228

Gooden, B. R., Smith, M. J., Tattersall, S. J. N., & Stockler, M. R. (2001). Hospital patients’ views on doctors and white coat. The Medical Journal of Australia, 175(4), 219–222. https://doi.org/10.5694/j.1326-5377.2001.tb143103.x

Harnette, P. R. (2001). Should doctors wear white coat? The Medical Journal of Australia, 174(7), 343–344. https://doi.org/10.5694/j.1326-5377.2001.tb143310.x

Hennessy, N., Harrison, D. A., & Aitkenhead, A. R. (1993). The effect of the anaesthetist’s attire on patient attitudes. The influence of dress on patient perception of the anaesthetist’s prestige. Anesthesia, 48(3), 219-222. https://doi.org/10.1111/j.1365-2044 1 993.tb06905.x

Hippocrates. (1923). Hippocrates (W. H. S. Jones, Trans.) (Vol. 2). Harvard University Press.

Ikusaka, M., Kamegai, M., Sunaga, T., Narita, N., Kobayashi, H., Yonenami, K., & Watanabe, M. (1999). Patients’ attitude toward consultations by a physician without a white coat in Japan. Internal Medicine, 38(7), 533–536. https://doi.org/10.2169/internalmedici ne.38.533

Jacob, G. (2007). Uniform and workwear: An evidence base for developing local policy. National Health Service. https://data.parliament.uk/DepositedPapers/Files/DEP2009-0656/DEP2009-0656.pdf

Keenum, A. J., Wallace, L. S., & Stevens, A. R. (2003). Patients’ attitude regarding physical characteristics of family practice physicians. Southern Medical Journal, 96(12), 1190-1194. https://doi.org/10.1097/01.smj.0000077011.58103.c1

Keio University Hospital. (2014, May 20). Cool Biz no jisshi ni tsuite [About the implementation of Cool Biz]. Keio University Hospital. https://www.hosp.keio.ac.jp/oshirase/hosp/detail/38033/

King, C., & Infection Prevention and Control Nurse. (2022). Hand hygiene policy: Including bare below the elbows (Ver.9). Leicestershire Partnership National Health Service Trust. https://www.leicspart.nhs.uk/wp-content/uploads/2022/06/Hand-Hygiene-Policy-inc-bare-below-the-elbows.pdf

Kurihara, H., Maeno, T., & Maeno, T. (2014). Importance of physicians’ attire: factors influencing the impression it makes on patients, a cross-sectional study. Asia Pacific Family Medicine, 13(1), 2. https://doi.org/10.1186/1447-056x-13-2

Li, S. F., & Haber, M. (2005). Patient attitude toward emergency physician attire. The Journal of Emergency Medicine, 29(1), 1-3. https://doi.org/10.1016/j.jemermed.2004.12.014

Lightbody, K. A., & Wilkie, M. D. (2013). Perceptions of doctors’ dress code: ENT patients’ perspective. Clinical Otolaryngology, 38(2), 188-190. https://doi.org/10.1111/coa.12084

Menahem, S., & Shvaretzman, P. (1998). Is our appearance important to our patients? Family Practice, 15(5), 391-397. https://doi.org/10.1093/fampra/15.5.391

Ministry of the Environment. (2017, April 25). Heisei 29 nendo Cool Biz ni tsuite [About Cool Biz in 2017]. Ministry of the Environment, Japan. https://www.env.go.jp/press/103993.html

Nair, B. R., Mears, S. R., Hitchcock, K. I., & Attia, J. R. (2002). Evidence-based physicians’ dressing: A crossover trial. The medical Journal of Australia, 177(11-12), 681-682. https://doi.org/10.5694/j.1326-5377.2002.tb05017.x

Neinstein, L. S., Stewart, D., & Gordon, N. (1985).  Effect of physician dress style on patient-physician relationship. Journal of Adolescent Health Car, 6(6), 456-459.  https://doi.org/10.1016/S0 197-0070(85)80053-X

Nishihara, N., Haneda, M., & Tanabe, S. (2010). A study of office workers’ clothes and subjective evaluations in an office with a preset air-conditioning temperature of 28°C in summer. Journal of Home Economics of Japan, 61(3), 169-175. https://doi.org/10.114 28/jhej.61.169

Nishina, D., Murakawa, S., & Uemura, Y. (2007). A Study on the Effects of the Cool Biz introduced into the Regional Joint Government Buildings in Hiroshima. Technical papers of annual meeting, the Society of Heating, Air-Conditioning and Sanitary Engineers of Japan. 1463-1466. https://doi.org/10.18948/shasetai kai.2007.2.0_1463

Oyama, T., Tanaka, Y., & Haga, J. (1963). Color-affection and color-symbolism in Japanese and American students. The Japanese Journal of. Psychology, 34(3), 109-121. https://doi.org/ 10.4992/JJPSY.34.109

Palazzo, S., & Hocken, D. B. (2010). Patients’ perspectives on how doctors dress. The Journal of Hospital Infection, 74(1), 30-34. https://doi.org/10.1016/j.jhin.2009.08.021

Pronchik, D. J., Sexton, J. D., Melanson, S. W., Patterson, J. W., & Heller, M. B. (1998). Does wearing a necktie influence patient perceptions of emergency department care? The Journal of Emergency Medicine, 16(4), 541-543.  https://doi.org/10.1016/s07 36-4679(98)00036-5

Rehman, S. U., Nietert, P. J., Cope, D. W., & Kilpatrick, A. O. (2005). What wear today? Effect of doctor’s attire on the trust and confidence of patient. The American Journal of Medicine, 118(11), 1279-1286. https://doi.org/10.1016/j.amjmed.2005.04.026

Shelton, C. L., Raistrick, C., Warburton, K., & Siddiqui, K. H. (2010). Can changes in clinical attire reduce likelihood of cross-infection without jeopardizing the doctor-patient relationship? The Journal of Hospital Infection, 74(1), 22-29. https://doi.org/10.10 16/j.jhin.2009.07.031

Takemura, Y., Atsumi, R., & Tsuda, T. (2008). Which medical interview behaviours are associated with patient satisfaction? Family Medicine, 40(4), 253-258. https://pubmed.ncbi.nlm.nih.gov/18382837/

Toquero, L., Aboumarzouk, O., Owers, C., Chiang, R., Thiagarajah, S., & Amin, S. (2011, April 02). Bare below the elbows-The patient’s perspective. Webmed Central. WebmedCentral. https://www.webmedcentral.com/article_view/1401

Wong, D., Nye, K., & Hollis, P. (1991). Microbial flora on doctors’ white coats. British Medical Journal, 303(6817), 1602-1604. https://doi.org/10.1136/bmj.303.6817.1602

