Submitted: 2 July 2023
Accepted: 17 November 2023
Published online: 2 April, TAPS 2024, 9(2), 51-59
https://doi.org/10.29060/TAPS.2024-9-2/OA3078

Soi Moi Chye¹, Rhun Yian Koh¹ & Pathiyil Ravi Shankar²

¹Department of Applied Biomedical Science and Biotechnology, School of Health Science, International Medical University, Kuala Lumpur, Malaysia; ²IMU Centre for Education, International Medical University, Kuala Lumpur, Malaysia

Abstract

Introduction: People skills play a crucial role in the professional development of Biomedical Scientists. A laboratory management and professional practice module was offered as part of the people skills development for Biomedical Science first-year students.  This study aims to describe the use of role-play to teach stress and anger management skills to Biomedical Science students and reports on students’ opinions of role-play as a teaching-learning method.

Methods: Students were divided into groups with 10 or 11 students per group. Each group of students presented a role-play for 15 to 20 min. This was followed by reflections by the group, feedback from other groups, and the facilitators. At the end of the session, student feedback was taken by a questionnaire using both closed (using a 5‑point Likert scale) and open‑ended questions. Statistical evaluation of the collected data was carried out using SPSS version 28 for Windows.

Results: A total of 96 students from the 2021 and 2022 cohorts participated in the role-plays. The survey was completed by 48 students from the 2021 intake and 33 students from the 2022 intake. The overall response rate was 84.37%. Respondents perceived role-play to be enjoyable, useful, and helpful for developing stress and anger management skills. They wanted role-play to be used as a teaching-learning method in the future.

Conclusions: Role-play can be effective to teach stress and anger management skills to undergraduate Biomedical Science first-year students.

Keywords:           Role-Plays, Stress and Anger Management Skills, Biomedical Science, Professional, Questionnaire, Feedback; Undergraduate

Practice Highlights

• Respondents perceived role-play to be enjoyable, useful, and helpful for developing stress and anger management skills.
• Role-play can be effective to teach stress and anger management skills to undergraduate Biomedical Science first-year students.
• Role-play was recommended to be used as a teaching-learning method in the future.

I. INTRODUCTION

People skills are the ability to communicate effectively with others, build relationships, and work collaboratively. People skills include active listening, empathy, conflict resolution, and teamwork. Anger and stress can impact people skills, especially interpersonal communication (Strumska-Cylwik, 2014). It is important to note that people who are easily angered and stressed often come from families that are disruptive, chaotic, and not skilled at emotional communication. Uncontrolled anger and stress can negatively affect physical health and emotional well-being and can lead to problems at work, in personal relationships, and in the overall quality of life (Armstrong, 2012). There is an important link between anger, stress, interpersonal skills, and emotional intelligence (Schutte et al., 2001). Bennett et al. (2016) reported that soft skills (people skills) are more critical for future employment than technical skills, and their enhancement has a lifelong impact. These skills are particularly important for health professionals due to the close relationship between them and their patients.

Health professionals are required to possess a technical background, which includes reasoning and critical judgment, as well as competency in communications, conflict resolution, negotiation, and decision-making (Morrell et al., 2020). A study among undergraduate medical students found a decline in students’ people skills, and a more technical approach replaced a more spontaneous and humane approach (Wahlqvist et al., 2005). Ahmad et al. (2014) concluded that most engineering students possess technical skills but lack people skills. One of the reasons is that teachers lack comprehensive knowledge and experience in teaching soft (people) skills to students (Ahmad et al., 2014). Ministry of Higher Education Malaysia (2005) states that the development of soft (people) skills requires a student-centred approach. Similarly, Mohd-Amin and Mohd-Nor (2010) and Morris (2009) suggest that teachers should be more creative when devising teaching and learning strategies so that students’ people skills can be more effectively organised and developed. Curriculum quality and teachers have an impact on students’ listening, responding, questioning, and formulating abilities (Morris, 2009). These skills acquired by an individual assist them in optimising their performance and include communication skills, teamwork, leadership skills, problem-solving skills, critical thinking skills, time management, and emotional intelligence (Siu et al., 2021). Teachers are therefore vital to implementing people skills relevant to the courses they teach. At our university student evaluations of laboratory management and professional practice module indicated they were not satisfied with the teaching of these skills through lectures. Students indicated that the lectures were boring, not effective, and the content was already known. Thus, we used a different method of role-play to teach stress and anger management skills. 

Role-play is defined as an approach to learning in which learners act out roles in case scenarios to provide targeted practice and feedback for the development of skill and competency (Nair, 2019). As a result, they gain a first-hand experience of human interactions and a better understanding of appropriate behavioural approaches to situations like those in real life. This approach emphasizes the learner’s need to know, self-direction, and varied experiences, contributing to the adoption of a problem-centred approach (Shankar et al., 2012). According to Harries and Raban (2012), role-play is a useful technique for engaging students in the learning process and environment. Through role-play, students can communicate and experience different situations and contexts, which can be used by teachers to develop students’ problem-solving, critical thinking, and creative skills. Furthermore, role-play allows students to experience a variety of different domains: cognitive, emotional, physical, and literacy domain (Beard et al., 1995). Additionally, role-play has been proven to be an effective method of developing skills such as active listening, problem-solving, empathy, teamwork, knowledge acquisition, and effective communication in various fields of training (Beard et al., 1995; Harden & Gleeson, 1975; Kim, 2018). Apart from this, role-play is an effective teaching strategy for health science students and is used by medical students to practice communication skills effectively and promote empathy and a more patient-centred approach to care (Ong et al., 2022). Based on the findings of Rønning and Bjørkly (2019), role-play in health sciences education enhances students’ therapeutic and communicative skills and facilitates personal and professional growth as it increases students’ ability to learn what it is like to be in others’ shoes and, through that experience, develop empathy and reflection. Role-play can be an effective tool for developing stress and anger management skills. It allows individuals to practice new behaviours and techniques in a safe and supportive environment, which can help to build confidence and improve overall well-being (Snowden & Rebar, 2018; Sutton, 2022).

The International Medical University (IMU), Bachelor of Science (Hons) in Biomedical Science programme is designed to produce work-ready graduates who are well-equipped with knowledge and are competent in practical, as well as people skills. The curriculum of the programme includes research-based teaching and problem-based learning, and students learn from experienced faculty. In addition to didactic large group teaching sessions (plenaries), the programme is also delivered through small group teaching sessions, such as problem-based learning, workshops, computer-aided learning, tutorials, seminars, presentations, etc. The learning outcomes of stress and anger management sessions are the definition of anger and stress; anger and stress management skills; contributing factors to stress and anger; and approaches to managing stress and anger engagement. The present study was conducted to explore the participants’ perception of the usefulness, understanding, enjoyment, and feedback of using role-play as a teaching-learning method for developing stress and anger management skills.

II. METHODS

Stress and anger management skills are a component of the laboratory management and professional practice module. This module is compulsory for first-year Biomedical Science students. Role-play was chosen to deliver stress and anger management skills because previous students were not satisfied with lectures as the teaching-learning method. Role play serves as a method of experiential learning in which learners assume various roles and engage in interactive experiences in diverse learning environments. The theory of experiential learning underscores the significance of acquiring knowledge through hands-on experience and subsequent reflection, constituting fundamental components of contemporary approaches to adult education (Nestel & Tierney, 2007).

A total of 96 students from the 2021 and 2022 cohorts participated in the role-plays. The sample size calculation is shown below.

The calculator.net (www.calculator.net) sample size calculator was used. The confidence level was 95%, and the margin of error was set at 5%, assuming a population % of 50% and a population size of 96. The recommended sample size using these parameters was 77.

The questionnaire used to obtain student feedback is based on that used by Shankar et al. (2012) with some modifications as shown in Appendix I. In that study, original role-play questionnaires were used by students from the third, fifth, and sixth semesters of the Medical Humanities module. Thus, some of the questions, such as “Have you been exposed to the use of role-plays for educational objectives before?” “Are you aware of the use of role-plays in medical education elsewhere?” were removed. The rest of the questions are similar. Feedback was obtained from the Biomedical Sciences programme first-year students. The questionnaires contained both close-ended (using a 5-point Likert scale) and open questions. The survey was conducted after the students completed the role-play from 18 to 22 October 2022. Participants were informed about the study’s objectives before participating, and they were required to provide written informed consent.

Data were analysed using MS Excel and SPSS version 28. The distribution of the scores for enjoyment, understanding, and usefulness were compared using the one-sample Kolmogorov-Smirnov test (p<0.05). The distributions were not normal and hence median and interquartile range were used as measures of central tendency and variation. The median (interquartile range) scores among the two cohorts and among males and females were compared using the independent samples median test (p<0.05). Each open comment was analysed systematically in an iterative manner by creating a thematic coding structure. As new themes emerged, the coding structure was revised, and the previous comments were reread for consistency. Moreover, the comparison of the difference between cohorts and gender for the perception of enjoyment, understanding, and usefulness was conducted because role-plays for cohort 2021 were conducted online due to Malaysia’s movement control order during the COVID-19 pandemic. However, the cohort 2022 role-plays were conducted physically. Studying gender differences in the perception of different educational interventions may be important because behaviours, styles of social interaction, academic motivations, and choices may be different across genders, and it helps identify disparities and promote equity and inclusivity in the classroom. It allows educators to address any biases or barriers that may hinder students’ educational opportunities and success (Myaskovsky et al., 2005).

III. RESULTS

A total of 96 students from 2021 (56) and 2022 cohorts (40) participated in the role-plays. A total of 81 students (overall response rate of 84.1%) participated in the survey. Our results show forty-eight students were from the 2021 cohort and the cohort response rate was 85.7%, Thirty-three students were from the 2022 cohort and the cohort response rate was 82.5%. The percentage of males was 22.22% and females were 77.78%.  According to Figure 1, 65% of students prefer role-play to teach stress and anger management skills, followed by small group discussions (15%), case-based learning (13.3%), and lectures (6.7%). This is based on question 8 of the questionnaire. Figure 2 illustrates the skills students learned during role-play. Communication skills were mentioned by 62.3% of the respondents, followed by teamwork (16.9%), stress and anger management (12.9%), and problem-solving skills (7.8%). This is based on question 4 of the questionnaire. The data that supports the study is available at https://doi.org/10.6084/m9.figshare.23607033.v1.

Figure 1. Instructional methods preferred by students to learn stress and anger management skills

Figure 2. Skills students learned through role-plays

Sixty-six students (90.4%) mentioned role-plays can be used for future topics/modules while 7 students (9.6%) were not in favor (based on question 9 of the questionnaire).

The perceptions of students about the use of role-play in anger and stress management were measured on a scale of 1 to 5 with 1 being the least and 5 being the highest. Table 2 shows the median and interquartile range of the scores for enjoyment, understanding, and usefulness among the two cohorts and among male and female students. There was no statistically significant difference in the scores between the two cohorts and between male and female students.

Submitted: 1 July 2023
Accepted: 24 October 2023
Published online: 2 April, TAPS 2024, 9(2), 39-50
https://doi.org/10.29060/TAPS.2024-9-2/OA3074

Muhammad Irfan Kamaruddin^1,2, Andi Alfian Zainuddin^1,3, Berti Nelwan^1,4, Sri Asriyani^1,5, Firdaus Hamid^1,6, Tenri Esa^1,7 & Irawan Yusuf^1,8

¹Department of Medical Education, Faculty of Medicine, Hasanuddin University, Indonesia; ²Department of Ophthalmology, Faculty of Medicine, Hasanuddin University, Indonesia; ³Department of Public Health, Faculty of Medicine, Hasanuddin University, Indonesia; ⁴Department of Pathology Anatomy, Faculty of Medicine, Hasanuddin University, Indonesia; ⁵Department of Radiology, Faculty of Medicine, Hasanuddin University, Indonesia; ⁶Department of Microbiology, Faculty of Medicine, Hasanuddin University, Indonesia; ⁷Department of Clinical Pathology, Faculty of Medicine, Hasanuddin University, Indonesia; ⁸Department of Physiology, Faculty of Medicine, Hasanuddin University, Indonesia

Abstract

Introduction: A good learning environment (LE) will affect the quality and standard of the learning process, student performance, and the outcome of the curriculum as well as predictor of the quality of health services. Our study aims to assess residents’ perception of the LE in Ophthalmology training programs for future improvement.

Methods: Mixed method with an explanatory sequential design was implemented in this study using the Post-graduate Hospital Educational Environment Measure (PHEEM) as a quantitative approach and open-ended questions collaborated with focus group discussion (FGD) as a qualitative measurement. A comparison of the quantitative data was made using parametric and non-parametric analyses. Thematic analyses were performed for qualitative data. Integration of quantitative and qualitative data was done by connecting both data.

Results: Fifty-three residents participated in this survey. The mean age was 30.96±2.18 years old, 64.15% were female and 77.36% are at the internship stage. The mean score of overall PHEEM was 123.40 ±12.35, indicated an excellent LE, while the mean score of perceptions of role autonomy, perceptions of teaching, and perceptions of social support were 42.57±4.62, 47.75±4.84 and 33.08±4.15, respectively. There is no significant difference between gender and study period with the perception of LE. Thematic analysis from qualitative data reveals six positive and five negative perception themes. All discovered themes confirmed concordance with the result of LE perception.

Conclusion: Learning environment perception in the ophthalmology residency program was excellent and essential for the student’s skills and performance quality. Some specific areas still need improvement strategies for institutional development.

Keywords:           Learning Environment, PHEEM, Ophthalmology, Residency, Mixed Method

Practice Highlights

• Ophthalmology resident has an excellent learning environment.
• Good teacher, learning system and social life will give positive perception on learning environment.
• Lack of learning opportunity, less mentoring time, and suboptimum facilities influence students negative perception of learning environment.

I. INTRODUCTION

A good learning environment (LE) will affect the learning process and student behavior and determine the outcome of the curriculum (Al-Shiekh et al., 2014; Bari et al., 2018; Binsaleh et al., 2015; Ong et al., 2019; Ong et al., 2020). Learners who experience an excellent LE will actively participate in the learning process (Clapham et al., 2007). With an ideal LE, learners can achieve better academic success than learners who perceive the LE negatively (Ong et al., 2019; Ong et al., 2020).

