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

Jia Le Ivan Tan¹ & Sashikumar Ganapathy²

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

Abstract

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

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

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

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

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

Practice Highlights

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

I. INTRODUCTION

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

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

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

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

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

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

II. METHODS

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

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

A. Interview Questions

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

B. Interviews

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

C. Thematic Analysis

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

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

III. RESULTS

A. Participant Demographics

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

Table 1. Participant demographics (n=15)

Note: Shifts are 8 hours long.

B. Thematic Analysis

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

Table 2. Major themes in procedural skill maintenance

C. Conceptualisation of Procedural Skill Maintenance (PSM)

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

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

(interview 3)

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

(interview 5)

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

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

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

(interview 9)

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

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

(interview 6)

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

(interview 12)

D. General Motivation

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

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

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

(interview 1)

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

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

(interview 7)

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

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

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

(interview 11)

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

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

(interview 13)

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

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

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

(interview 11)

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

E. Barriers to Maintenance of Procedural Skills

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

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

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

(interview 10)

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

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

(interview 8)

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

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

(interview 2)

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

2) Lack of time:

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

(interview 1)

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

3) Lack of support:

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

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

(interview 4)

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

IV. DISCUSSION

A. Comparison to the Original Study

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

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

Table 3. Comparison of major themes

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

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

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

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

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

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

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

B. Challenges of Maintenance

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

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

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

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

C. Applications in KKH

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

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

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

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

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

D. Practical Recommendations

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

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

E. Limitations

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

V. CONCLUSION

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

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

Notes on Contributors

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

Ethical Approval

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

Data Availability

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

Acknowledgments

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

Funding

This study is not funded by any organisations.

Declaration of Interest

The authors have no potential conflicts to disclose.

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

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

Michiko Goto¹, Ryota Sakamoto², Hideki Wakabayashi³ & Yousuke Takemura⁴

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

Abstract

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

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

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

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

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

Practice Highlights

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

Figure 1. Scrubs in 15 different colours

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

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

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

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

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

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

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

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

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

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

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

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

B. Question 2

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

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

IV. DISCUSSION

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

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

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

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

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

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

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

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

A. Limitations

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

V. CONCLUSION

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

Notes on Contributors

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

Ethical Approval

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

Data Availability

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

Acknowledgements

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

Funding

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

Declaration of Interest

No conflict of interest, financial or otherwise, exists.

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

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

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

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

Abstract

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

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

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

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

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

Practice Highlights

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

Table 1. Response frequency for Likert-type questions

IV. DISCUSSION

A. Keeping Pace with the Digital World

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

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

B. Assessment Authenticity and Relevance

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

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

C. Challenges with Implementation

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

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

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

D. Study Limitations

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

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

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

E. Implications of a Virtual Approach

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

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

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

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

V. CONCLUSION

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

Notes on Contributors

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

Ethical Approval

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

Data Availability

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

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

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

Acknowledgement

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

Funding

The authors received no specific funding for this study.

Declaration of Interest

The authors report no conflicts of interest.

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

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

Mary XiaoRong Chen¹ & Dora Howes²

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

Abstract

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

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

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

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

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

Practice Highlights

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

III. RESULTS

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

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

Theme 1. Professionals with Knowledge and Moral Character

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

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

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

(S37)

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

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

(S44)

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

 (S08)

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

Theme 2. The Construction of Professional Identity

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

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

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

(S17)

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

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

(S17)

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

(S28)

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

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

(S63)

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

(S17)

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

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

(S64)

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

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

(S54)

IV. DISCUSSION

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

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

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

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

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

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

V. CONCLUSION

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

Notes on Contributors

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

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

Both authors read and approved the final manuscript.

Ethical Approval

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

Data Availability

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

Acknowledgement

We thank all student nurses who participated in the research.

Funding

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

Declaration of Interest

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

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

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.