Yamada, Y., Takahashi, O., Ohde, S., Deshpande, G. A., & Fukui, T. (2010). Patient’s preference for doctor’s attire in Japan. Internal Medicine, 49(15), 1521–1526. https://doi.org/10.2169/internalme dicine.49.3572

*Hideki Wakabayashi
Department of Community Medicine,
Mie University School of Medicine,
2-174, Edobashi,
Tsu, Mie,
514-8507, Japan
+81-59-231-5290
Email address: hidekiwaka@med.mie-u.ac.jp

Submitted: 20 April 2023
Accepted: 19 October 2023
Published online: 2 April, TAPS 2024, 9(2), 70-80
https://doi.org/10.29060/TAPS.2024-9-2/OA3044

Xiang Ren Tan^1,2, Anthony J Goff¹ & Li Whye Cindy Ng^1,3

¹Health and Social Sciences, Singapore Institute of Technology, Singapore; ²Human Potential Translational Research Programme, Yong Loo Lin School of Medicine, National University of Singapore, Singapore; ³Department of Physiotherapy, Singapore General Hospital, Singapore

Abstract

Introduction: Objective structured clinical examinations have traditionally been used to assess clinical skills. However, these face-to-face clinical assessments were hindered by physical and social restrictions imposed during COVID-19. This created a need to develop novel approaches for reliable assessment of clinical skills. We explored and evaluated a virtual exercise teleconsultation assessment (VETA) to replicate a teleconsultation setting where physiotherapy students were assessed on exercise prescription and coaching skills.

Methods: We conducted a cross-sectional mixed-methods study using convenience sampling. A VETA was implemented for 172 physiotherapy students via Zoom to allow synchronous interaction with standardised patients (SPs). 67 students and 9 SPs completed two separate post evaluation surveys on themes relating to administration, support, authenticity, effectiveness, and value of the VETA. Likert-type responses were categorised as positive, neutral, or negative while coded qualitative responses were consolidated into themes by inductive content analysis.

Results: 76% of students agreed that the assessment was authentic while 93% felt that the SPs were realistic and believable. Responders also highlighted important challenges including the limited camera viewing angle, time and space constraint, adequacy of equipment and reliability of connectivity. Exploratory factor analysis of responses revealed three latent constructs: (1) clarity of assessment, (2) clinical relevance, and (3) value of assessment.

Conclusion: Despite the technical challenges, VETA demonstrated clarity and value as an alternative assessment and showed relevance to future telehealth practice, which is increasingly pervasive in clinical settings. This paper demonstrates a feasible approach for the virtual assessment of clinical competencies.

Keywords:           Health Sciences Education, Virtual Assessment, Clinical Skills, OSCE, Physiotherapy, Exercise Prescription

Practice Highlights

• The ability to assess students non-obtrusively allows for fair assessment with reduced anxiety.
• Despite several technical challenges, VETA demonstrated value as an alternative assessment.
• An appropriate context of use, content validity and authenticity of virtual assessment are crucial.
• VETA format may be used for distant learning and remote assessment of clinical competency.
• Virtual care delivery should be included as part of healthcare professionals’ formal training.

Table 1. Response frequency for Likert-type questions

IV. DISCUSSION

A. Keeping Pace with the Digital World

With the advent of technology and increasing prevalence of virtual care (Stamenova et al., 2022), there is a need to rethink conventional assessments of clinical competencies in medical and allied health education. Formal exposure, training, and assessment of clinical care delivery over virtual platforms will be important to prepare students for the digital world, beyond traditional face-to-face environments (Fickenscher & Pagliaro, 2021). Many digitally empowered patients have turned to web-based platform for telerehabilitation services (Brennan et al., 2009). This underscores the need for future healthcare professionals to demonstrate clinical competencies that complement the virtual mode of care delivery.

In our study, VETA was designed as an alternative to traditional OSCEs for the reliable assessment of exercise prescription and coaching skills of physiotherapy students within a simulated teleconsultation setting. Standardised patients were involved to enhance the realism of the consultation session where it allows students to practice patient-centred care and professionalism in patient handling. VETA has garnered largely positive experience from both students and SPs. The qualitative responses from the surveys were supportive of the validity, authenticity, and value of VETA; however, important limitations have been highlighted to consider for improvements in the future. This represents a real-world use case of online synchronous assessment that can be implemented to evaluate clinical skills and competencies in medical or allied health education.

B. Assessment Authenticity and Relevance

In this study, VETA provided a unique opportunity for students to conduct and experience a simulated teleconsultation and it has been largely perceived as a valid and authentic assessment. The content validity of VETA can be assessed from the realistic clinical tasks perceived by students, the test content which represents what the curriculum needs to assess (exercise prescription and coaching skills), and the right domains being tested such as communication and patient-care skills and the safe conduct of exercise (American Educational Research Association, 2014). The authenticity and value of VETA were echoed by both the quantitative and qualitative responses in this study where students felt that it was a good way to equip them with skills necessary for telehealth practice. It is paramount to note that the challenge in conducting physical assessments under COVID-19 climate is not uniquely experienced by students but also, by health practitioners (Chen et al., 2020). Telerehabilitation has been advocated and practiced during the pandemic (Turolla et al., 2020; Werneke et al., 2021) to improve accessibility to care despite the movement restrictions.

The current pandemic may bring forth a new era where telehealth becomes more significant and forms a vital service delivery platform for allied health professionals in the future (Negrini et al., 2020). Hence, this supports the relevance of a teleconsultation setting with standardised patients in our virtual assessment. The lack of exercise equipment provided during examination, albeit perceived as a limitation by students, could present a learning opportunity for students to react and cope in low-resource settings which is valuable to their future professional practice. In addition, the ability to assess students’ performance non-obtrusively allows a fair assessment with introducing unnecessary anxiety with the presence of assessor, which might be unavoidable in conventional OSCE stations (Ferreira et al., 2020). Therefore, VETA serves as a viable alternative that allows remote assessment of clinical competency in physiotherapy students.

C. Challenges with Implementation

VETA was conducted synchronously through Zoom platform within campus with students and SPs residing in different locations. Consequently, a reliable IT support structure and network connectivity was crucial to the success of the online assessment (Hopwood et al., 2021). Indeed, the connectivity issue has been reflected in this study where it has led to the loss of precious time for students to perform their teleconsultation. In this scenario, the examiner had to make a precise judgement to either (1) extend the timing and risk delays to the examination process, or (2) determine if there was enough “interaction content” to assess with and proceed with original scheduled time. Therefore, this underscores the need to include buffer time for similar situations when planning for virtual assessment.