The clinical LE is an essential factor influencing the quality of medical education in residency programs (Sandhu et al., 2018). The resident LE, which mostly took place at the hospital, differs from that of medical students. This environment has many destructive factors that impact residents’ performance and mentality and can result in residents experiencing symptoms of burnout (Prins et al., 2010; Ripp et al., 2017). Suboptimal clinical LE have been associated with poor patient care and learning outcomes (General Medical Council, 2016). Therefore, efforts to improve the quality of the LE not only positively impact the environment in which learners learn and participate in patient care but also affect the practice of graduate doctors in the future.

This study aims to determine the residents’ perception of LE in the ophthalmology training program. Based on current data, there is still no study about ophthalmology residents’ perception of LE and its associated factors. This study is a pioneer and pilot study of LE in Ophthalmology training programs, especially in Indonesia.

II. METHODS

A. Study Design and Subjects

This mixed methods study was conducted with explanatory sequential design with both quantitative and qualitative measurements that were performed from January to May 2023 at two main teaching hospitals for the ophthalmology specialist program (OSP) Faculty of Medicine, Hasanuddin University in Makassar, Indonesia.

The study consists of two phases; the first is an offline survey comprising The PHEEM questionnaire and open questions data collection. The second phase of the study was focus group discussion (FGD).

Total sampling was used to determine the sample for the study’s first phase. Our inclusion criteria for the first phase were ophthalmology residents who have experience training in both main teaching hospitals and have attended a minimum of 6 months of ophthalmology residency training. Sixty residents met the inclusion criterion, and seven were excluded because they could not participate in the offline survey due to personal reasons. Fifty-three residents were included in the first phase of the study.

On the other hand, purposive sampling was employed to decide on phase two study participants. The PHEEM score, open-ended questions responses, and representation for each year of residency training were used to ensure heterogeneity of participants for different perspectives. Residents with high and low PHEEM scores and with exciting and evoking responses to open-ended questions were selected as respondents while considering resident representation for each year of training. Twenty residents were included in phase 2 of the study. The residents were divided into two groups consisting of 10 residents to attend FGD.

B. Study Instruments and Procedure

A cross-sectional survey that included a paper based PHEEM questionnaire, open-ended questions, and sociodemographic data, including age, gender, and year of residency, was distributed to all study subjects. The survey was conducted by single-trained data collector which was not part of the study program. Before administration, the study background, including its purposes and potential impacts, was explained to the residents and the written consent of each resident was obtained. Resident confidentiality and anonymity were also guaranteed.

The PHEEM consists of 40 items regarding LE subdivided into three subscales, each assessing perception of role of autonomy, perceptions of teaching, and perceptions of social support. It is scored on a 5-point Likert scale ranging from “strongly disagree” (0) to “strongly agree” (4), with a maximum score of 160. The findings were interpreted according to the original study shown in Supplement Table 1 (Roff et al., 2005). Four negative questions (questions 7, 8, 11, 13) were scored in reverse. PHEEM has been validated to assess the post-graduate clinical learning environment after the original study, including after translation to different languages, including the Bahasa Indonesia version (Raharjanti & Ramadianto, 2016; Roff et al., 2005). Multiple subsequent studies have shown good internal reliability (Bari et al., 2018; Clapham et al., 2007; Ong et al., 2019). The Bahasa Indonesia version of the PHEEM questionnaire was used to suit the local context. Bahasa Indonesia version of the PHEEM Questionnaire shows good validity and reliability (Raharjanti & Ramadianto, 2016). Eight open questions were added to the questionnaire. The questions were related to 3 subscales on the PHEEM questionnaire. Validation of the open-ended questions was done by expert judgment from two experts.

A semi-structured focus group session was conducted among the selected group of residents to supplement the PHEEM results. Two FGD session was done with a group size of ten. The FGD questions focused on exploring supporting and barrier factors that influence a good LE. The session lasted 60-90 minutes and was guided by a single-trained facilitator experienced in qualitative research methodology. FGD was conducted until new insights were no longer attained, reaching saturation.

Both quantitative and qualitative demographic data were coded by the trained data collector for maintaining the anonymity of the data. The response from both anonymous data were stored securely by the author for further analyses.

C. Statistical Analyses

Quantitative data were analysed using IBM Statistical Package for Social Sciences (SPSS) version 25. Descriptive statistics were presented using percentages, means, and standard deviation (SD). Internal reliability was assessed using Cronbach’s alpha coefficient. Comparison of quantitative data was made using Independent T-Test, Mann–Whitney U-Test, One-way ANOVA, and Kruskal–Wallis H-test. A p-value <0.05 was considered statistically significant.

For qualitative analyses, transcriptions of the open-ended questions answers and the audio and video recording of FGD were made by an independent data collector, and its accuracy was confirmed by the first author and the FGD facilitator. For open-ended questions, participants were coded with “P(Participant Code)-OEQ” (e.g. participant 1:P1-OEQ) while for FGD participants were coded with “P(Participant Code)-FGD(Group)” (e.g. participant 1 in FGD 2: P1-FGD2). The transcripts were coded into common themes independently by two investigators and discussed using thematic analysis using QDA Miner Version 5.0 for open questions and MAXQDA Analytics Pro 2020 for FGD.

III. RESULTS

A. Quantitative Data

Fifty-three ophthalmology residents were included in this mixed-method study, with the majority being female (64.15%). The mean age of residents was 30.96±2.18 years old. The largest age group is aged 30-34 (67.93%). 77.36% of respondents are at the internship stage or in the year 1 to 3 period of study, where respondents in year 3 have the most significant number of residents (32.08%).

Internal reliability of the PHEEM score was good, with Cronbach’s alpha coefficient of 0.872. No significant change with the removal of any of the 40 questions, proving its good internal reliability. Data in the perception of the role of autonomy was not normally distributed (P<0.05), but in the perception of teaching (P=0.200), perception of social support (P=0.200), also overall PHEEM score (P=0.200), the data were distributed normally.

As shown in Table 1, the mean score (SD) of the overall PHEEM score was 123.40±12.35, which is categorised as an excellent learning environment (LE) (>120). The mean perceptions for each subscale were 42.57±4.62 for perceptions of the role of autonomy classified as “more positive than negative”; 47.75±4.84 for perceptions of teaching classified as “model teachers”; 33.08±4.15 for perceptions of social support classified as “more pros than cons.”

No	PHEEM Subscales	Mean (SD)	Interpretation	Maximum Score
1	Perceptions of role of autonomy	42.57±4.62	more positive than negative	56
2	Perceptions of teaching	47.75±4.84	model teachers	60
3	Perceptions of social support	33.08±4.15	more pros than cons	44
4	Overall PHEEM	123.40±12.35	Excellent	160

Table 1. The PHEEM scores

Abbreviation: PHEEM, Postgraduate Hospital Environment Measure; SD, Standard Deviation.

From the overall PHEEM item, there are 28 items with an average score >3, nine items in the perception of the role of autonomy, twelve items in teaching perception, and seven items in the perception of social support (Table 2). Only one item has a score >3.5 or is classified as real positive points; that is item number 3 (I have protected educational time in this post) for the perception of teaching. The highest score for the perception of the role of autonomy was item 34 (The training in this post makes me feel ready to be a consultant) and item 24 (I feel physically safe within the hospital environment) in the perception of social support.

C. Quantitative and Qualitative Data Integration

The integration of quantitative and qualitative data can be shown in Figure 1 and Supplement Table 2. Overall, the mean total PHEEM scores (123.40±12.35), which indicated an excellent LE environment, were confirmed by more positive perception themes compared with negative perception found in qualitative data analyses (Figure 1). Besides, we could also see that in each subscale, the composition of the themes connecting to each subscale could confirm the results of the quantitative data, whether the trend of the graphs is primarily high, average, or low. For example, in the perception of teaching, we could see mostly positive perception themes were connected to the subscale rather than negative perception; from this, we could say that the quantitative data of the perception of teaching in which mostly classified as model’s teacher was confirmed by its connection towards the final themes.

Figure 1. Integration of overall quantitative data classification with qualitative data

Quantitative data represent by graph and qualitative data (positive and negative perceptions) represent by box. Perceptions in the circle area means that it was connected to the area. Overlapping box in the circle means that perception was connected to more than one area.

In each subscale, the high and low items’ scores were confirmed with the final themes, both for positive and negative perception (Supplement Table 2). All positive perceptions confirmed quantitative results by related with a minimum of one item from 3 subscales with mostly high mean scores (>3). Only three negative perceptions related to a minimum of one item from 3 subscales with low scores (<3) confirm these themes’ relation to quantitative results. One negative perception (Inadequate learning opportunities among residents/discrimination issue) is connected to an item with high scores, showing that this theme did not confirm the quantitative finding. Two themes appear contradictory in positive and negative perceptions (well-established facilities and suboptimum facilities). Both themes were related to the same item in which the scores were not high or low, which could confirm the possibility from both perspectives.

IV. DISCUSSION

Our finding shows an excellent perception of LE of ophthalmology residents. Based on previously published articles, this study has the highest score for overall scores and for each subscale among peer-reviewed publications of PHEEM studies worldwide. The highest score from a previous peer-reviewed publication was a study by Ong et al. (2020), which reported a more positive than negative internal medicine residents’ perceptions of their LE in Singapore. On the contrary, Fisseha et al. (2021) and Liaqat et al. (2019) reported a plenty of problems LE from the perception of internal medicine residents in Ethiopia and pediatric surgery residents’ perception in Iran, respectively. Many factors, such as differences in discipline and sites of training, could cause the differences. There is no previous study yet about ophthalmic residents’ perception of LE using PHEEM. However, it is previously proved that some studies evaluated several different training programs reported that there is a difference in overall and subscale PHEEM scores among various training programs (Chan et al., 2016). In line with discipline, studies that evaluated different sites of training mainly reported that there is a different score between sites of training (Chan et al., 2016). Another reason for the difference could be a result of the differences in curriculum and teaching methods. Some studies reported increasing perception of LE after implementing modern curriculum and student-centred learning (Brown et al., 2011; Shankar et al., 2014). The themes found from our qualitative study also supported this excellent perception of residents toward their LE. Most of our themes were positive and related to all aspects of the PHEEM questionnaire. Gruppen et al. (2019) reported a conceptual framework of LE in which all components of the framework, i.e., personal, social, physical, and organisational, supported and covered by our positive perception themes finding, confirming the excellent perception of LE from the residents.

We did not find any different perceptions of LE between gender and year of study. Our findings were similar to some studies that reported no gender differences (Al-Shiekh et al., 2014; Ong et al., 2020; Sandhu et al., 2018). Other studies have different results; some studies reported that males have a better perception than females (Fisseha et al., 2021; Gough et al., 2010); on the contrary, Liaqat et al. (2019) reported a better perception of females than males. Similar to Risberg et al. (2003) that reported, gender issues were more significant and essential during clinical consultation than tutoring. Our qualitative data did not confirm our quantitative results. There is one negative perception theme in which some of our students feel that there is a discrimination issue related to learning opportunities; one of them is gender discrimination. Although our quantitative data show no differences between gender, the negative perception theme regarding discrimination issues must be taken into account by the stakeholder.

Concerning the year of training, we also found no significant difference in perception. The finding regarding different perceptions for different years of training was varied. Our result was the same with some studies (Ong et al., 2019; Sandhu et al., 2018), but other studies also reported higher PHEEM scores for senior to junior (Gough et al., 2010; Khoja, 2015; Liaqat et al., 2019; Pinnock et al., 2009), and some studies also reported that junior has better score than senior (Fisseha et al., 2021; Mahendran et al., 2013). The differences in perception of junior and senior residents could be explained by some reason, such as available access to educational opportunities (Mahendran et al., 2013), greater responsibility with increased seniority (Pinnock et al., 2009), and different training locations for trainees of different seniority (Khoja, 2015).

All subscales show promising results; residents’ perception of teaching was the highest among other subscales. Our qualitative data also support this finding; most of our positive theme was related to the perception of teaching, one of them being a good clinical teacher. Despite good perceptions on teaching, residents also experienced less mentoring time with clinical teachers. Fisseha et al. (2021) also reported the same issue. Inadequate supervision was proved to be a barrier in post-graduate medical education, as reported by Talib et al. (2019). Ong et al. (2019) also reported that focus group data suggested that inadequate supervisor contact and feedback resulted in negative perceptions of the LE. This finding informs us that residents need appropriate supervision, and clinical teachers should be understanding and prepared for their roles in residency training programs (Ramani & Leinster, 2008). Increasing learning time without any addition to supervisor-resident contact time still results in a low perception of LE (Silkens et al., 2018), proving the importance of the supervisor-resident relationship. Besides, good supervisory strategies proved to be contributed to a good LE (Boor, 2009). A good teaching environment influences the standard of the learning process (Al-Shiekh et al., 2014; Bari et al., 2018), satisfaction with education, and determines the outcome of the curriculum (Bari et al., 2018; Binsaleh et al., 2015). Faculty should focus on developing adequate supervision and teaching skills programs for clinical teachers.

Perception of social support has the lowest score among other; it is affirmed by our qualitative finding in which three negative perception was connected to this subscale. Similar results were also reported from studies in intensive care and pediatric training program (Al-Shiekh et al., 2014; Clapham et al., 2007). Related to social support, catering facilities is problem area of this study, other studies also identified this issue as a problem (Al-Shiekh et al., 2014; Binsaleh et al., 2015; Fisseha et al., 2021; Ong et al., 2020). This finding was not specifically appeared on FGD, but the strategy to solve the problem should be considered. Another interesting result related to social support is about facilities. The topic has both perspectives, positive and negative. Quantitative item related to this finding was not had very high or very low scores, supporting that some facilities were good, but there is still area for improvement, especially for diagnostic tools and surgical training facilities, as stated in FGD. Other studies also reported that suboptimal facilities related to hospital diagnostic tools were also a barrier to achieving good LE (Fisseha et al., 2021; Talib et al., 2019). Schönrock-Adema et al. (2012) have highlighted that interaction and collaboration with others were significant in determining the LE. Faculty should pay attention to social support as it has a vital role in a residency program, as it could alleviate the effects of stress, depression, and burnout (Vieira, 2008). Strategy to escalate this area should be considered, especially in providing good facilities for the learning process.

Residents’ perception of the role of autonomy is also satisfying, most of the positive themes confirmed this subscale. Good autonomy can improve decision-making skills, self-confidence, and responsibility, which further influence the readiness of residents to be independent (Allen et al., 2019). It also improves work satisfaction and can reduce burnout (Allen et al., 2019). Although overall autonomy perception was good, there are some areas for improvement. Our finding shows that residents were imposed with inappropriate tasks, such as administrative tasks. Some activities not related to education are also obligated to the residents at a certain level of training. This condition could lead to an excessive, inappropriate workload and interfere with protected educational time. Therefore, the faculty should set precise regulations regarding job descriptions and accountability.

Our study was done in the main teaching hospital which was part of a university-based study program, the results could be benefit for other hospital with same basis. It shows that university-based program has a good teaching area especially for the curriculum and teaching resources including human resources and facilities. University-based teaching hospital could enhance their program by maximising their teaching area also paying attention to some factors that could be a barrier in university-based program such as learning opportunity and inappropriate task.

A mixed method with explanatory sequential design is fundamental in our study as it provides a comprehensive perception of residents. Qualitative data make our finding more solid, show us some weaknesses, and emphasise our areas for improvement which are not easily identified from quantitative analyses. This is also a pioneer study for ophthalmology residents’ perception of LE, making our finding also crucial in adding insight to understanding residency LE from multiple perspectives. On the other hand, several limitations were also identified. First, our study was only done in one centre and discipline, which may limit data generalisability. Second, the study time constraint was cross-sectional, so the causative relation between factors could not be established. Third, differences perceptions in each different training year cannot be ascertained because there can be information bias related to the perceptions of second-year students and so on towards their experiences in previous years. Fourth, the researcher is a clinical lecturer from the program who conducted the study, which could be the subject of bias. However, a single trained data collector was used to collect open-ended questions data and facilitate FGD to reduce the possible bias effect.

V. CONCLUSION

In conclusion, our finding shows that our resident has an excellent perception of their ophthalmology residency training. The program has strong areas such as a good clinical teacher, a well-organised learning system, and a good social environment. Several areas should pay attention to, especially equal learning opportunities, mentoring time, and facilities. Faculty should organise strategies for preserving current LE and to further improve the LE along with monitoring and evaluation. Our finding could be benefit for other university-based teaching hospital especially in Asia regions to enhance their program. Further study involving multiple centres and disciplines should be done to give a more general perspective of LE in residency training.

Notes on Contributors

Muhammad Irfan Kamaruddin involved in conception or design of the work, data collection, data analysis and interpretation, drafting the article, critical revision of the article, and final approval of the version to be published.

Andi Alfian Zainuddin involved in conception or design of the work, data analysis and interpretation, critical revision of the article, and final approval of the version to be published.

Berti Julian Nelwan involved in conception or design of the work, critical revision of the article, and final approval of the version to be published.

Sri Asriyani involved in conception or design of the work, critical revision of the article, and final approval of the version to be published.

Firdaus Hamid involved in conception or design of the work, critical revision of the article, and final approval of the version to be published.

Tenri Esa involved in conception or design of the work, critical revision of the article, and final approval of the version to be published.

Irawan Yusuf involved in conception or design of the work, critical revision of the article, and final approval of the version to be published.

Ethical Approval

Before conducting the research, permission was obtained from Faculty of Medicine, Hasanuddin University Institutional Review Board  (Reference number 36/UN4.6.4.5.31/PP36/2023). Participants were informed of the objectives and purpose of the study. They were invited to sign an informed consent if they agreed to be part of the study. Every participant was given a chance to deliberate on their rights to participate, refuse, or withdraw at any time they wished to do so.

Data Availability

The authors confirm that the data supporting the findings of this study are available within the article and its quantitative data along with supplemental tables are openly available in Figshare repository https://doi.org/10.6084/m9.figshare.23606157. Representative qualitative data translated into English are shown in the Result section (Kamaruddin et al., 2023). All qualitative data, open questions, and the FGD protocol which all written in Bahasa, are available from the corresponding author on reasonable request.

Acknowledgement

The authors would like to express our sincere gratitude to Ichlas Nanang Affandi from the Psychology study program, Faculty of Medicine, Hasanuddin University, for his valuable support throughout the research process. His expertise in qualitative study helps us to overcome challenges. In particular, we would like to thank Natalia Widiasih Raharjanti, MD, from the Department of Psychiatry, Faculty of Medicine University of Indonesia, and Assistant Professor Henok Fisseha, MD, from the Department of Internal Medicine, St. Paul’s Hospital Millennium Medical College, Addis Ababa, Ethiopia for their support in allowing us to use their research instrument and study protocol as one of our references in our research. Thank you also to Rusdina Bte Ladju, MD, Ph.D., for her valuable input to our manuscript. We are also grateful to the Department of Medical Education, Faculty of Medicine, Hasanuddin University, and Department of Ophthalmology, Faculty of Medicine, Hasanuddin University, for providing us with the resources and support needed to complete this study.

Funding

None of the authors receive any financial support for this study.

Declaration of Interest

The authors did not have a conflict of interest to be declared in this study.

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*Muhammad Irfan Kamaruddin
Department of Medical Education,
Faculty of Medicine, Hasanuddin University,
Jalan Perintis Kemerdekaan KM 10
Makassar 90245
Email: iphenk_tampo@yahoo.com

Submitted: 6 October 2023
Accepted: 6 December 2023
Published online: 2 April, TAPS 2024, 9(2), 28-38
https://doi.org/10.29060/TAPS.2024-9-2/OA3151

Sinead Kado¹, Simon Clarke² & Sandra Carr¹

¹Division of Health Professions Education, School of Allied Health, University of Western Australia, Australia; ²Graduate School of Education, University of Western Australia, Australia

Abstract

Introduction: Health Professions Education (HPE) leadership development is advocated for success at the individual, team, and institutional levels. Many leadership theories exist informed mainly by Western perspectives, however, Pacific HPE leadership has not been investigated. Therefore, this research aimed to understand Pacific HPE leaders’ perspectives to develop substantive theory to guide faculty development in this setting and add nuanced perspectives to the international HPE leadership discourse.

Methods: Using an interpretivist case-study methodology, seven HPE leaders were purposefully recruited. Data collection tools included Rich Pictures, Talanoa Zoom interviews, and reflective journals. Participants drew a picture on ‘Being an HPE leader’, subsequently explaining their depiction, and then reflected on leadership events in their journals over six months. Codes and themes were identified using Miles, Huberman and Saldaña’s approach.

Results: Metaphors were assigned to three HPE leadership styles identified: The ‘Bridge’- helping students from novice to competent; the ‘Coconut Tree’- multiple roles and sturdy in the storm; and the ‘Boat’ – navigating towards the vision.

Conclusions: Rich Pictures, interviews and reflective journals allowed HPE leaders to reflect on ‘Being an HPE Leader’ and revealed tacit perspectives. This study suggests there are different styles of leadership, pertinent to the Pacific context, depending on the aims, strategies, and attributes of different HPE leaders. Although grounded in the Pacific, certain aspects may resonate in similar contexts. Notwithstanding that many facets of leadership identified align with current leadership models, intrapersonal emotional intelligence and cultural aspects of HPE leadership should be considered when designing contextually embedded faculty development.

Keywords:           Medical Education, Health Professions Education, Leadership, Qualitative Research, Case Study, Pacific

Practice Highlights

• Rich Pictures assist revealing tacit perspectives by facilitating reflection on leadership.
• Many aspects of contemporary leadership are practiced in HPE leadership in the Pacific.
• Development of intrapersonal emotional intelligence is required to thrive in this challenging context.
• A better understanding of HPE Leadership in the Global South is required to inform a Global HPE leadership framework.

I. INTRODUCTION

Effective leadership is advocated to foster growth in the ever-evolving Health Professions Education (HPE) landscape and ensure success at the individual, team, and institutional levels (Lieff & Yammarino, 2016; McKimm & Swanwick, 2013; Sandhu, 2019; Steinert et al., 2012). However, Health Professions Education (HPE) leadership is a complex social phenomenon encompassing relationships, cultural and personal influences (Steinert et al., 2012; van Diggele et al., 2020), making it difficult to define, and then guide development. Whilst many leadership development initiatives exist purporting to enhance leadership capabilities, multiple systematic reviews investigating leadership development at the undergraduate (Evans et al., 2023; Lyons et al., 2018; Rodríguez-Feria et al., 2023), graduate (Lyons et al., 2021; Onyura et al., 2019; Sadowski et al., 2018; Sultan et al., 2019) and faculty (Steinert et al., 2012) level found that leadership development is rarely grounded in theoretical frameworks and that evaluation of interventions remains superficial. Similar issues occur in other HPE disciplines including pharmacy (Reed et al., 2019) and interprofessional (Brewer et al., 2016) education. These systematic reviews recommend that leadership development needs grounding in theoretical frameworks and capabilities assessed over a longitudinal period.

Additionally, across the reviews there was a dearth of studies from the global south informing their conclusions; most studies originated from the United States followed by the UK, Canada, Europe and Australia. Although established frameworks exist for physician leadership, including CanMEDS, NHS medical leadership competency framework, and ACGME, (Onyura et al., 2019) there is only one recently proposed for health professions educators (McKimm et al., 2022), based on the authors’ expertise and contemporary leadership theories, but not on empirical literature around HPE leadership. However, recommendations are that to develop tomorrow’s HPE leaders an empirically informed, culturally sensitive, leadership framework for health professions educators is required (Ramani et al., 2020; Sandhu, 2019).

Empirical research around HPE leadership has mainly been deductively analysed, using Western leadership frameworks, including Yukl’s power model (Sundberg et al., 2015), Bolman and Deal’s four frames model of leadership (Lieff, 2010), Goleman’s six leadership styles (Saxena et al., 2017), and character-based leadership (Torti et al., 2022). This deductive analysis potentially misses important aspects of leadership, indeed one example of subsequent inductive analysis identified different themes including reflection and feedback not included in the original deductive analysis (Lieff & Albert, 2012; Lieff, 2010). Additionally, most empirical research has relied on semi-structured interviews alone (Lieff et al., 2013; Lieff, 2010; Saxena et al., 2017; Sundberg et al., 2015; Torti et al., 2022), which may not have encapsulated all aspects of leadership, and have been conducted in Western contexts. Spoken language may not convey all the cultural contexts and meanings (Amazonas et al., 2019; Brocklesby & Beall, 2018; Lyon, 2020) and therefore it is recommended considering complementary data collection tools to further our understanding of HPE leadership (Lieff & Albert, 2012; Varpio et al., 2017). Furthermore, there are consistent calls to investigate HPE leadership in different cultural contexts to inform a faculty development framework (Dujeepa et al., 2019; Steinert et al., 2012; Varpio et al., 2017).

From a Pacific perspective, HPE leadership development is required (Kado et al., 2022; Sweet et al., 2018), however, HPE leadership from the cultural perspective of contemporary leaders in the Pacific is not currently described. Thus, this research reported here embarked on understanding the perspectives of current HPE leaders from this Pacific global south context to provide empirical evidence towards a framework for HPE leadership in this setting to guide faculty development. Furthermore, it contributes a diverse perspective to the current HPE leadership literature to assist building a more nuanced global HPE leadership theory.

This article describes the empirical research conducted at a major Pacific University utilizing an interpretivist case study approach. It then outlines three styles of leadership identified and discusses how these relate to competencies purported to be needed at different levels of leadership and the current theoretical and empirical discourse around HPE leadership. Implications from this discussion will provide recommendations for Pacific faculty development. Through rich, deep description it is hoped that others in similar settings will resonate with the findings, drawing on insights to apply in their own contexts.

II. METHODS

To understand Pacific perspectives around HPE leadership an interpretivist case study was undertaken at a major Pacific University (Denzin & Lincoln, 2000; Silverman, 1997). A qualitative methodology facilitated participants’ perspectives to be fully explored, and using several innovative data sets through a case study approach enabled tacit perspectives to be revealed and triangulated (Merriam, 1988; Merriam & Tisdell, 2016). The case was bound by health professionals who had completed a health education degree and had an active University HPE leadership role. Seven of ten eligible HPE leaders volunteered following purposeful recruitment and ethics approval. Written consent was provided and then data were collected through Rich Pictures, Talanoa interviews, and reflective journals over a one-year period (April 2021 to April 2022), with each participant assigned a pseudonym to maintain anonymity. Each data collection method was chosen to provide rich data to complement and build the interpretation of Pacific HPE leadership guided by the central research question ‘What are the perspectives of Pacific GCME graduates on being an HPE leader?’

First, Rich Pictures (Cristancho & Helmich, 2019; Gisby et al., 2023; Kado et al., 2023a) were used to reveal tacit perspectives on being an HPE leader. Participants drew a picture depicting ‘Being an HPE leader’ and then a subsequent Talanoa interview (Hindley et al., 2020; Tunufa’i, 2016) explored the deeper meanings of the picture and how they enacted leadership. Talanoa is a Pacific way of communicating where people are free to ‘tala’- talk ‘noa’- around the subject (Hindley et al., 2020). Thus, similar to semi-structured interviews, a set of guiding questions was used such as ‘Tell me about your picture’ and ‘How do you see yourself as an educational leader in this picture’, nevertheless the participants were allowed to ‘talanoa’ or talk around these questions in a culturally comfortable manner. These Talanoa interviews were held via Zoom (Gray et al., 2020) as the research was conducted in the midst of the Covid-19 pandemic. Next, following an orientation session on reflection (Schön, 1987), participants were requested to use a reflective journal with guiding questions and reflective prompts over six months. The reflective journals (Filep et al., 2018; Milligan & Bartlett, 2018) provided an avenue for the HPE leaders to reflect on doing leadership contemporaneously and with minimal influence from the researcher (Alaszewski, 2006). Finally, the second Talanoa interview was conducted, as planned after initial data analysis, exploring aspects of motivation and the influence of culture more deeply, with questions such as: ‘What motivates you to continue in your role as an HPE leader?’ and ‘How do you think the culture has shaped your leadership journey?’