Furthermore, the wearing of masks has resulted in the muffling of voices which prevented effective communication between students and SPs on the teleconferencing platform. Facial gestures and expression are known to play an important role in interpersonal communication, comprehension, and the delivery of intended messages and this can be affected by mask-wearing (Mheidly et al., 2020). To ensure that the SP is able to understand the prescription adequately, transparent face-masks could be worn to facilitate communication. Nonetheless, we advocate that allied health students should learn and master non-verbal communication skills as transparent face-masks may not be commonly used in clinical settings.

Time and space allocation have also been perceived to be inadequate. Based on students’ qualitative feedback, the perceived lack of time was pertaining to the interaction with the SP during exercise prescription, and not the duration for reading and planning. Pacing of speech, ensuring clarity and prioritising of information to convey are instrumental in time-effective clinical communication which students need to master (Laidlaw et al., 2014). Therefore, the timing of teleconsultation has to be optimised, not solely based on students’ expectations, but also on the assessment criteria and desired difficulty level. Furthermore, the time allocated should reflect the duration of an actual teleconsultation session where it has been reported in vascular telemedicine setting to be approximately 10 minutes (Baldwin et al., 2003), similar to the VETA format. Secondly, to ensure that SPs can perform exercise freely and safely, future runs of the assessment should cater for 20 to 50 square feet of space in the rooms, as recommended by American Council on Exercise (American Council on Exercise, 2009).

D. Study Limitations

In our study, only 39% of the total student cohort who undertook the VETA completed the survey. Hence, this may inadvertently create responders’ bias in the survey findings (e.g., those who had a positive experience may feel more motivated to participate). In our study, the evaluation survey was disseminated to students only a day after the conduct of VETA. Future studies may explore administering the survey immediately after the completion of the virtual assessment, via accessible QR codes or weblinks, to encourage greater participation rate.

Additionally, the assessment scope of VETA was limited to only a single domain of skill competency (safe exercise coaching and prescription) of the physiotherapy program and may not represent the relevance of such format for evaluating other competencies. As VETA has only been evaluated in one school setting, it remains to be ascertained if a similar format can be successfully adopted by other universities or a different structured health sciences program. Future studies may explore VETA’s implementation in other settings (i.e., evaluating other clinical competencies or conducted in other programs) and identify the potential facilitators and barriers to its adoption.

Despite the use of self-reported questionnaires to evaluate predetermined themes, the exploratory factor analysis has showed that the “effectiveness” component may not be reliably assessed by the items that were designated. To be an effective assessment, it also implies that the assessment has to mimic actual clinical settings and test skills relevant to a physiotherapist. Therefore, the same items have been correlated to the identified constructs such as clinical relevance (directly linked to assessment authenticity) and the value of assessment. Nonetheless, the distilled 13-item subset survey with good internal consistency can be employed to evaluate other novel assessments related to clinical competency.

E. Implications of a Virtual Approach

Virtual OSCE, while shown to be a useful examination format, cannot entirely replace the traditional OSCE in the assessment of physical skills which is required for allied health professional practice. For instance, hands-on skills such as manual therapy involving the massage, manipulation and mobilisation of muscles and joints, are critical to restore the patient’s functional capabilities and promote their self-efficacy (Bronfort et al., 2010). It is challenging to assess such components using virtual assessments. Specific to therapeutic exercises, it is vital to assess physical facilitation (provision of support and tactile cues) during coaching of exercise to frail individuals or patients with mobility limitations. This cannot be properly assessed without allowing physical close contact with the SPs.

Nonetheless, the success of VETA in this study highlights the feasibility of assessing specific clinical skills reliably using an online synchronous approach. When utilised in an appropriate context (e.g., for assessing online exercise prescription skills), the virtual assessment can help students gain literacy and confidence in online care delivery. At the same time, it allows them to appreciate and navigate the challenges in virtual care settings such as the lack of space or limited camera viewing angle identified in this study. With the COVID-19 pandemic, the demonstration of clinical competency over an online platform may prove to be as, if not more, relevant than traditional face-to-face assessments.

F. Looking Ahead: The Application and Value of Virtual Assessments

To understand how virtual assessments can play a bigger role in medical or allied health education, it is first important to identify which clinical skillsets and competencies are applicable or commonly used in telehealth settings. This can help in the selection of appropriate assessment to be used. Digital literacy and proficiency in the use of telehealth technologies should form a key component of undergraduate clinical education. The use of web-based or teleconferencing platforms for care delivery should also be included as part of their formal training as a healthcare professional. This will help equip the students with the relevant skills for the evolving digital world. There is also a need for a paradigm shift to not just rely on traditional OSCEs for clinical assessments, but to incorporate elements of technology and virtual care delivery relevant to telehealth practice wherever applicable.

V. CONCLUSION

While there are still technical difficulties to consider, our current model and examination setup provides an initial framework for others to adopt as an online synchronous method to assess clinical skills, especially during lockdowns or restricted periods. Furthermore, this VETA format may be used for distant learning and remote assessment of clinical competency for healthcare workers residing in rural areas (Palmer et al., 2015) or students on placement in medically underserved areas. As the use of virtual assessments removes geographical barriers, this allows other experienced teachers and faculty from external institutions to join as assessors or observers to calibrate and align assessment outcomes, thereby enhancing the overall quality of medical education across institutions. Taken together, the use of virtual clinical skills assessment is promising and should be carefully considered for integration into the current medical or allied health education system.

Notes on Contributors

TXR contributed to the study design, conceptualised VETA, conducted data collection and analysis, and drafted the manuscript. AG contributed to assessment design and results interpretation. CN devised the study, innovated the VETA format, conducted data collection and contributed to results interpretation. All authors have read and approved the final manuscript.

Ethical Approval

The study was exempted from ethical review with the use of anonymous surveys with no recording of any identifiable information. In line with the Declaration of Helsinki and the institutional IRB exemption criteria, the study presents minimal risk to participants, does not touch on sensitive topics, does not involve vulnerable population, and does not involve deception or withholding of study’s stated aims and objectives from participants.

Data Availability

Datasets generated and/or analysed during the current study are available from the following DOIs: https://doi.org/10.6084/m9.figshare.22641013

https://doi.org/10.6084/m9.figshare.22641115

https://doi.org/10.6084/m9.figshare.22640998

Acknowledgement

We would like to thank all the students and standardised patients who participated in this study.

Funding

The authors received no specific funding for this study.

Declaration of Interest

The authors report no conflicts of interest.

References

American Council on Exercise. (2009). American council on exercise: How to design a home gym. Retrieved April 4, 2022, from https://www.acefitness.org/resources/everyone/blog/6625/home-gym-design-how-to-design-a-home-gym/

American Educational Research Association. (2014). Standards for educational and psychological testing. American Educational Research Association.

Baldwin, L., Clarke, M., Hands, L., Knott, M., & Jones, R. (2003). The effect of telemedicine on consultation time. Journal of Telemedicine and Telecare, 9 Suppl 1, S71-73.