A. Data Analysis

Data analysis was guided by Bell et al.’s (2019) framework for the Rich Pictures and Miles, Huberman and Saldaña’s (2014) approach for the textual data. Bell et al.’s (2019) framework comprises seven steps including:

1. Locating the style – context of the Rich Picture
2. Descriptive features – colour, shapes, and drawings
3. Primary features – which aspects are bold or central
4. Value features – linkages between images
5. Low-level interpretation – overall picture
6. High-level interpretation – interpretation from the artist
7. Critical judgement – has the participant reflected and engaged with the drawing?

 

For this research, we relied primarily on the high-level interpretation and other aspects were asked in the Talanoa interview as the research was based on the participants’ perspectives.

Data analysis began immediately after the interviews with the primary researcher (SK) noting initial impressions in her research journal and then transcribing the interviews verbatim. Data were anonymised and entered into NVivo for further analysis, copies of the transcripts were also stored in the University’s data management system. The data were further analysed using Miles, Huberman and Saldaña’s (2014) approach which consists of three linked stages:

1) Data Condensation:

Data condensation involves ensuring relevant data to answer the research question is captured and synthesised through coding, memoing and developing concepts.

2) Data Display:

Data is displayed using data summaries and pictorial illustrations to convey the main ideas.

3) Drawing and Verifying Conclusions:

Conclusions illustrate the themes and propositions abstracted from the data display.

This article focuses on the results of the second stage of data analysis, data display, which illustrated three styles of leadership identified through data interpretation. Initial coding was done by the primary researcher (SK) and discussed with the principal supervisor (SC) to refine. Concepts were developed together and the data summaries were compiled by SK and then revised through discussion (SK, SC & SC). The process was iterative where new codes and concepts were discussed and transcripts re-read to ensure alignment. Finally, composite narratives were produced for each leadership style, consisting of the participants’ voices combined to maintain anonymity, (Willis, 2018) and a synopsis of each style of leadership was interpreted by the primary researcher, providing rich data summaries for the leadership styles identified. These can be accessed through Figshare: https://doi.org/10.6084/m9.figshare.24241195.v1 (Kado et al., 2023b)

B. Researcher Positionality

The primary researcher is a white, Anglo-Saxon, medical educator who had completed medical training in the UK and then subsequently lived and worked in a Pacific culture for over 20 years. She completed the health education degree with the research participants and was known to them. At the time of the research, she was not employed at the Pacific University and had no authority over them. Whilst having a deep understanding of the culture and context in which the research was conducted, there is the possibility that her Western upbringing will have influenced the interpretation. This was minimised by taking steps to ensure trustworthiness.

C. Trustworthiness

Trustworthiness was maintained through several avenues. First, the primary researcher practised reflexivity by maintaining a diary throughout the research process to note ideas and meanings from the data. Second, triangulation of the results occurred through data analysis discussions with the research team and differences agreed to. Third, member checking was utilised at each step of the analysis whereby research participants were asked to confirm the transcripts, composite narratives and summaries, and the leadership styles.

D. Ethics Approval

Ethics approval was granted by the University of Western Australia (UWA – 2019/RA/4/20/6529) and the Fijian Ministry of Health (Fiji – FNHRERC 31/2020). Furthermore, the University ethics department was consulted and they gained access to the participants ensuring they felt under no obligation to participate in the research.

III. RESULTS

Seven HPE leaders participated, their academic positions, ethnicities, specialities, years of service and age range are depicted in Figure 1. One participant had originated from a Global South country outside the Pacific but had resided in the Pacific for over 25 years.

Figure 1. Demographics of Pacific HPE Leaders

Figure 2. Being a Bridge

Figure 3. Being a Coconut Tree

The ‘coconut trees’ of HPE leadership had multiple roles and a passion for developing and helping others. Their multiple fronds as HPE leaders included primarily being a clinician and educator, alongside a researcher, administrator, committee lead, and organisation member. They are aiming to ensure excellence and achieve this by valuing both feedback and evaluation to improve themselves, others and the curriculum.

‘I am basically multitasking, I can wear different hats and can achieve a lot of things with the different activities. So, we are teaching, teaching, but we are also at the same time we are learning ourselves, and not just because of a one way delivery, it’s two ways, we get the feedback from the students’

-Judith (1st Interview)

 

They are rooted in the foundations of faculty development (GCME – Graduate Certificate of Medical Education) and have grown strong, sturdy and resilient, and yet adaptable to the constant changes and challenges they face. Their experiences have enabled them to grow in confidence but also to nurture others to develop their own leadership style. Jane and Judith understand the importance of working together towards a common goal and ensuring the team is committed and feels valued, providing the support that is required.

 

‘And I think the way GCME was structured and taught I think that really helped us. If you look at who’s holding these leadership roles, it’s those who did GCME’.

-Judith (2nd Interview)

‘We have a group of young faculty staff who wants to make a difference as medical educators and I believe my leadership style is more of a coach.’

-Judith (Reflective Journal)

Although they are juggling many roles and at times feel overwhelmed they are committed to improving health education in the Pacific. They enlist the assistance of experts in this quest.

‘I have liaised with my network to ask for supplementary teaching for our Postgraduate trainees.’

-Jane (Reflective Journal)

Overall, they know they need to ‘walk the talk’ to develop the next generation of HPE leaders, as they endeavour to promote excellence in HPE.

C. Being a Boat

Being a Boat was illustrated by Julie and James who were striving to sail to a vision on the horizon to improve HPE at the individual and organisational level. James describes this as a journey with his Rich Picture and interview excerpt (Figure 4).

 

Figure 4. Being a Boat

James and Julie visualised themselves on a leadership journey in a boat heading towards a vision of excellence in health professions education. They are both intrinsically motivated to do their best by building a strong leadership team, utilising the strengths of the group and collaborating with external stakeholders.

Identify the strengths in people that we can nurture and play to the people’s strengths. If we play to the strength of people and all the strengths complement each other it’s really good.

-James (1st Interview)

Although they are both consultants in their clinical domain, their identity is now more embedded in their leadership role in health professions education. Their focus is on ensuring good curriculum, development for faculty and leaders, and improving University processes.

What we need is some more basic foundational learning…health professions education for the whole college and so that would be something I would totally pursue to allow and to think of something that would be doable.

-Julie (1st Interview) 

Their journey is fraught with navigating University obstacles and the storms of change, especially the COVID-19 pandemic. These frustrations have left them exhausted and overwhelmed, on the verge of burnout, and in need of respite and support.

I had been frustrated with the processes and felt so much more could be done to support staff and students.

-Julie (Reflective Journal)

Stress in an already uncertain environment in the midst of a Pandemic.

-James (Reflective Journal)

The boat’s overall aim is to grow the next generation of HPE leaders across the whole college through curriculum development and support from the University.

 

IV. DISCUSSION

In our Pacific setting, all the HPE leaders were aiming to develop excellent healthcare workers to make a difference to the health of the Pacific, however, they did this in different ways. Three styles of leadership were identified across the HPE leaders, which were given visual metaphors of ‘The Bridge, Coconut Tree and Boat’. ‘The Bridges’ focused on developing competent and caring students, ‘The Coconut Trees’ had multiple roles and nurtured their successors as well as the students, and ‘The Boats’ focused on the system level to provide the necessary supports for HPE leaders and the students.

These three styles of leadership could be conceptualised as levels, similar to Maxwell’s (2011) five levels of leadership which classifies leadership as a process through position – a leadership title, permission – developing relationships, production – getting things done, people development – empowering others, and pinnacle – growing the organisation, however, McKimm et al. (2022) argue that all HPEs can be leaders, they do not need to be in a position of leadership. Although our participants were primarily in positions of leadership, they did not specifically identify that their position assisted or deterred their leadership journey, therefore, it is difficult to say if this positional status impacted their leadership style. From their interviews and journals, the HPE leaders were more focused on relationship building, the second level: permission. Each style of leadership focused on different aspects of building relationships: ‘The Bridges’ nurturing their students, ‘The Coconut Trees’ developing both students and faculty and ‘The Boats’ collaborating with faculty and external stakeholders to support the college. Relationship building or the interpersonal aspects of leadership were key in all styles of leadership. This is well supported across the theoretical (McKimm et al., 2022; Pinder & Shabbits, 2018; Sandhu, 2019) and empirical research (Lieff & Albert, 2012; Varpio et al., 2017) around HPE leadership.

Focusing on the next level, production, that is getting results from others through influence and credibility, all styles of HPE leaders were respected consultants in their field and were able to influence students, faculty, and the institution. Indeed, evidence suggests that to be a respected HPE leader it is necessary to first have a reputation as an excellent clinician or researcher as being a good educator is often perceived as less esteemed (Maile et al., 2019; Sundberg et al., 2015). Did this hamper their progression to the fourth level, reproduction? All styles of leadership encouraged empowering others, whether that be at the student or faculty level, although they utilised different strategies. ‘The Bridge’ acted as a role model to develop novice students into competent health professionals, ‘The Coconut Tree’ utilised a coaching style to nurture the next generation of HPEs and ‘The Boats’ focused on developing structures and courses within the University to ensure succession planning. The HPE leaders displayed an authentic approach to developing others by often ‘walking the talk’ and being open to feedback, especially the coconut trees (Lieff & Yammarino, 2016; McKimm et al., 2022). Finally, the impact the leaders had on the organisation varied and this is perhaps where the styles of leadership differed most in comparison to the final level of pinnacle, developing future HPE leaders and growing the university. This was an ideal envisioned by ‘The Bridges’ but was actualised by ‘The Coconut Trees’ at a local departmental level and by ‘The Boats’ at the wider college level. Here a more adaptive style of leadership was portrayed by engaging with the challenges of a low-resource setting and the pandemic and seeking innovative solutions to address them (McKimm et al., 2022).

We would argue that rather than moving through levels of leadership that all these factors, bar level one, position, are evident in the different styles of leadership portrayed in this setting, albeit expressed in different ways. Additionally, although adaptive leadership has been advocated for HPE leaders during these challenging times (McKimm et al., 2022) some aspects were not evident in our HPE leaders. While they acknowledged being stressed and frustrated there was little evidence of them identifying ways to build resilience and perseverance and other intrapersonal aspects of emotional intelligence (Goleman, 2001). To build HPE leaders’ emotional intelligence capacities we would advocate utilising faculty development strategies that enhance reflection, such as Rich Pictures, and cultural ‘Talanoa’ discussions to assist future HPE leaders in reflecting on their experiences and developing strategies to overcome their obstacles (Cammock et al., 2021; Kado et al., 2023a). We also concur with Lyons et al. (2021) that ‘bespoke’ faculty development is recommended to encompass different styles of leadership encountered in the Pacific cultural setting, rather than using frameworks from an entirely Western perspective.

A. Strengths and Limitations of the Research

This study is the first to our knowledge, investigating HPE leadership in a Pacific setting and it followed leaders over a prolonged period to obtain rich, deep data, using novel data collection methods such as Rich Pictures and Talanoa interviews enabling unique perspectives to be captured.

Nevertheless, there are several limitations including, a small sample size of seven participants at only one institution. This study was also conducted during the Covid-19 pandemic limiting face-to-face interactions which may have affected the findings attributable to Zoom interviews and the unprecedented experiences of the HPE leaders. Additionally, although several measures were taken to increase the trustworthiness of the research there is the real possibility that the findings have been affected by the unconscious biases of the primary researcher (SK).

V. CONCLUSION

Pacific HPE leaders displayed three styles of leadership that were conceptualised as ‘Being a Bridge’ – focusing on being an effective educator and clinician; ‘Being a Coconut Tree’ – aiming to develop faculty whilst also maintaining their clinical and educator identities; and ‘Being a Boat’ who were mostly aiming for organisational change. They accomplished these styles through similar strategies based on developing relationships, being credible and empowering others that are advocated in the different levels of leadership, and which mirrored aspects of authentic and adaptable leadership. However, although the Pacific HPE leaders identified themselves as resilient and adaptable they also expressed significant challenges in relation to the University and the Covid-19 pandemic in this low-resource global south setting. Intrapersonal aspects of emotional intelligence could strengthen HPE leaders’ resilience in this cultural setting through faculty development that encourages reflection, such as Rich Pictures and Talanoa.

Notes on Contributors

Dr Sinead Kado is a doctor, medical educator and PhD candidate who reviewed the literature, designed the study, and then collected and analysed the research data, before drafting the original manuscript.

Professor Simon Clarke is a senior honorary research fellow at the University of Western Australia who reviewed and revised the study design, reviewed the data analysis and critically revised the manuscript.

Professor Sandra Carr is the Head of Health Professions Education at the University of Western Australia who revised the study design, analysed the data and then critically revised the manuscript.

All authors have read and approved the final manuscript.

Ethical Approval

Ethics approval was granted by the University of Western Australia (UWA – 2019/RA/4/20/6529) and the Fijian Ministry of Health (Fiji – FNHRERC 31/2020).

Data Availability

Supplementary data in the form of composite narratives – the combined narratives of several participants, and the data summaries interpreted by the researchers are available in Figshare at https://doi.org/10.6084/m9.figshare.24241195.v1. Original full transcripts are not available due to anonymity and confidentiality issues.

Acknowledgement

The authors would like to acknowledge the research participants for their commitment and engagement with the research.

Funding

The primary researcher (SK) was in receipt of an Australian Government Research Training Program (RTP) scholarship for this research.

Declaration of Interest

The researchers declare that they have no known conflicts of interest, including financial, consultant, institutional and other relationships that might lead to bias.