Barra-Ortiz, H. A. d. l., Gómez-Miranda, L. A., & Fuente-Astroza, J. I. d. l. (2021). Objective structured clinical examination (OSCE) to assess the clinical skills of physical therapy students when using physical agents. Revista de la Facultad de Medicina, 69(3), Article e83545.

Blythe, J., Patel, N. S. A., Spiring, W., Easton, G., Evans, D., Meskevicius-Sadler, E., Noshib, H., & Gordon, H. (2021). Undertaking a high stakes virtual OSCE (“VOSCE”) during Covid-19. BMC Medical Education, 21, Article 221. https://doi.org/10.1186/s12909-021-02660-5

Brennan, D. M., Mawson, S., & Brownsell, S. (2009). Telerehabilitation: Enabling the remote delivery of healthcare, rehabilitation, and self management. Studies in Health Technology and Informatics, 145, 231-248.

Bronfort, G., Haas, M., Evans, R., Leininger, B., & Triano, J. (2010). Effectiveness of manual therapies: The UK evidence report. Chiropractic & Osteopathy, 18, Article 3. https://doi.org/10.1186/1746-1340-18-3

Chen, D. E., Tay, E. K., Tan, P. L., Su, P., Koh, M. M., Ong, P. L., Chew, E., & Ng, Y. S. (2020). The impact of COVID-19 pandemic on rehabilitation in Singapore. Annals of the Academy of Medicine of Singapore, 49(11), 925-927. https://doi.org/10.47102/annals-acadmedsg.2020297

Chisnall, B., Vince, T., Hall, S., & Tribe, R. (2015). Evaluation of outcomes of a formative objective structured clinical examination for second-year UK medical students. International Journal of Medical Education, 6, 76-83. https://doi.org/10.5116/ijme.5572.a534

Cleland, J. A., Abe, K., & Rethans, J. J. (2009). The use of simulated patients in medical education: AMEE Guide No 42. Medical Teacher, 31(6), 477-486.

Deldar, K., Bahaadinbeigy, K., & Tara, S. M. (2016). Teleconsultation and clinical decision making: A systematic review. Acta Informatica Medica, 24(4), 286-292.

Deville, R. L., Fellers, C. M., & Howard, M. L. (2021). Lessons learned pivoting to a virtual OSCE: Pharmacy faculty and student perspectives. Currents in Pharmacy Teaching and Learning, 13(11), 1498-1502. https://doi.org/10.1016/j.cptl.2021.06.046

Downing, S. M. (2004). Reliability: On the reproducibility of assessment data. Medical Education, 38(9), 1006-1012.

Edwards, M., & Martin, A. (1989). The objective structured clinical examination as a method of occupational therapy student evaluation. Canadian Journal of Occupational Therapy, 56(3), 128-131.

Elo, S., & Kyngäs, H. (2008). The qualitative content analysis process. Journal of Advance Nursing, 62(1), 107-115.

Farahat, E., Rice, G., Daher, N., Heine, N., Schneider, L., & Connell, B. (2015). Objective structured clinical examination (OSCE) improves perceived readiness for clinical placement in nutrition and dietetic students. Journal of Allied Health, 44(4), 208-214.

Ferreira, É. d. M. R., Pinto, R. Z., Arantes, P. M. M., Vieira, É. L. M., Teixeira, A. L., Ferreira, F. R., & Vaz, D. V. (2020). Stress, anxiety, self-efficacy, and the meanings that physical therapy students attribute to their experience with an objective structured clinical examination. BMC Medical Education, 20(1), 296. https://doi.org/10.1186/s12909-020-02202-5

Fickenscher, K., & Pagliaro, J. A. (2021). Education in virtual care delivery: Clinician education and digital health literacy. Healthcare Information Technology for Cardiovascular Medicine, 111-125. https://doi.org/10.1007/978-3-030-81030-6_9  

Fouad, S., Gouda, E., Nasser, A. A., & Kamal, D. (2019). Perception of students, staff and simulated patients towards objective structured clinical examination (OSCE). Education in Medicine Journal, 11(2), 27-42. https://doi.org/10.21315/eimj2019.11.2.4

Gormley, G. (2011). Summative OSCEs in undergraduate medical education. The Ulster Medical Journal, 80(3), 127-132.

Grover, S., Pandya, M., Ranasinghe, C., Ramji, S. P., Bola, H., & Raj, S. (2022). Assessing the utility of virtual OSCE sessions as an educational tool: A national pilot study. BMC Medical Education, 22(1), 178. https://doi.org/10.1186/s12909-022-03248-3

Hannan, T. A., Umar, S. Y., Rob, Z., & Choudhury, R. R. (2021). Designing and running an online objective structured clinical examination (OSCE) on Zoom: A peer-led example. Medical Teacher, 43(6), 651-655.

Harden, R. M., Stevenson, M., Downie, W. W., & Wilson, G. M. (1975). Assessment of clinical competence using objective structured examination. British Medical Journal, 1, 447-451. https://doi.org/10.1136/bmj.1.5955.447

Hopwood, J., Myers, G., & Sturrock, A. (2021). Twelve tips for conducting a virtual OSCE. Medical Teacher, 43(6), 633-636.

Hsieh, H. F., & Shannon, S. E. (2005). Three approaches to qualitative content analysis. Qualitative Health Research, 15(9), 1277-1288.

Jo, K. H., & An, G. J. (2014). Qualitative content analysis experiences with objective structured clinical examination among Korean nursing students. Japan Journal of Nursing Science, 11(2), 79-86.

Khan, K. Z., Ramachandran, S., Gaunt, K., & Pushkar, P. (2013). The objective structured clinical examination (OSCE): AMEE Guide No. 81. Part I: An historical and theoretical perspective. Medical Teacher, 35(9), e1437-1446.

Kumar, A., Sarkar, M., Davis, E., Morphet, J., Maloney, S., Ilic, D., & Palermo, C. (2021). Impact of the COVID-19 pandemic on teaching and learning in health professional education: A mixed methods study protocol. BMC Medical Education, 21(1), 439. https://doi.org/10.1186/s12909-021-02871-w

Laidlaw, A., Salisbury, H., Doherty, E. M., & Wiskin, C. (2014). National survey of clinical communication assessment in medical education in the United Kingdom (UK). BMC Medical Education, 14, 10. https://doi.org/10.1186/1472-6920-14-10

Liang, Z. C., Ooi, S. B. S., & Wang, W. (2020). Pandemics and their impact on medical training: Lessons from Singapore. Academic Medicine, 95(9), 1359-1361. https://doi.org/10.1097/acm.0000000000003441

Lovink, A., Groenier, M., van der Niet, A., Miedema, H., & Rethans, J. J. (2021). The contribution of simulated patients to meaningful student learning. Perspectives on Medical Education, 10(6), 341-346. https://doi.org/10.1007/s40037-021-00684-7

Major, S., Sawan, L., Vognsen, J., & Jabre, M. (2020). COVID-19 pandemic prompts the development of a web-OSCE using Zoom teleconferencing to resume medical students’ clinical skills training at Weill Cornell Medicine-Qatar. BMJ Simulation & Technology Enhanced Learning, 6(6), 376-377. https://doi.org/10.1136/bmjstel-2020-000629

Mheidly, N., Fares, M. Y., Zalzale, H., & Fares, J. (2020). Effect of face masks on interpersonal communication during the COVID-19 pandemic. Frontiers in Public Health, 8. https://doi.org/10.3389/fpubh.2020.582191

Negrini, S., Kiekens, C., Bernetti, A., Capecci, M., Ceravolo, M. G., Lavezzi, S., Zampolini, M., & Boldrini, P. (2020). Telemedicine from research to practice during the pandemic. “Instant paper from the field” on rehabilitation answers to the COVID-19 emergency. European Journal of Physical and Rehabilitation Medicine, 56(3), 327-330. https://doi.org/10.23736/s1973-9087.20.06331-5

Norman, G. (2002). Research in medical education: Three decades of progress. British Medical Journal, 324(7353), 1560-1562. https://doi.org/10.1136/bmj.324.7353.1560

Palmer, R. T., Biagioli, F. E., Mujcic, J., Schneider, B. N., Spires, L., & Dodson, L. G. (2015). The feasibility and acceptability of administering a telemedicine objective structured clinical exam as a solution for providing equivalent education to remote and rural learners. Rural Remote Health, 15(4), 3399.

Pettit, M., Shukla, S., Zhang, J., Sunil Kumar, K. H., & Khanduja, V. (2021). Virtual exams: Has COVID-19 provided the impetus to change assessment methods in medicine? Bone & Joint Open, 2(2), 111-118. https://doi.org/10.1302/2633-1462.22.BJO-2020-0142.R1  

Prettyman, A. V., Knight, E. P., & Allison, T. E. (2018). Objective structured clinical examination from virtually anywhere! The Journal for Nurse Practitioners, 14(8), e157-e163. https://doi.org/10.1016/j.nurpra.2018.05.007

Rickles, N. M., Tieu, P., Myers, L., Galal, S., & Chung, V. (2009). The impact of a standardized patient program on student learning of communication skills. American Journal of Pharmaceutical Education, 73(1), 4.

Shirwaikar, A. (2015). Objective structured clinical examination (OSCE) in pharmacy education – a trend. Pharmacy Practice, 13(4), 627-627. https://doi.org/10.18549/PharmPract.2015.04.627

Silva, C. C., Lunardi, A. C., Mendes, F. A., Souza, F. F., & Carvalho, C. R. (2011). Objective structured clinical evaluation as an assessment method for undergraduate chest physical therapy students: A cross-sectional study. Brazilian Journal of Physical Therapy, 15, 481-486.

Stamenova, V., Chu, C., Pang, A., Fang, J., Shakeri, A., Cram, P., Bhattacharyya, O., Bhatia, R. S., & Tadrous, M. (2022). Virtual care use during the COVID-19 pandemic and its impact on healthcare utilization in patients with chronic disease: A population-based repeated cross-sectional study. PLOS ONE, 17(4), Article e0267218. https://doi.org/10.1371/journal.pone.0267218

Tan, X. R., & Ng, C. L. W. (2022, January 20-21). Perceptions of allied health students and standardised patients towards virtual exercise teleconsultation assessment (VETA) during COVID-19. Applied Learning Conference 2022, Singapore.

Turolla, A., Rossettini, G., Viceconti, A., Palese, A., & Geri, T. (2020). Musculoskeletal physical therapy during the COVID-19 pandemic: Is telerehabilitation the answer? Physical Therapy, 100(8), 1260-1264. https://doi.org/10.1093/ptj/pzaa093

Watkins, M. W. (2018). Exploratory factor analysis: A guide to best practice. Journal of Black Psychology, 44(3), 219-246.

Werneke, M. W., Deutscher, D., Grigsby, D., Tucker, C. A., Mioduski, J. E., & Hayes, D. (2021). Telerehabilitation during the COVID-19 pandemic in outpatient rehabilitation settings: A descriptive study. Physical Therapy, 101(7). https://doi.org/10.1093/ptj/pzab110  

Wessel, J., Williams, R., Finch, E., & Gémus, M. (2003). Reliability and validity of an objective structured clinical examination for physical therapy students. Journal of Allied Health, 32(4), 266-269.

Zayyan, M. (2011). Objective structured clinical examination: The assessment of choice. Oman Medical Journal, 26(4), 219-222. https://doi.org/10.5001/omj.2011.55

*Tan Xiang Ren
SIT Dover Campus,
10 Dover Drive,
Singapore 138683
Email: XiangRen.Tan@singaporetech.edu.sg

Submitted: 30 May 2023
Accepted: 24 October 2023
Published online: 2 April, TAPS 2024, 9(2), 60-69
https://doi.org/10.29060/TAPS.2024-9-2/OA3062

Mary XiaoRong Chen¹ & Dora Howes²

¹Health and Social Sciences, Singapore Institute of Technology, Singapore; ²Nursing & Health Care School, School of Medicine, Dentistry & Nursing^, University of Glasgow, United Kingdom

Abstract

Introduction: Nurses’ professional identity is important for their career orientation and clinical practice. This study explored Singaporean nurses’ perceptions of professional identity. The results provide an understanding of how guided learning and reflection could help nurses in their professional identity formation and development.

Methods: Using an exploratory descriptive qualitative research study and purposive sampling by researchers teaching in the programme, 64 Registered Nurses with a diploma qualification pursuing a Bachelor of Science degree with Honours in Nursing programme in Singapore were invited to participate. They responded to open ended survey questions online, which were analysed using a thematic analysis. Ethical approval was obtained.

Results: All 64 first year students were invited to participate at the start of the module and upon the completion. The response rates were 94% and 81% respectively. Two overarching themes – “nurses as professionals with knowledge and moral character” and “the construction of professional identity” – emerged from the data.

Conclusion: The nurses perceived their professional nursing identity as a construct comprised of knowledge and moral characteristics, which is consistent with international literature. A professional nursing identity, relationships with other healthcare professionals, patients and confidence in practice were all interrelated. Guided reflection and discussion on clinical experiences and social interactions helped students become aware of their professional identity and responsibilities. Such purposive educational effort needs to be started early and supported through the students’ educational journey into clinical practice.  