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*Sinead Kado
Division of Health Professions Education,
University of Western Australia
Perth, 6009, Australia
Email: sinead.kado@research.uwa.edu.au

Submitted: 16 July 2023
Accepted: 21 December 2023
Published online: 2 April, TAPS 2024, 9(2), 18-27
https://doi.org/10.29060/TAPS.2024-9-2/OA3098

Natalia Puspadewi

Medical Education Unit, School of Medicine and Health Sciences, Atma Jaya Catholic University of Indonesia, Indonesia

Abstract

Introduction: Developing a professional identity involves understanding what it means to be a professional in a certain sociocultural context. Hence, defining the characteristics and/or attributes of a professional (ideal) physician is an important step in developing educational strategies that support professional identity formation. To date, there are still limited studies that explore undergraduate medical students’ professional identity. This study aimed to define the characteristics and/or attributes of an ideal physician from five first-year and three fourth-year undergraduate medical students.

Methods: Qualitative case studies were conducted with eight undergraduate medical students from a private Catholic medical school in Jakarta, Indonesia. The study findings were generated from participants’ in-depth interviews using in vivo coding and thematic analysis. Findings were triangulated with supporting evidence obtained from classroom observations and faculty interviews.

Results: First-year participants modeled their professional identities based on their memorable prior interactions with one or more physicians. They mainly cited humanistic attributes as a part of their professional identity. Fourth-year participants emphasised clinical competence and excellence as a major part of their professional identities, while maintaining humanistic and social responsibilities as supporting attributes. Several characteristics unique to Indonesian’s physician identity were ‘Pengayom’ and ‘Jiwa Sosial’.

Conclusion: Study participants defined their professional identities based on Indonesian societal perceptions of physicians, prior interactions with healthcare, and interactions with medical educators during formal and informal learning activities.

Keywords:           Professional Identity Formation, Indonesia Undergraduate Medical Students, Physician Identity

Practice Highlights

• Defining the attributes of ideal physicians is important for developing strategies that support PI.
• Prior interactions with healthcare and formal/informal learning activities influence PI definition.

The first year of the medical curriculum was indicated to be an important transition point that shaped all participants’ PI. In particular, all participants mentioned the school orientation as one of the learning moments that triggered their identity negotiation. Participants were introduced to the school’s expectations of them as medical students and future physicians. These expectations include the characteristics of self-regulated and life-long learners and those of professional physicians (See Appendix No. 19-20). For example, Jasmine “learned to be disciplined and responsible and she believed that the school orientation “helped shape [her] basic personality as a physician [who needs] to be disciplined and responsible [as well as] trustworthy.” (Jasmine, Interview 1, Line 115-118).

The shifts in participants’ physician identity definition indicated that participants engaged in a dialectical conversation that stimulated them to merge their core or personal identity with the institution’s perception of ideal physicians (“virtual/ideal identity) as interpreted in their curriculum, which was a part of one’s identity negotiation process (Gee, 2003). In the cross-case analysis, we found that participants’ reactions toward the values, characteristics, and attributes instilled by the faculty varied. For example, some participants saw the importance of being on time (‘discipline’) as well as being academically honest by avoiding plagiarism and cheating during exams (‘honesty’), which they accepted as a part of their physician identity. On the other hand, other participants struggled to understand the relevance of being on time and academically honest with their future physician roles or aspirations. This became a major challenge for these participants in incorporating those values into their physician identity. Nevertheless, no participants rejected any characteristics/attributes instilled by the institution even if those characteristics/attributes were distinctly different from their personal beliefs system (See Appendix No. 21-23).

Any new or contradictory characteristics or attributes to one’s core identity pose a professional dilemma that triggers an identity negotiation (Spencer et al., 1997). During this identity negotiation process, the study participants tried to merge their core identity, which was represented by their definition of the ideal physician that they aspired to be, either by accepting, rejecting, or integrating the new characteristics/attributes into their core identity (Cruess et al., 2015).

The acceptance of new characteristics/attributes into one’s physician identity will be easier if it is consistent with one’s core identity; however, it is still possible to instill characteristics/attributes that contradict one’s core identity if they are provided with the long-term benefit of accepting those characteristics/attributes (Guillemot et al., 2022). This underlined the importance of providing students with the relevancy of developing certain characteristics/attributes desired from a professional physician during their educational phase to support their PIF.

V. CONCLUSION

This case study found that first-year participants prioritised humanistic characteristics as the foreground of their professional identity, and medical professionalism as their background. Meanwhile, fourth-year participants developed a projected identity that embodied the general values of the medical profession and those promoted by their institution. The perceived image of ideal physicians as constructed by the Indonesian society’s ideal image of a physician, prior interactions with Indonesian physicians that influenced their decisions to study medicine, and interactions with the medical teachers during formal and informal learning activities influenced the way participants defined their professional identity.

Notes on Contributors

Natalia Puspadewi contributed to the work’s conception and design by developing the study proposal, protocols and instruments, data collection, analysis, and interpretation. Further, Natalia also drafted and revised the manuscript and ensured that all aspects of the work were accountable, and followed all procedures to ensure data security and anonymity.

Ethical Approval

This study was a part of a doctoral dissertation. The University of Rochester acted as the author’s host institution, and Atma Jaya Catholic University of Indonesia, School of Medicine and Health Sciences, was the research site. Ethical approval was provided by the University of Rochester RSRB (a letter of exempt determination was obtained on July 8^th, 2021 for Study ID 00006273) and the Atma Jaya Catholic University of Indonesia, School of Medicine and Health Sciences Ethics Committee (ethical clearance certificate  No. 08/07/KEP-FKUAJ/2021).

Data Availability

The data supporting the findings of this study are openly available in the Figshare repository

https://doi.org/10.6084/m9.figshare.23684235. The data were not translated into English to preserve the Indonesian sociocultural nuances captured in the interviews. All data were coded and analysed in vivo in Bahasa Indonesia before being translated into English for presentation in this manuscript.

Acknowledgement

We would like to express our gratitude to those who have contributed to this study and article development: Dr. Rafaella Borasi as the head of the dissertation committee and advisor, Dr. Sarah Peyre as dissertation committee member, and Gracia Amanta, MD and Cristopher David, MD who helped with manuscript organisation and layouts.

Funding

This study was funded by the Atma Jaya Catholic University of Indonesia and American Indonesian Cultural and Education Foundation.

Declaration of Interest

The author has no conflicts of interest to disclose.

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*Natalia Puspadewi
School of Medicine and Health Sciences,
Atma Jaya Catholic University of Indonesia,
Jl. Pluit Selatan Raya No. 19, Penjaringan,
Jakarta Utara, 14440
Email: natalia.puspadewi@atmajaya.ac.id

Submitted: 1 May 2023
Accepted: 21 December 2023
Published online: 2 April, TAPS 2024, 9(2), 5-17
https://doi.org/10.29060/TAPS.2024-9-2/OA3053

WCD Karunaratne¹, Madawa Chandratilake², Kosala Marambe³

¹Centre for Medical Education, School of Medicine, University of Dundee, United Kingdom; ²Department of Medical Education, Faculty of Medicine, University of Kelaniya, Sri Lanka; ³Department of Medical Education, University of Peradeniya, Sri Lanka

Abstract

Introduction: The literature confirms the challenges of learning clinical reasoning experienced by junior doctors during their transition into the workplace. This study was conducted to explore junior doctors’ experiences of clinical reasoning development and recognise the necessary adjustments required to improve the development of clinical reasoning skills.

Methods: A hermeneutic phenomenological study was conducted using multiple methods of data collection, including semi-structured and narrative interviews (n=18) and post-consultation discussions (n=48). All interviews and post-consultation discussions were analysed to generate themes and identify patterns and associations to explain the dataset.

Results: During the transition, junior doctors’ approach to clinical reasoning changed from a ‘disease-oriented’ to a ‘practice-oriented’ approach, giving rise to the ‘Practice-oriented clinical skills development framework’ helpful in developing clinical reasoning skills. The freedom to reason within a supportive work environment, the trainees’ emotional commitment to patient care, and their early integration into the healthcare team were identified as particularly supportive. The service-oriented nature of the internship, the interrupted supervisory relationships, and early exposure to acute care settings posed challenges for learning clinical reasoning. These findings highlighted the clinical teachers’ role, possible teaching strategies, and the specific changes required at the system level to develop clinical reasoning skills among junior doctors. 

Conclusion: The ‘Practice-oriented clinical skills development framework’ is a valuable reference point for clinical teachers to facilitate the development of clinical reasoning skills among junior doctors. In addition, this research has provided insights into the responsibilities of clinical teachers, teaching strategies, and the system-related changes that may be necessary to facilitate this process.

Keywords:           Clinical Reasoning, Medical Decision Making, Medical Graduates, Junior Doctor Transition, Hermeneutic Phenomenology, Qualitative Research

Practice Highlights

• A safe environment and early healthcare team integration facilitate learning clinical reasoning.
• Adopting a comprehensive approach to reasoning can overcome specialty-specific reasoning challenges.
• Trainees’ emotional commitment toward patients could help them learn clinical reasoning skills.
• Interrupted supervisory relationships and early acute care exposure can hamper learning reasoning.
• Ensuring junior doctor training is both service and learning oriented is of paramount importance.

I. INTRODUCTION

Clinical reasoning is composed of cognitive processes, metacognitive processors, and behaviour during the application of critical thinking to a clinical situation and is heavily influenced by numerous contextual factors related to the doctor, patient, and the clinical environment (Durning et al., 2011; Durning et al., 2013; Norman, 2005).

The clinical reasoning of learners evolves along the continuum of medical education with unique challenges associated with major transition phases, the progression from non-clinical to clinical stage, medical graduate to junior doctor, and specialist trainee to medical specialist (Teunissen & Westerman, 2011). Notably, the medical graduate to junior doctor transition presents more pronounced difficulties (Brennan et al., 2010), primarily due to changing roles and responsibilities towards patient care, limited experience in navigating clinical uncertainties, and the need to work within multi-professional teams with limited support.  Consequently, these factors have contributed to a steep learning curve for developing clinical reasoning skills (Brennan et al., 2010; Lempp et al., 2005; Prince et al., 2004; Tallentire et al., 2017). The challenges in developing reasoning skills are associated with the reduced applicability of undergraduate training in clinical practice (Cave et al., 2009; Monrouxe et al., 2017), coordinating and organising clinical and administrative responsibilities (Cameron et al., 2014; Teunissen & Westerman, 2011), and dealing with diverse contextual factors in practice. These factors encompass navigating hierarchical relationships and meeting the expectations of seniors, difficulties in recognising disease severity, uncertainty regarding their role, and tension in interpersonal relationships with team members (Cameron et al., 2014; Tallentire et al., 2011, 2017). When these challenges are not resolved, they could boil down to deficits in clinical reasoning and diagnostic error leading to adverse patient outcomes (Graber et al., 2005; Huckman & Barro, 2005; Jen et al., 2009).

The challenging nature of the junior doctor transition is shared across many similar contexts globally (Prince et al., 2000; Teunissen & Westerman, 2011) calling for a coherent approach to facilitate learning clinical reasoning. Concerns around clinical reasoning deficits of doctors continue to soar even today in resourceful developed countries (Health Services Safety Investigation Body, 2022; Huckman & Barro, 2005; Jen et al., 2009), emphasising the need for faculty to take decisive actions to resolve it! Unless for the limited research on clinical reasoning outside the western region (Lee et al., 2021), the situation could have been the same elsewhere.

There is ample evidence of numerous factors that may improve the development of clinical reasoning skills. Accordingly, work experience (Ericsson, 2004; Norman, 2005; Norman et al., 2007), a strong foundation on basic biomedical concepts (Woods, 2007), reflective practice (Mamede et al., 2008, 2012), feedback (Hattie & Timperley, 2007), learning from others during practice, and conducive organisational context for learning (Goldacre et al., 2003; Hattie & Timperley, 2007; Lempp et al., 2005) are found to be central in learning clinical reasoning. This evidence, however, is not specific to junior doctors. The learning needs of junior doctors in transition may vary from other trainee doctors and other health professions staff. Therefore, it has become critical that the clinical reasoning experiences, challenges, and practices of junior doctors as a vulnerable group of trainees are understood well to be able to better support their development of clinical reasoning.

When exploring this period of transition, the five-stage model of adult skill acquisition from novice to expert (Dreyfus, 2004), can help understand how junior doctors progress in relation to these stages. The situated learning theory (S. J. Durning & Artino, 2011; Lave, 1991) can provide the basis for understanding the social nature of learning clinical reasoning. The influence of contextual factors on mediating internal motivation for learning clinical reasoning can be understood through the self-determination theory (Ryan & Deci, 2000; Taylor & Hamdy, 2013). Therefore, to gain a better understanding of the transition experiences from medical graduates to junior doctors, a longitudinal study was designed using the above theoretical models as the conceptual framework to explore the following research questions:

(1) How do junior doctors evaluate their learning experiences of clinical reasoning development?

(2) What adjustments in the application of different educational means into the learning environment are necessary to improve the development of clinical reasoning skills?

II. METHODS

A. Methodology

The methodological approach of hermeneutic phenomenology (Crotty, 1998; Laverty, 2003) was employed in this study (Kafle, 2011; Laverty, 2003). Such an approach to clinical reasoning was adopted by other researchers exploring clinical reasoning (Ajjawi & Higgs, 2007; Langridge et al., 2015; Robertson, 2012).

B. Study Setting

The study was conducted at the North Colombo Teaching Hospital, Ragama, Sri Lanka with ethical clearance (P/11/01/16) from the Faculty of Medicine, University of Kelaniya.

In Sri Lanka, medical undergraduate training is a five-year programme with two pre-clinical and three clinical years. After graduation, medical graduates follow a 12-month internship where they work under a consultant for six months each in any of the two main clinical specialities, namely, Medicine, Surgery, Paediatrics, and Gynaecology & Obstetrics before obtaining full registration as a medical doctor.