Keywords:           Professional Identity of Nursing, Singapore Nurses, Image of Nursing, Social Perception of Nursing in Singapore, Nurse Education

Practice Highlights

• Professional nursing identity can be facilitated by guided reflection.
• Purposive educational effort needs to be started early and continued in clinical practice.
• Awareness of professional identity relates to practice, relationship and professional development.

III. RESULTS

All 64 students agreed to participate and signed the consent form. The response rate at each collection point was 94% and 81% respectively. While the reason for the drop is not clear, it is possible that the demands from competing modules at the time of the second survey were influential.

Two overarching themes emerged (Table 4). The first, “Nursing profession is perceived as a profession with knowledge and moral character” stood out clearly from the responses given. It encompassed the subthemes of knowledge and moral character. The second theme – “The construction of professional identity” – elicited codes that made up the subthemes of social factors, identity challenges and nurses’ role in the construction of their professional identity.

Theme 1. Professionals with Knowledge and Moral Character

Students perceived a professional nurse as someone with a “good character, and capable of knowing” and “doing what was needed with self-control and discipline”. The theme was supported with two subthemes – ‘knowledge’ and ‘moral character’. 

1) Knowledge: The students believed a professional nurse needed to engage in learning throughout their professional lifetime. A knowledgeable nurse was described as “knowing the job well” and “having special knowledge and being able to perform well”. The knowledgeable nurse could create new knowledge through study as exemplified in the quote below.

“…Professionalism is the outcome of a work that can have both the elements of arts and science …. been thoroughly sorted out to create knowledge that could be of relevance to the present study or development for future studies.”

(S37)

2) Moral character: The moral character of a professional nurse encompasses the moral agency demonstrated in his/her daily practice. A nurse needed to be “someone with good virtues and moral values” and uphold “ethical conduct and practice contentiously beyond any selfish thoughts”. The quotes below indicate some of these moral characteristics:

“Nursing is a job that is not meant for anyone, it takes dedication, strength and passion to be one.”

(S44)

“Because we work together as a team, it is important to trust each other based on the individual training that we had gone through and are able to carry out our duties well. It also serves as a form of accountability to people in our team and people receiving care from us”

 (S08)

Students were clearly aware of the ethical code expected of them, which was reassuring in terms of the pre-registration education received.

Theme 2. The Construction of Professional Identity

This theme illuminated how the students viewed the construction of their professional identity. Three subthemes including ‘a social perception’, ‘identity challenges’ and ‘realising their role in the construction of professional identity’ were elicited.

1) A social perception: The students’ perception of their professional identity was influenced by the images and values directed towards nursing by society in comparison to other professions. The students perceived doctors, lawyers, and teachers as well-respected professionals. Doctors were “in a white coat with a stethoscope around their neck with confidence” while lawyers and teachers had “nice and neat suits” and were deemed to be “a sage or Master Yoda”, or “a confident global speaker”, “the force is within them”, or “have an aura of superiority, authority and power”. In contrast, the students viewed themselves as engaging in a “low skill/dirty job and of lower social status” due to the nature of the essential care they delivered daily. Such socially perceived images of being a professional were internalised resulting in the projection of a poor perception of their care work and image, as indicated here.

“When the word professionalism…the image of a doctor comes to my mind…portrayed as a superior figure as compared to a nurse… they (patients) will usually turn for help from [the] doctors as they perceive that doctor[s] have all the information and knowledge…parents also encourage or advise their children to become doctors…

(S17)

2) Identity challenges: Closely linked to social perception, the students encountered identity challenges from their interactions with people around them. They noted the development of special relationships with patients while remaining deferential to doctors. Some students also felt the process of professionalisation was akin to a sorting method, which differentiated professionals into higher or lower social status. Such relationships caused confusion and challenged their professional identity as the following quotations exemplify.

“I think that by having professional identity…only favours the doctors… Even if nurses make the right decision and doctors are wrong in the case, patients will still think that doctors are always right.”

(S17)

“The effect of professional identity in our practice is that the people around us may or may not get [us] respected. For example, in front of the doctors, we would portray like a maid who just do as what they say. However, in front of patients, we are their healthcare advocates which they listened to. Thus, it is a mixture of set of identity…”

(S28)

3) Realising their role in the construction of professional identity: The guided reflection created a safe space and provided methods for students to learn from their own and others’ experiences. As the module progressed, students came to realise their roles and their relationship with other professionals, as well as their responsibility in constructing their professional identity and how this identity was then portrayed to others. The quotes below offer some examples:

“The effects of the professional identity are how you portray the occupation to the world. People tend to judge the occupation by the way we portray ourselves.”

(S63)

“I value my role as a nurse as I feel that nurses can play a lot of roles…versatile, as nurses have greater knowledge than patients think. Also, nurses have judgment and good assessment skills so that we can identify what is not right with patients right away.”

(S17)

At a wider level, the students portrayed an optimistic outlook on their professional status with reference to the approved prescription rights to APNs in Singapore (Liew, 2018). The students felt their devotion towards patients led to them gaining wider trust and respect, as shown here:

“I valued the fact that my role gave me a sense of responsibility to advocate to the best of my patient’s interest. And the fact that more people are approaching nurses for advice makes me feel that we have slowly gained public trust on nurses.”

(S64)

The students believed that mutual respect was essential for quality patient care, positive relationships, and the affirmation of their professional identity. Student S54 provided an example.

“As a nurse, I feel that mutual respect is vital for nursing. As the nurse respects the patient as an individual to provide the best quality care, the value for respect towards nurses should also be established as professionals.”

(S54)

IV. DISCUSSION

The study demonstrated that students perceived nursing as a professional with knowledge and moral character, which is consistent with the professional requirement by the SNB (2011). However, students perceived a lack of awareness of nurses’ roles and some confusion about nursing identity by the public and other healthcare professionals, which does not reflect the intended development of nursing practice.

The repeated comments of nurses being perceived as inferior to doctors by the public indicated that to them, nursing is still viewed negatively and of lower social status in Singapore, similar to the study done by Tay et al. (2012) ten years ago where nurses felt devalued and disrespected. Internationally, a division in the treatment towards doctors and nurses persists, as people tend to give doctors credit and recognition and view nurses as having a complementary role (de Araujo Sartorio & Pavone Zoboli, 2010; de Meis et al., 2007; Johnson, 2018; Kemmer & Paes da Silva, 2007). The biased perception and treatment contribute to the devaluation of nursing, resulting in a focus solely on nursing functions and categories, rather than profiling nursing’s professional identity.

Despite more nurses pursuing higher education and leading comprehensive patient care roles such as APNs in Singapore, patients still have a poor perception of their roles and lack awareness of the preparation needed (Woo et al., 2020). A study set in a primary care setting found that doctors viewed APNs as competent clinical partners, but their roles were not well understood (Soh et al., 2021). This role confusion is possibly due to the breadth of nurses’ roles and a failure to communicate their professional roles effectively to the public. Pimenta and Souza (2017) reviewed 55 newspapers concerning the professional identity of nursing from 1983 to 2012 and found that nursing was treated as a unified entity. There was no differentiation between “nursing practiced by nurses” from the “nursing practiced by the other workers making up the team” (Pimenta & Souza, 2017, p4) indicating there is still much work to be done to make the roles of nurses more comprehendible and visible.

This study showed how intentional education can help nurses to reflect on their clinical experiences and form a positive professional identity. The finding is consistent with that of a recent study by Fitzgerald and Clukey (2022, p1349) who found that reflection helped students to “think about thinking”, connecting the dots together to know what nursing really is and internalise their professional identity. The educational effort highlighted in both studies can be extended to interprofessional education, to create opportunities for different professional groups to learn together and understand one another’s abilities and roles better. In Singapore, studies on interprofessional learning revealed improved communication, mutual respect, trust and changing the stereotypes and attitudes towards the nurse–physician relationship (Liaw et al., 2014; Liaw et al., 2023). Another study demonstrated how interprofessional virtual rounds helped students from six healthcare courses, including nursing, to gain insights into one another’s professional role and build mutual trust (Liaw et al., 2020). However, these studies were all based in schools with a short duration of learning. Intentional education and long-term studies on professional identity and interprofessional relationships should be continued in clinical settings.

A Singaporean ethnographic study by Chen et al. (2021) exposed the complexity of nurses’ daily work and how nurses navigated their participation and relationships with other healthcare workers. The deliberation of nurses’ professional identity is not a single professional affair, but that of all healthcare professionals. Nevertheless, more action is needed from nurses, nurse educators, and nursing leaders to define, develop, and portray their professional identity. Ben Natan and Becker (2010) urged nurses to let the public know what their work entailed by giving speeches and presenting their work through social media. With the Healthier SG movement (MOH, 2023), it is foreseeable that nurses will play more important roles in preventive and community health. Nurses should seek opportunities to communicate their roles and articulate their abilities to the public.

This study collected data from only one group of nurses undergoing a top-up degree study. Many nurses did not explain their ideas in detail. Future studies can consider using interviews and focus group discussions to explore these ideas in further depth. Nurses from various nursing schools and clinical settings could also be included and views from the public and other healthcare professionals would be welcomed.

V. CONCLUSION

Nursing identity is influenced by multiple factors, which can cause role confusion. The educational effort is vital to nurture nurses’ abilities to reflect, deliberate and communicate their professional identity. Nursing schools in Singapore and further afield need to include such intentional reflective approaches to help nursing students deliberate their professional identity and to nurture their ability to do so throughout their professional careers. Nurses and nursing leaders need to be more proactive in communicating their professional values and roles. More longer-term research is needed in both education and clinical practice settings to understand the sustained effect of education on nurses’ ongoing negotiation of their professional identity.

Notes on Contributors

Dr Mary XiaoRong Chen reviewed the literature, designed the study, conducted the data collection, data analysis and wrote the transcript.

Dr Dora Howes reviewed the data analysis, contributed to the manuscript and gave critical feedback on the final version.

Both authors read and approved the final manuscript.

Ethical Approval

The study was approved by the Singapore Insitute of Technology Ethics Committee (Project 2018007).

Data Availability

The data that support the findings of this study are available in the repository at: https://doi.org/10.25447/sit.23515425

Acknowledgement

We thank all student nurses who participated in the research.

Funding

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

Declaration of Interest

The authors do not have any conflicts of interest. Participation in the research was voluntary and anonymous. Student nurses were assured that their participation or nonparticipation would not affect their learning or academic standing.

References

Bartlett, J. (2015). The profession of nursing. Jones & Bartlett Learning. Retrieved 14 November from http://samples.jbpub.com/9781449649029/46066_CH01_6031.pdf

Ben Natan, M., & Becker, F. (2010). Israelis’ perceived motivation for choosing a nursing career. Nurse Education Today, 30(4), 308-313. https://doi.org/10.1016/j.nedt.2009.08.006

Benner, P., Sutphen, M., Leonard, V., & Day, L. (2009). Educating nurses: A call for radical transformation (Vol. 15). John Wiley & Sons.

Black, B. P. (2014). Professional nursing concepts & challenges (7th ed.). Elsevier.

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.

Chen, M. X. (2020). The evolving identity and competence of new nursing graduates in practice: A community of practice perspective [EdD Thesis, UCL (University College London)]. https://discovery.ucl.ac.uk/id/eprint/10115351/

Chen, M. X., Newman, M., & Park, S. (2021). Becoming a member of a nursing community of practice: Negotiating performance competence and identity. Journal of Vocational Education & Training, 1-15. https://doi.org/10.1080/13636820.2021.2015715

Clements, A. J., Kinman, G., Leggetter, S., Teoh, K., & Guppy, A. (2016). Exploring commitment, professional identity, and support for student nurses. Nurse Education in Practice, 16(1), 20-26. https://doi.org/10.1016/j.nepr.2015.06.001

Clouder, L. (2003). Becoming professional: Exploring the complexities of professional socialisation in health and social care. Learning in Health and Social Care, 2(4), 213-222. https://doi.org/10.1046/j.1473-6861.2003.00052.x

Crigger, N., & Godfrey, N. (2014). From the inside out: A new approach to teaching professional identity formation and professional ethics. Journal of Professional Nursing, 30(5), 376-382. https://doi.org/10.1016/j.profnurs.2014.03.004

de Araujo Sartorio, N., & Pavone Zoboli, E. L. C. (2010). Images of a ‘good nurse’ presented by teaching staff. Nursing Ethics, 17(6), 687-694. https://doi.org/10.1177/0969733010378930

de Meis, C., de Almeida Souza, C., & da Silva Filho, J. F. (2007). House and street: Narratives of professional identity among nurses. Journal of Professional Nursing, 23(6), 325-328. https://doi.org/10.1016/j.profnurs.2007.06.004

Deppoliti, D. (2008). Exploring how new registered nurses construct professional identity in hospital settings. The Journal of Continuing Education in Nursing, 39(6), 255-262. https://doi.org/10.3928/00220124-20080601-03  

Fitzgerald, A., & Clukey, L. (2022). Factors influencing nursing professional identity development: A qualitative study. Nursing Forum, 57(6), 1346-1353. https://doi.org/10.1111/nuf.12816

Girvin, J., Jackson, D., & Hutchinson, M. (2016). Contemporary public perceptions of nursing: A systematic review and narrative synthesis of the international research evidence. Journal of Nursing Management, 24(8), 994-1006. https://doi.org/10.1111/jonm.1241 3