C. Study Design and Sampling

The study participants were junior doctors during the 12 months of internship following graduation. Maximum variation sampling (Cohen et al., 2017), which enabled purposefully selecting the widest range of variation on dimensions of interest relevant to learning and practicing clinical reasoning was employed. The concept of ‘information power’ which sought not theoretical saturation but sufficient information to address the research questions informed the sample size (Malterud et al., 2016; Varpio et al., 2017). Hence, junior doctors working in the four main clinical specialties, in both university clinical wards staffed by university clinical academics and other clinical wards composed of medical consultants under the Ministry of Health and according to gender were enrolled in the study following informed consent.

Accordingly, eighteen junior doctors (n=18, males=8, females=10) from the four main clinical specialities (Medicine-4, Surgery-5, Paediatrics-4, Obstetrics and Gynaecology-5) were enrolled in the first stage of the study. The second stage of the study imposed heavy demands on the study participants because it involved recording multiple doctor-patient encounters and subsequent discussions based on stimulated recall. Therefore, out of the initially recruited participants, only the well-articulated consenting participants (n=8), who could proficiently express their thoughts and reasoning to obtain a good insight into the nature of practicing clinical reasoning were enrolled in this stage.

D. Data Collection

The data collection proceeded in two stages. 

During the first stage, a combination of individual semi-structured interviews with narrative interviews were conducted.  Semi-structured interviews allowed probing where necessary (Cohen et al., 2017), while the narratives allowed participants to tell their stories of clinical reasoning (Muylaert et al., 2014). Each lasted for 45-50 minutes.

The second stage included audio-recording the patient consultations of the selected participants on predefined dates during the first and second six months of their internship. The consultations were replayed, and post-consultation discussions were conducted soon afterward by employing a stimulated recall method, to account for a total of 48 post-consultation discussions. As clinical reasoning is a concept revealed only in action (Charlin et al., 2000), employing such an approach was considered essential during this study.

E. Data Analysis

All interviews and discussions were transcribed verbatim. The data analysis followed phenomenological and hermeneutic strategies, which required a thorough description of lived experiences (Ajjawi & Higgs, 2007) and employing a hermeneutic circle for data interpretation by moving back and forth between the parts and the whole of the experience to reach a deeper understanding of the experience (Laverty, 2003).

Thematic data analysis (Braun & Clarke, 2012) was conducted to generate themes explaining the data set as a whole. 

The principal researcher developed two thematic frameworks for the two stages of the study. The two supervisors of the project re-coded selected transcripts from each stage. These independently derived frameworks were discussed, themes refined, and new themes identified until an agreement was reached. The finalised thematic framework was employed to code all the transcripts using the Atlas.ti qualitative data analysis tool.

III. RESULTS

A total of 18 individual interviews and 48 post-consultation discussions were analysed giving rise to seven themes. During analysis, it was noted that the factors that inform the development of clinical reasoning could be condensed together as a model. This is presented later in the text.

Each theme is elaborated below with quotations.  When more than one quotation is required to describe a theme, these are presented within a table. Additional supportive quotations are openly available in Figshare at https://doi.org/10.6084/m9.figshare.23536548.v2 (Karunaratne et al., 2023).

A. A Safe and Supportive Working Environment Empowers Junior Doctors to Develop Clinical Reasoning Skills

It was the collective view that a ‘safe’ work environment is characterised by easy access to more experienced doctors, and the presence of a safety net of seniors who review junior doctors’ work and understand their reasoning challenges. It provided junior doctors the opportunity and freedom to practice clinical reasoning independently, learn from errors, and arrive at their own reasoning decisions.

Such a conducive work environment also provided them with opportunities to emulate seniors and receive real-time feedback while actively participating in authentic tasks and applying knowledge and skills acquired during their undergraduate training.

“I’m working in a unit where each admission is clerked by the registrar. So, in that case, we are always in feedback…What I usually do is sometimes I clerk the patients first, and after that, I compare it with the registrar’s clerking. So, in that case, we can easily adapt their clerking.”

(MP3, Medicine, Male, Phase-1) 

B. Learning to Reason with Clinical Problems is Situated and Facilitated by Work Experience

Work experience provided the opportunity to learn from repeated exposure to clinical presentations and their variations, learn from seniors, and lapses of reasoning. However, work experience alone is not solely sufficient, and it is the collective influence of many other factors that help learn clinical reasoning. These factors are captured by the model developed from this study.

With work experience, junior doctors’ approach to reasoning changed from a ‘disease-oriented approach’ developed through undergraduate education to a ‘practice-oriented approach’. In the practice-oriented approach, junior doctors actively analyse clinical problems instead of matching them with memorised configurations of disease presentations.

They also developed ‘instincts’ for swift decision-making, sharpened through experience in recognising contextual factors in patient presentations. This was especially valuable for identifying acute cases requiring urgent care. In addition, they recognised the impact of the previous disease burden in formulating differential diagnoses, leading to a broader approach in their clinical reasoning.

Table 1 illustrates participant quotations that shed light on the role of work experience in learning clinical reasoning skills.

“…This approach in the ward is always problem-based. We’re dealing with problems. We try to solve the problems. That approach as a student was trying to fit the history into one of the long cases we have studied…Now we are not worried about that broad category. We will instead deal with the different problems that they have.”  (MP2, Medicine, Male, Phase-1)

“I think it’s just being with the patients. You realise that … it’s not just what’s written in the book…I mean now, if you’re just walking past a patient, you realise that this patient is not well. Whereas initially, you would have to go through the ward round and… go through the records, and then only you’ll see it. I don’t know how you get that but…” (MP2, Medicine, Male, Phase-1)

“…Once a child with hypovolemic shock came to the ward. I was in the ward alone. I was very afraid at that time as I was in my first week of internship. So, nothing was on my mind, and I called my senior and he asked me to give (fluid) boluses until he came…. (There was another emergency at the same time). An Angioedema child came to the ward. I thought of (laughing)… running away from the ward. Because it was the initial period, it was very difficult, and our clinical knowledge was also poor. But now, we can manage any emergencies until the senior comes.” (PP, Paediatrics, Female, Phase-1)

(When enquired on the reasons for commencing consultations with comorbidities?) “… Even the presenting complaint may be related to past medical conditions as well…and even this patient has diabetes… so, they can present in various ways… As an intern, I developed that. As an undergraduate, we are asking for name, age, where are you from, and then go on to take the history first…” (MP4, Medicine, Female, Phase-2)

Table 1. Quotes illuminating that learning clinical reasoning is situated and facilitated by work experience

C. Internal Motivation and the Ability to Reflect and Employ Self-directed Learning are Powerful Tools for Developing Clinical Reasoning Skills

Learning clinical reasoning necessitated junior doctors to be internally driven for learning.  Such internal motivation made them willing to learn from any source and be self-directed in their own learning. These individuals progressed rapidly in learning to reason with clinical problems compared to others who were not internally motivated.

Maintenance of internal motivation throughout the internship necessitated external encouragement even for the motivated particularly from the senior staff. There was a similar effect when the work environment fostered a culture of learning with the inclusion and recognition of junior doctors as a group of learners.

Table 2 presents participant quotations that highlight the significance of internal motivation in developing clinical reasoning skills.

“(reasoning with a complicated presentation) …With this kind of patient, it’ll refresh our memory. Going through how to take the history, how to use the basics, and how you investigate and manage…It is not like people coming with gastritis, or headache. Those are just simple things. But actually, it’s a pleasure to have these kinds of patients.”   (MP3, Medicine, Male, Phase-2)

“I think you don’t need people who are good at what they do, I mean, you need people who are competent, but er…, you need a pleasant environment. Even if, there are, like 50 patients, if the people you work with are good, you can go through it. But then, if someone is really unpleasant, then that day is ruined.”  (MP1, Medicine, Female, Phase-1)

Table 2. Quotes illuminating internal motivation, reflective practice, and being self-directed as central to learning clinical reasoning skills

D. Caring and Compassionate Attitudes towards Patients Facilitate Developing Clinical Reasoning Skills

The individual caring and compassionate attitudes towards patients and the positive role modeling of senior doctors motivated junior doctors to learn clinical reasoning. Work experience nurtured these attitudes irrespective of gender, reflecting the potential to learn them during practice. However, a heavy workload and orientation towards efficiency in practice hindered the development of such attitudes among junior doctors.

“We’ve realised that although we’re members of a team, even individually, we can always do something for the patients. So, we always try to do something at our level. But we’re always willing to take the feeling from everyone above us to help.”

(MP1, Medicine, Female, Phase-1)

 

E. Collaborating within a Healthcare Team and Engaging in Ward Activities and Procedures Help Expedite the Development of Clinical Reasoning Skills

Junior doctors learn mostly from registrars, who are the immediate seniors and near-peers. In addition, peers and other healthcare staff contribute to their learning by timely sharing of information and working as a team. Patients’ unique characteristics which demand variation in reasoning also provide learning opportunities.

“I think the main influence is probably the registrars. Because we’re mostly in contact with them…So, in a way through working with them, I think I have learned quite a lot. Different ones will teach you different skills. Some are good at acute medicine and how to do that, and some are very willing to teach us how to do a pleural tap… So, from different people, we have learned different things.”

(MP2, Medicine, Male, Phase-1) 

F. The Increasing Recognition of Professional Responsibility and Accountability towards Patient Care Drives Learning Clinical Reasoning

This was a strong theme commonly experienced by all junior doctors. During this transition, junior doctors recognised the patient care responsibilities vested in them and experienced a change of role from an undergraduate to a medical doctor.  This led them to internalise their role and work towards meeting these expectations, whilst learning from all opportunities. 

“We realise that somehow, we’ve got to do something. It wasn’t like that as students. (Now, as doctors) If we can’t take an ABG (Arterial Blood Gas) once, we will try ten times and somehow take the ABG. We realise- we have that ownership, “This is my patient. I will do something for her.” So, I think that’s a good thing. We didn’t have that as students.”

(MP1, Medicine, Female, Phase-1) 

Parallel to the change of role, they were accepted as members of a community of doctors actively involved in providing patient care, which gave them a sense of inclusion and prestige and they worked hard towards meeting the expectations, which in turn helped them learn clinical reasoning.

G. Diversity of Personal, Interpersonal, and Contextual Factors Impede the Development of Clinical Reasoning Skills

Several negative influences on learning clinical reasoning exist.

The personal factors that can diminish learning clinical reasoning are related to a lack of internal motivation to learn and limited use of reflective practice.

In addition, external factors such as lack of encouragement and limited recognition of their contribution as doctors further demotivate junior doctors. Settings supervised by several senior clinicians provide better learning opportunities, but they also expose them to experience individual variations of reasoning due to staff working patterns and hinder their ability to appreciate the continuity of care.

Moreover, as junior doctors, they handle a heavy workload and work under time constraints, which gives them limited opportunity to reflect and learn from experience. Junior doctors also experience the presence of a power gap between juniors and seniors within the healthcare team and maintenance of this hierarchy is a barrier to learning during practice.

Table 3 presents participant quotes highlighting the diversity of contextual factors that hinder learning clinical reasoning skills.

“…usually hiccups occur with failures of… all types of failures…  I do not have much knowledge about those things. Actually, I got to know that hiccups occur due to organ failure also, after this patient… (laughs)” (no intentions to learn more expressed)   (SP2, Medicine, Male, Phase-2)

“…here I think, in our unit, because the consultant changes daily, I think that is a negative point. The fact that you don’t have that connection with one person, and the fact that there is no continuity in care…” (MP1, Medicine, Female, Phase-1)

“…I mean, there are too many admissions some days and you’re just trying to get through from one patient to the next one. So, you don’t really have that much time to analyse the problem as such. I mean, when the ward is less heavy, I’m trying to figure out what’s wrong but some days it’s a little bit… like going through.” (MP2, Medicine, Male)

Table 3. Quotes illuminating contextual factors that impede the development of clinical reasoning skills

In addition, the discussions with junior doctors revealed that their main goal during the internship was to arrive at a diagnosis and/or manage patients’ clinical problems.  No learning-related goals were readily verbalised.

 

(When enquired about the goals of reasoning during the internship)
“That…..err…is… coming to a final diagnosis and starting the treatment…Basically, we are supposed to recognise life-threatening conditions and treat them.”

 (MP3, Medicine, Male, Phase-2)

 

Similarly, the informal discussions with senior clinicians revealed their limited expectations of the contribution of the internship towards facilitating the development of clinical reasoning skills among juniors. This could be due to the service orientation of the internship leaving ‘learning to happen’ concurrently without being actively encouraged. This is not conducive to learning clinical reasoning.

H. The Construction of the ‘practice-oriented clinical reasoning skills development framework’

Embedded within the seven themes were a multitude of factors that could be clearly categorised as ‘Facilitators’, ‘Drivers’, ‘Sources’, and ‘Challenges’ of developing clinical reasoning skills. These factors helped junior doctors to migrate from a disease-oriented to a practice-oriented approach to clinical reasoning (Figure 1).

The categorisation was informed by how these factors influenced the development of clinical reasoning skills. ‘Facilitators’ actively support learning, while ‘drivers’ exert strong internal pressure to motivate learning clinical reasoning. A ‘source’ is an individual or an activity, that helps learn clinical reasoning through interacting with them. ‘Challenges’ are either internal or external to an individual and negatively influence the development of clinical reasoning skills.