Goh, T. (2022, August 3). Resignation rates of nurses in public hospitals at a five-year high in 2021. The Straits Times. https://www.straitstimes.com/singapore/politics/resignation-rates-of-nurses-in-public-hospitals-at-a-five-year-high-in-2021-says-rahayu-mahzam

Hoyle, L. P., Kyle, R. G., & Mahoney, C. (2017). Nurses’ views on the impact of mass media on the public perception of nursing and nurse–service user interactions. Journal of Research in Nursing, 22(8), 586-596. https://doi.org/10.1177/1744987117736 363  

Hunter, D., McCallum, J., & Howes, D. (2019). Defining exploratory-descriptive qualitative (EDQ) research and considering its application to healthcare. Journal of Nursing and Health Care, 4(1). https://eprints.gla.ac.uk/180272/

Johnson, M., Cowin, L. S., Wilson, I., & Young, H. (2012). Professional identity and nursing: Contemporary theoretical developments and future research challenges: Nurses, careers and professional identity. International Nursing Review, 59(4), 562-569. https://doi.org/10.1111/j.1466-7657.2012.01013.x

Johnson, S. E. (2018). “Convince your patients and you will convince society”: Career decisions and professional identity among nurses in India. SAGE Open, 8(1). https://doi.org/10.1177/2158244018763014

Kemmer, L. F., & Paes da Silva, M. J. (2007). Nurses’ visibility according to the perceptions of the communication professionals. Revista Latino-Americana de Enfermagem, 15(2), 191-198. https://doi.org/10.1590/S0104-11692007000200002  

Liaw, S. Y., Siau, C., Zhou, W. T., & Lau, T. C. (2014). Interprofessional simulation-based education program: A promising approach for changing stereotypes and improving attitudes toward nurse–physician collaboration. Applied Nursing Research, 27(4), 258-260. https://doi.org/10.1016/j.apnr.2014.03. 005

Liaw, S. Y., Tan, J. Z., Lim, S., Zhou, W., Yap, J., Ratan, R., Ooi, S. L., Wong, S. J., Seah, B., & Chua, W. L. (2023). Artificial intelligence in virtual reality simulation for interprofessional communication training: Mixed method study. Nurse Education Today, 122, Article 105718. https://doi.org/10.1016/j.nedt.2023. 105718

Liaw, S. Y., Wu, L. T., Soh, S. L. H., Ringsted, C., Lau, T. C., & Lim, W. S. (2020). Virtual reality simulation in interprofessional round training for health care students: A qualitative evaluation study. Clinical Simulation in Nursing, 45, 42-46. https://doi.org/10.1016/j.ecns.2020.03.013 

Liew, I. (2018, July 2). First pharmacists, advanced practice nurses certified to prescribe medicines. The Straits Times. https://www.straitstimes.com/singapore/first-pharmacists-advanced-practice-nurses-now-certified-to-prescribe-medicines

Mao, A., Lu, S.-e., Lin, Y., & He, M. (2021). A scoping review on the influencing factors and development process of professional identity among nursing students and nurses. Journal of Professional Nursing, 37(2), 391-398. https://doi.org/10.1016/j.p rofnurs.2020.04.018

Marique, G., & Stinglhamber, F. (2011). Identification to proximal targets and affective organizational commitment: The mediating role of organizational identification. Journal of Personnel Psychology, 10(3), 107-117. https://doi.org/10.1027/1866-5888/ a000040

Miles, M. B., Huberman, A. M., & Saldaña, J. (2019). Qualitative data analysis: A methods sourcebook (4^th ed.). SAGE.

Ministry of Health. (2012). Nursing Careers. https://www.moh.gov.sg/hpp/nurses/career-practices/CareerNPracticesDetails/nursing-careers

Peate, I. (2016). Nursing against the odds. British Journal of Nursing, 25(7), 357-357. https://doi.org/10.12968/bjon.2016.25.7.357  

Pimenta, A. d. L., & Souza, M. d. L. d. (2017). The professional identity of nursing in the papers published by Reben. Texto & Contexto Enfermagem, 26(01), e4370015. https://doi.org/10.1590/0104-07072016004370015   

Sabanciogullari, S., & Dogan, S. (2015). Relationship between job satisfaction, professional identity and intention to leave the profession among nurses in Turkey. Journal of Nursing Management, 23(8), 1076-1085. https://doi.org/10.1111/jonm.12256

Sather, D. L. (2020). Who Am I? A Case Study of Professional Identity Development in Undergraduates [PhD Thesis, Northcentral University]. ProQuest Dissertations Publishing. https://www.proquest.com/openview/236d1081c0cef0fafcb075a2c36dd183/1?pq-origsite=gscholar&cbl=18750&diss=y

Singapore Nursing Board. (2011). Standard of practice for nurses and midwives. https://www.healthprofessionals.gov.sg/docs/librariesprovider4/publications/snb_standards_of_practices.pdf

Slay, H. S., & Smith, D. A. (2011). Professional identity construction: Using narrative to understand the negotiation of professional and stigmatized cultural identities. Human Relations, 64(1), 85-107. https://doi.org/10.1177/0018726710384290

Soh, B. F. J. R., Ang, W. H. D., De Roza, J. G., Quek, I. P., Lim, P. S., & Lau, Y. (2021). They are partners in care: A qualitative exploration of physicians’ perceptions of primary care Advanced Practice Nurses. Journal of Nursing Scholarship, 53(5), 542-551. https://doi.org/10.1111/jnu.12665

Tay, L. H., Ang, E., & Hegney, D. (2012). Nurses’ perceptions of the barriers in effective communication with inpatient cancer adults in Singapore. Journal of Clinical Nursing, 21(17-18), 2647-2658. https://doi.org/10.1111/j.1365-2702.2011.03977.x

Ten Hoeve, Y., Jansen, G., & Roodbol, P. (2014). The nursing profession: Public image, self-concept and professional identity. A discussion paper. Journal of Advanced Nursing, 70(2), 295-309. https://doi.org/10.1111/jan.12177

Woo, B., Koh, K., Zhou, W., Wei Lim, T., Lopez, V., & Tam, W. (2020). Understanding the role of an advanced practice nurse through the perspectives of patients with cardiovascular disease: A qualitative study. Journal of Clinical Nursing, 29(9-10), 1623-1634. https://doi.org/10.1111/jocn.15224

Xu, C., Koh, K. W. L., & Zhou, W. (2022). The development of advanced practice nurses in Singapore. International Nursing Review. https://doi.org/10.1111/inr.12810

*Mary Chen Xiaorong
10 Dover Drive,
Singapore 138680
Email: Mary.chen@singaporetech.edu.sg / xiaorong8@gmail.com