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*WCD Karunaratne
Centre for Medical Education,
University of Dundee
Scotland, DD2 4BF
+44 7594 504928
Email: dilminikarunaratne@gmail.com / Wkarunaratne001@dundee.ac.uk

Submitted: 27 April 2023
Accepted: 17 August 2023
Published online: 2 January, TAPS 2024, 9(1), 36-41
https://doi.org/10.29060/TAPS.2024-9-1/OA3051

Mae Yue Tan^1,2, Zong Jie Koh^1,3, Shoban Krishna Kumar⁴, Rui Min Foo⁵, Rou An Tan⁶, Nisha Suyien Chandran^7,8 Jeremy Bingyuan Lin^1,2, Malcolm Mahadevan⁹ & Eng Loon Tng⁵

¹Department of Paediatrics, Khoo Teck Puat – National University Children’s Medical Institute, National University Health System, Singapore; ²Department of Paediatrics & ⁸Department of Medicine, Yong Loo Lin School of Medicine, National University of Singapore, Singapore; ³Department of General Surgery, University Surgical Cluster, National University Health System, Singapore; ⁴Division of Advanced Internal Medicine, Department of Medicine, National University Hospital, National University Health System, Singapore; ⁵Department of Medicine & ⁶Department of Intensive Care Medicine, Ng Teng Fong General Hospital, National University Health System, Singapore; ⁷Division of Dermatology, Department of Medicine, National University Hospital, National University Health System, Singapore; ⁹Emergency Medicine Department, National University Hospital, National University Health System, Singapore

Abstract

Introduction: The night float (NF) system has been instituted in some hospitals in Singapore to improve the working hours and wellbeing of junior doctors. There have been concerns of compromised learning and patient safety with NF. The objective of this study is to compare clinical competency outcomes, based on existing assessment framework, between post-graduate year 1 (PGY1) doctors working on NF versus traditional call (TC) systems. The secondary aim was to explore patient safety outcomes between these groups of PGY1s.

Methods: Data on the formal assessments of PGY1s using the Entrustable Professional Activities (EPAs) and medical errors were prospectively collected between May 2021 and April 2022 from two hospitals that employed different on-call systems. Data was analysed descriptively. Categorical data was analysed using the Chi-square test or Fisher’s exact test where appropriate.

Results: One hundred and ninety-three PGY1s consented to the study. There was no statistically significant difference in the clinical competency of PGY1s in both groups. The number of PGY1s who had ‘needs improvement’ scores in a detailed EPA was not significantly different (9.0% in the NF group versus vs 3.7% in the TC group (p = 0.14)). They nonetheless passed the overall core EPA and no PGY1 failed their postings. No serious reportable medical errors occurred in either group.

Conclusion: PGY1s who worked on NF are equally competent compared to those who worked on TC based on the EPA assessment matrix. Patient safety is not compromised by PGY1s working on NF.

Keywords:           Clinical competence, Float, Junior doctor, Patient safety, Wellbeing

Practice Highlights

• Night float did not affect competency of post-graduate Year 1 doctors on current assessments.
• Night float did not lead to compromised patient safety.
• We provide objective data in consideration of restructuring working hours for junior doctors.

I. INTRODUCTION

Post graduate year 1 (PGY1) doctors are fresh graduates who are in their transitional year where they learn clinical decision-making skills and how to perform simple medical procedures independently. In Singapore, following the Medical Registration Act, PGY1s are required to complete 4 months of Internal Medicine and 4 months of General Surgery or Orthopaedic Surgery, with another 4-month posting of their choice in their 12 months as a PGY1 (Ministry of Health Holdings Pte Ltd, 2018).  As part of the national PGY1 training framework (Ministry of Health, 2019), each hospital is required to provide training (teaching activities) to allow PGY1s to achieve their learning and competency outcomes. PGY1s are assessed via a standardized matrix which is used across all hospital rotations and institutions.  They are expected to achieve competency in situations where senior supervision is less readily available, for example, while working on-call. PGY1 duties are similar regardless of discipline as they focus on core medical competencies common to general medical practice.

In Singapore, some hospitals have instituted the night float (NF) system as a service model where a dedicated team of doctors, including PGY1s, take over the care of patients for consecutive nights in a week. A different team of doctors will resume care of patients the following day. This facilitates timely handovers of patient management, eliminates the need for prolonged post-night call working hours and provides junior doctors with adequate rest, avoiding sleep deprivation. Conversely, in the traditional call (TC) system, junior doctors commence night duties immediately after their daytime routines. Frequently, at the end of their night calls, PGY1s continue with daytime work till mid-day or later, resulting in shifts of up to 36 hours.

The Accreditation Council for Graduate Medical Education (ACGME) guidelines recommended a maximum of 80 hours of duties per week based on extant literature on the impact of prolonged duty hours on burnout and fatigue (Singapore Medical Council, 2017), medical errors and adverse events (Barger et al., 2006; Landrigan et al., 2004; Trockel et al., 2020). Departments that have instituted the NF system have significantly improved their compliance to duty hour recommendations. However, concerns were raised regarding reduced training opportunities, specifically during the after-office hour period due to the reduced working hours with NF as well as potential compromises in patient safety arising from communication lapses associated with frequent handovers (Desai et al., 2013; Sun et al., 2016). These concerns have prevented widespread adoption of NF in Singapore hospital systems.

Two studies in Singapore have shown that residents who worked on NF felt that it did not affect their learning outcomes or compromise patient safety (Loo et al., 2020; Tan et al., 2019). However, these studies assessed the perceptions of junior doctors and provided no objective data for comparison of NF against TC. We thus aimed to compare clinical competency outcomes between PGY1s who worked on NF and those who worked on TC, across similar specialties. The secondary aim was to explore any differences in patient safety and medical errors between these two groups. We chose the PGY1 group for this study for the following reasons. Firstly, PGY1 training outcomes and assessments are standardized nationwide thus allowing for direct comparisons across institutions. Additionally, any policy implementation or change would impact all PGY1s across the board equally. In contrast, physicians in their later years of training (PGY2 and above) are a heterogenous group with their training assessment frameworks dependent on the relevant speciality programmes. Secondly, PGY1s are considered to have the one of the highest risks of burnout among physicians and are likely to benefit most from well-being initiatives. Lastly, the PGY1 year is a compulsory year of formative training with PGY1s subsequently graduating as fully licensed physicians. This decisive and important transitional year from medical training to clinical practice underscores the importance of considerations for their training and competency.

II. METHODS

This study was conducted over three rotations (each PGY1 rotation spans 4 months) from May 2021 to April 2022. PGY1s working in National University Health System cluster (either in National University Hospital where NF is the structure for PGY1s rotating through General Surgery, Internal Medicine, and Orthopaedics (since January 2022), or Ng Teng Fong General Hospital where TC is practiced) were invited to participate via emails. PGY1s could opt out of the study. Ethics approval was obtained [National Healthcare Group Domain Specific Review Board (NHG DSRB), Singapore; Reference No.: 2021/00536].

Prospective data was collected from formal educational and workplace-based assessments. Currently, the Entrustable Professional Activities (EPAs) framework, which describes professional activities that a trainee can be entrusted to perform at varying levels of supervision, is used for this purpose. EPAs are established milestones in post graduate medical education to gauge whether trainees have achieved necessary skill sets that are appropriate for their level of training. In its current form, the local EPA framework for PGY1s includes 7 ‘core EPA’ groups. Each ‘core EPA’ group further encompasses a list of ‘detailed EPAs’. An example of a ‘core EPA’ and its ‘detailed EPAs’ is shown in Table 1. At the end of a rotation during their final evaluation, PGY1s are evaluated by their supervisors for each ‘detailed EPA’ as part of their ‘Learning Needs’. A grading of ‘needs improvement’ for a detailed EPA indicates that the PGY1 has not demonstrated sufficient competence in that specific activity. No input is required if a PGY1 is deemed to have met expectations for the detailed EPA. In performing this evaluation, the supervisor is expected to canvass feedback from other team and faculty members who have worked with the PGY1. At the end of the rotation, should all EPAs (core and detailed) be assessed as competent, the supervisor would grade the posting outcome as a pass, with the opportunity to nominate the PGY1 for the national outstanding PGY1 award.

Submitted: 28 January 2023
Accepted: 17 August 2023
Published online: 2 January, TAPS 2024, 9(1), 3-19
https://doi.org/10.29060/TAPS.2024-9-1/OA2947

Thun How Ong¹, Hwee Kuan Ong², Adrian Chan¹, Dujeepa D. Samarasekera³ & Cees Van der Vleuten⁴

¹Department of Respiratory and Critical Care Medicine, Singapore General Hospital, Duke-NUS Medical School, Singapore; ²Department of Physiotherapy, Singapore General Hospital; ³Centre for Medical Education, Yong Loo Lin School of Medicine, National University of Singapore, Singapore; ⁴Department of Educational Development and Research, Maastricht University, Maastricht, The Netherlands

Abstract

Introduction: The mini-Clinical Evaluation Exercise (CEX) is meant to provide on the spot feedback to trainees. We hypothesised that an ultra-short assessment tool with just one global entrustment scale (micro-CEX) would encourage faculty to provide better feedback compared to the traditional multiple domain mini-CEX.

Methods: 59 pairs of faculty and trainees from internal medicine completed both the 7-item mini-CEX and a micro-CEX and were surveyed regarding their perceptions of the 2 forms. Wordcount and specificity of the feedback was assessed. Participants were subsequently interviewed to elicit their views on factors affecting the utility of the CEX.

Results: Quantity and quality of feedback increased with the micro-CEX compared to the mini-CEX. Wordcount increased from 9.5 to 17.5 words, and specificity increased from 1.6 to 2.3 on a 4-point scale, p < 0.05 in both cases. Faculty and residents both felt the micro-CEX provided better assessment and feedback. The micro-CEX, but not the mini-CEX, was able to discriminate between residents in different years of training. The mini-CEX showed a strong halo effect between different domains of scoring. In interviews, ease of administration, immediacy of assessment, clarity of purpose, structuring of desired feedback, assessor-trainee pairing and alignment with trainee learning goals were identified as important features to optimize utility of the (mini or micro or both) CEX.

Conclusions: Simplifying the assessment component of the CEX frees faculty to concentrate on feedback and this improves both quantity and quality of feedback. How the form is administered on the ground impacts its practical utility.

Keywords:           Workplace Based Assessment, Mini-CEX, Micro-CEX, Feedback, Assessment

Practice Highlights

• Simplifying the assessment component of the CEX frees faculty to concentrate on feedback.
• A simpler form can result in better and more feedback.
• Making it easy for faculty to use the form is important and increases its utility in providing feedback and assessment.

I. INTRODUCTION

The Mini-CEX is one of the most widely used work-placed based assessment (WBA) tools and is supported by a large body of theoretical and empirical evidence which have shown that when used in the context of repeated sampling, it is both a valid assessment tool and is also an effective education tool in giving feedback to the trainee (Hawkins et al., 2010; Norcini et al., 2003). However, in practice, the educational value of the mini-CEX, as measured chiefly by trainee and faculty perceptions and satisfaction, varied significantly (Lorwald et al., 2018). Factors affecting the educational value have been described by Lorwald et al. and categorised into context of usage, and user, implementation and outcome factors (Lorwald et al., 2018).

Context refers to the situation in which the mini-CEX is executed, and factors which impact its actual usage, such as time needed for conducting the Mini-CEX, or the usability of the tool. Time constraint on the part of both the residents and the assessors is an especially frequent issue across multiple studies (Bindal et al., 2011; Brazil et al., 2012; Castanelli et al., 2016; Lörwald et al., 2018; Morris et al., 2006; Nair et al., 2008; Yanting et al., 2016). The mini-CEX was conceived as a 30-minute exercise of directly observed assessment, and there are 6 or 7 domains which faculty are expected to assess (Norcini et al., 2003). In a busy clinical environment however, what actually occurs is often a brief clinical encounter of 10-15 minutes or even less where only a few of the mini-CEX’s domains were assessed (Berendonk et al., 2018).

User factors refers to trainee and faculty knowledge of the mini-CEX and their perceptions of its use. Studies have found that the mini-CEX is frequently regarded as a check box exercise (Bindal et al., 2011; Sabey & Harris, 2011). Assessor’s and trainee’s training and attitudes, or unfamiliarity with the WBA tools also negatively impact the educational value of the mini-CEX (Lörwald et al., 2018). Reports have shown that educating faculty on the formative intent of mini-CEX can improve feedback provided (Liao et al., 2013).

Implementation factors refer to how the mini-CEX is actually executed on the ground. Some studies have reported that the mini-CEX often occurs without actual direct observation (Lörwald et al., 2018) or feedback provided (Weston & Smith, 2014). Implementation in turn affected outcome, which refers to the trainees appraisal of the feedback received (Lörwald et al., 2018).

One way of improving the educational value of the mini-CEX then might be to improve the context of its usage, by redesigning the mini-CEX to better fit the realities of the clinical workplace. In different clinical encounters, specific domains of performance are more easily and obviously observed and assessed than others (Crossley & Jolly, 2012). Reducing the number of dimensions the assessors are asked to rate was shown to decrease measured cognitive load and improved interobserver reliability (Tavares et al., 2016). It has also been shown that using rating scales that align with the clinician’s cognitive schema perform better, for instance, scales that ask the clinician assessors about the trainees ability to practice safely with decreasing levels of supervision (i.e. entrustability) showed better discrimination and higher reliability (Weller et al., 2014). Compared to multidimension rating scales, global rating scales have greater reliability and validity in assessing candidates in OSCE examinations (Regehr et al., 1998), assessing technical competence in procedures (Walzak et al., 2015) and in simulation-based training (Ilgen et al., 2015).

We proposed therefore to replace the multiple domains with a single rating asking faculty what level of supervision the resident would require in performing a similar task, i.e. a global entrustment scale. The shorter assessment task should refocus the faculty on the feedback component, whilst still retaining the ability to identify trainee progression. One such form has been proposed by Kogan and Holmboe (2018), and we designated this the micro-CEX.

We hypothesised that these changes would improve the usability (“context” as described by Lorwald et al.) and hence improve the educational value of the assessment, measured in this study by the specificity and quality of the feedback given by faculty.

Our study aims to show therefore that the shorter micro-CEX can provide better feedback than the usual mini-CEX. We also sought to find out, from the perspective of the end-users, what other adjustments to the implementation and design of the mini or micro-CEX can be made to improve its acceptability, educational value and validity.

The study focussed on the following questions:

Does the micro-CEX stimulate faculty to provide more specific and actionable feedback compared to the mini-CEX?

Can the micro-CEX provide discriminatory assessment for residents across different years of practice?

What are the perceptions of the faculty and residents regarding the factors affecting utility of the assessment instrument in providing feedback and assessment?

II. METHODS

A. Setting and Subjects

The study was conducted in the division of Internal Medicine in a 1700 bed hospital in Singapore between September and December 2018. All faculty and residents rotating through internal medicine were invited to participate via e-mail, and agreeable faculty and residents paired up. In usual practice, residents must complete at least 2 mini-CEX covering standard inpatient or outpatient encounters during each three-month internal medicine posting, hence both residents and faculty are familiar with the usual mini-CEX.

B. Design

In order to evaluate for any participant reactivity affecting the CEX data (i.e. a Hawthorne effect) (Paradis & Sutkin, 2017), a baseline sample of 30 of the usual mini-CEX performed in the 3 months prior to the study was randomly selected and deidentified (from June to August 2018) . The quantity and specificity of feedback in these was evaluated as detailed below.

For the study itself, faculty and residents used the usual mini-CEX as the first assessment in the first 2 weeks of the month, followed by a second assessment using the micro-CEX in the next 2 weeks. This sequence was chosen as performing the micro-CEX first might affect how the subsequent mini-CEX was performed. Cases chosen for the mini-CEX and micro-CEX were inpatient or outpatient internal medicine encounters, and faculty were simply instructed to choose cases that represented typical cases of average difficulty with no restrictions on the exact cases to be chosen.

Faculty and residents completed an anonymised survey on their experiences at the end of the study and were invited to participate in a semi-structured group interview to elicit their views regarding which aspects of the mini-CEX exercise influenced feedback and assessment (Appendix 2). Both faculty and residents were informed that the survey and interviews were part of this study and participation in either was taken to be implied consent. The workflow of the study is seen in Figure 1.

Figure 1. Study workflow

Submitted: 5 April 2023
Accepted: 17 August 2023
Published online: 2 January, TAPS 2024, 9(1), 28-35
https://doi.org/10.29060/TAPS.2024-9-1/OA3035

Aminda Faizura Omar, Tun Yasmin Iffah Mohd Suria Affandi, Mohd Isyrafuddin Ismail, Mas Suryalis Ahmad & Ilham Wan Mokhtar

Comprehensive Care Centre of Studies, Faculty of Dentistry, Universiti Teknologi MARA, Malaysia

Abstract

Introduction: This study was undertaken to investigate students’ perceptions of innovation-integrated learning, adopted as an alternative approach for special care dentistry (SCD) training.

Methods: Ninety final-year dental students from the 2021 cohort were divided into eight groups to complete an innovation project dedicated to eight categories of patients with special health care needs. Discussion and final presentations, involving related experts were conducted remotely via an online platform. Then, students were invited to answer a validated online feedback survey on their perceptions of the learning approach.

Results: The response rate for the feedback survey was 91.1% (n=82). Most students agreed that the activity was interesting, improved their knowledge and understanding of SCD, allowed engagement between peers, supported sharing of ideas and experiences, encouraged student–lecturer interactions, and enhanced knowledge integration and application. Students also expressed that the activity enhanced creativity and innovation, instilled an interest and positive attitude toward learning SCD, and encouraged teamwork. However, a few students noted facing some limitations in completing their projects (i.e., technological challenges and reduced physical access to purchase materials). Around half felt neutral about having an increased workload from this activity. Moreover, perceptions differed regarding time and financial commitments, as well as supervisors’ and patients’ involvement during the project development process.

Conclusion: Students perceived that the innovation-oriented learning activity, was beneficial in multiple aspects of SCD training.

Keywords:           Innovation, Learning, Dental Students, Perception

Practice Highlights

• We have developed a new integrated teaching method via the utilisation of innovation development for special needs groups.
• Students’ perceptions of this learning method were explored using both quantitative and qualitative methods via an online feedback questionnaire.
• Overall, students positively responded to the teaching method when it came to improving their knowledge and understanding of SCD, engagement between peers, sharing of ideas and experiences, student–lecturer interactions, and knowledge integration and application.
• This novel teaching method achieves the highest level of Bloom’s Taxonomy which is to create something new.

I. INTRODUCTION

Special care dentistry (SCD) involves managing patients with special health care needs, such as those with physical, intellectual, psychological impairments as well as complex medical conditions (Royal Australasian College of Dental Surgeons, 2021). At the undergraduate level, many teaching and learning activities have been conducted to provide students with learning experience in this area of patient care. These activities include lectures, community-based learning, simulation exercises and clinical training (Ahmad, Mokhtar, et al., 2020; Mohamed Rohani & Mohd Nor, 2021). Students who received training in SCD were found to have demonstrated better comfort and attitudes in managing patients with special health care needs (Mohamed Rohani et al., 2021).

However, these learning activities may be compromised by situations that limit face-to-face interactions, either among students, between teacher and learners, as well as with the patients. Such situations may happen due to disease (such as the recent COVID-19 pandemic), geographical barriers and accessibility issues (Amir et al., 2020). It was found that limitations of dental training that requires physical contact may compromise students’ learning experience, thus affecting their competency, knowledge and confidence in patient care (Chang et al., 2021).

Meanwhile, it has become incumbent on dental education providers to prepare future graduates with essential skills that are deemed beneficial for practicing health care professionals. These skills include innovation, leadership, critical thinking and enterpreneurial abilities (Malaysian Dental Council, 2021). Acquisition of these abilities have been associated with many aspects of personal and professional development including emotional intelligence and practice management (Saleem et al., 2019; Wang et al., 2020).

In view of the various challenges and demands of the current (and future) educational environment and healthcare needs, an innovation-integrated educational approach was developed and adopted as an alternative teaching and learning method to teach SCD. This approach, undertaken mostly remotely using an online learning platform, involved the integration of students’ cognitive function, psychomotor ability, and affective skills through the development of innovative products to address oral health issues experienced by the different categories of patients with special health care needs. As a novel educational approach, assessment of its effectiveness is therefore essential. This study was undertaken to investigate students’ perceptions of the innovation-integrated learning, conducted remotely via an online platform, developed during the COVID-19 pandemic, as an alternative approach for SCD training.

II. METHODS

A. Study design

This was a descriptive, cross-sectional, quantitative and qualitative study, using a validated online feedback questionnaire involving the final-year undergraduate students of the Bachelor of Dental Surgery program of the Faculty of Dentistry, Universiti Teknologi MARA.

B. Study Population

Because this module is a compulsory component of the final-year undergraduate dental curriculum (Faculty of Dentistry, 2022), all students were required to be involved with the group innovation project. However, participation in the online feedback survey was voluntary. At the beginning of the semester, the students were made aware of the study and that their participation in the innovation program and the research were treated separately.

All students who agreed to participate in the online feedback survey provided informed consent, attached to the information sheet supplied to all potential participants via their official university email. To avoid coercion, students were provided with an explanation in the information sheet that their participation was entirely voluntary and anonymous. Those who wished not to participate in the online feedback survey would not be penalised, and they could withdraw their participation at any point without having to provide a justification.

C. Study Instrument

The questionnaire used for the online feedback survey was adopted from the study by Rowe and Wood (2008). It was content-validated by a panel of 2 experts in dental education before its use in the main survey. From the item-level content validatiy index (I-CVI) for each item as well as a summation of the I-CVI divided by the number of average (S-CVI/Ave), a  score of 1 was obtained for both indices as the  panelists rated all items with a score of 3 or 4. The questionnaire consisted of nine items about the perception of students towards this teaching method, measured using a 5-point Likert scale (strongly disagree, disagree, neutral, agree, and strongly agree). Open-ended questions were included at the end of the questionnaire to further explore students’ perceptions of the learning activities.

D. Study Conduct

For the group innovation project, all final-year students (n=90) were divided into eight groups, based on their assigned clinical groupings. Each group was assigned to an academic or clinical specialist in SCD, who acted as a supervisor. Eight categories of patients with special health care needs were identified and randomly allocated to the different groups. The categories of patients were 1) hearing disability, 2) speech disability, 3) visual disability, 4) geriatric, 5) Down syndrome, 6) autism, 7) cerebral palsy, and 8) dementia.

Students were given three months to develop innovative products. They were expected to engage with their supervisors during the whole development process, which involved 1) identification of health complications related to the condition and its impact on oral health, 2) understanding of issues related to patients’ oral health care; 3) creation of a prototype to address the related oral health–related complications. Because all students were at the time subjected to restrictions in having physical classes due to COVID-19 (Samat et al., 2020), large-group discussions and final presentations were undertaken remotely online.

At the end of this group activity, an online presentation, judged by experts in related fields, was conducted as a form of assessment, as well as constructive feedback on improvements and the marketability of the product. Students were then invited to participate in the online feedback questionnaire, which was distributed via their official university email. An English language questionnaire was used as the respondents were undergraduate dental students with a good command and understanding of the language. A reminder email was sent a week later, with another reminder sent the following week.

E. Data Analysis

To maximise the outcome, quantitative data were simplified into a 3-point Likert scale (agree, neutral, and disagree). Using SPSS version 27, the frequency of the data was analysed to compare students’ responses for each item. For analysis of the benefits, the nine items of the questionnaire were further categorised into different themes: Theme 1—Acceptance of the teaching method concept (Item 1), Theme 2—Effectiveness of teaching method (Items 2, 3, 6, and 7), Theme 3—Important role of supervisors (Items 4, 5, and 8), and Theme 4—Impact on students’ workload (Item 9).

For the qualitative component, data were analysed via thematic analysis involving open and closed coding. Emerging themes were then identified based on these codes, which were then validated through comparisons amongst researchers.

F. Ethical Approval

Ethics approval was obtained from the Research Ethics Committee (REC) Universiti Teknologi MARA, Malaysia, in accordance with the Declaration of Helsinki (REC12/2021 [MR 1004]).

III. RESULTS

A total of 82 out of 90 students returned the questionnaire, giving a response rate of 91.1%. The frequency of responses for each question or item, categorised into the different themes, is shown in Table 1.

Submitted: 30 January 2023
Accepted: 2 August 2023
Published online: 2 January, TAPS 2024, 9(1), 20-27
https://doi.org/10.29060/TAPS.2024-9-1/OA2999

Mitsumi Masuda, Naomi Kimura & Akemi Nakagaki

Graduate School of Nursing, Nagoya City University, Japan

Abstract

Introduction: The level of BLS achievement at the end of basic education is not clear, so to develop a BLS training program using QCPR Learner^Ⓡ and to verify its effectiveness.

Methods: A quantitative descriptive study design was used. The developed BLS program was implemented for 81 fourth-year students at the school of nursing. The program consisted of 2 minutes of training per student and real-time feedback by QCPR Learner^Ⓡ as well as feedback among students and from faculty members and was conducted twice for each student. Evaluation was conducted from three aspects: learner response and program evaluation both using questionnaires, learning achievement of QCPR score.

Results: The mean values of learners’ responses before and after the program were: attention, 4.32 before and 4.59 after; relevance, 4.48 before and 4.75 after; confidence, 2.32 before and 3.78 after; and satisfaction, 2.12 before and 3.41 after, which increased significantly after the program. The QCPR Learner^Ⓡ scores increased significantly from 74.08 for the first time to 86.76 for the second time. In the free response, some respondents stated that “visualisation of the procedure by the application improved my skills.”

Conclusion: The results of the evaluation from three aspects showed that this program was effective in improving students’ motivation to learn and skills.

Keywords:           Basic Life Support, Real-Time Feedback, Basic Nursing Education, Simulation Training, QCPR Learner

Practice Highlights

• Real-time feedback application was effective in increasing motivation to learn and BLS skills.
• QCPR Learner^Ⓡ can be easily installed on the learner’s device, making it suitable for self-learning.

I. INTRODUCTION

Submitted: 9 February 2023
Accepted: 15 May 2023
Published online: 3 October, TAPS 2023, 8(4), 23-35
https://doi.org/10.29060/TAPS.2023-8-4/OA3006

Sethapong Lertsakulbunlue¹, Kaophiphat Thammasoon², Kanlaya Jongcherdchootrakul³, Boonsub Sakboonyarat³ & Anupong Kantiwong¹

¹Department of Pharmacology, Phramongkutklao College of Medicine, Thailand; ²Department of Personnel Administration Division, Phramongkutklao College of Medicine, Thailand; ³Department of Military and Community Medicine, Phramongkutklao College of Medicine, Thailand

Abstract

Introduction: Although medical research (MR) is constantly promoted, a global deficit of medical researchers has been noted. We aimed to explore the relationship among practice, perceptions, attitudes, barriers and motivation toward MR and its impacts on MR publication.

Methods: A cross-sectional study included 262 senior medical students and interns. An electronic, standardised Likert scale questionnaire was used to collect the data. Binary logistic regression was used to determine the odds ratio between characteristics and MR publication. Confirmatory factor analysis was used to confirm the loading factor of each question, and structural equation modeling (SEM) was used to investigate the relationship between latent variables and MR publication.

Results: Cronbach’s alpha revealed a good internal reliability of 0.93. The accumulated grade point average did not differ between those who had published and those who had not. MR presentations were strongly associated with MR publication. SEM showed that attitudes (0.71, p<0.001) and perceptions (0.27, p<0.001) had a direct effect on practices. Practices (0.49, p<0.001) and attitudes (0.30, p<0.001) had a direct effect on motivation, while motivation had a total effect = 0.36, p<0.001 on MR publication through MR presentation as a mediator.

Conclusion: Positive attitudes and perceptions might lead to positivity in the intention to practice MR, which would lead to motivation and finally increase the odds of MR publication. Different approaches to promote excitement and perceptions in MR learning should be encouraged by teachers and faculty members.

Keywords:           Medical Research, Students, Perceptions, Attitudes, Barriers, Motivation

Practice Highlights

• Enjoyment and excitement should be promoted while learning medical research.
• Medical research experiences enhanced publication, particularly medical research presentations.
• Extracurricular medical research activities should be routinely promoted.
• Facilitators in medical research might be tailor-made for each individual.
• Regular meetings regarding medical research with mentors or role models should be held.