Change is never easy: How management theories can help operationalise change in medical education

Advancing collaboration in health professions education in the general practice domain, developing a national research agenda

BACKGROUND

Health professions education (HPE) research in the General Practice domain (GP-HPE) is vital for high-quality healthcare. Collaboration among GP-HPE researchers is crucial but challenging. Formulating a research agenda, involving stakeholders, and fostering inter-institutional collaboration can address these challenges and connect educational research and practice.

METHODS

We used Q-methodology to explore perspectives on GP-HPE research of participants from all Dutch postgraduate GP training institutes. Participants individually sorted statements based on the relevance of future GP-HPE research for educational practice. Data analysis comprised inverted factor analysis, rotation, and qualitative interpretation of configurations of all statements. The National Meeting on Educational Research took a participatory approach.

RESULTS

We included 73 participants with diverse involvement in GP-HPE research. We identified five distinct perspectives, each representing a research focus area for developing and innovating GP education: the clinician scientist, the socially engaged GP, the specific GP identity, the GP as an entrepreneur, and the GP engaged in lifelong learning.

DISCUSSION

The resulting five perspectives align with General Practice hallmarks. Q-methodology and a participatory approach facilitated collaboration among stakeholders. Successful inter-institutional collaboration requires a common goal, neutral leadership, participant commitment, regular meetings, audit trail support, process transparency, and reflexivity. Future research should address evidence gaps within these perspectives.

CONCLUSION

Using Q-methodology turned out to be valuable for compiling a national research agenda for GP-HPE research. The research process helped to cross boundaries between researchers in different institutions, thus putting inter-institutional collaborative advantage center stage. Our approach could provide a conceivable procedure for HPE researchers worldwide.

Identity conflicts of student affairs officers in a medical university

INTRODUCTION

Collaboration between student affairs officers and the faculty is important in dealing with the recent rapid changes in medical education, and mutual understanding is essential to ensure that participants become a cohesive social group. This study explores the identity conflicts of student affairs officers in medical universities using the figured worlds theory.

METHODS

An exploratory qualitative case study was conducted with 24 student affairs officers at a private medical university in Japan. Data were collected through face-to-face, semi-structured interviews and analysed using thematic analysis from the perspective of a social constructivism paradigm.

RESULTS

Qualitative analysis revealed the following three themes regarding the identity conflicts of student affairs officers: differences in the perception of medical students, difficulties in building trusting relationships with the faculty, and resistance to the medical university's traditional atmosphere. Student affairs officers tended to provide support from a student-centred perspective when interacting with medical students, while the faculty employed a teacher-centred perspective.

DISCUSSION

To promote understanding between professions, it is necessary to set aside certain professional views and welcome dialogue with other professionals with different values, while also understanding the multi-layered context of medical education, so that conflicts can be handled optimally and relationships can be professionalised for social cohesion.

Using Group Concept Mapping to Explore Medical Education's Blind Spots

PHENOMENON

All individuals and groups have blind spots that can lead to mistakes, perpetuate biases, and limit innovations. The goal of this study was to better understand how blind spots manifest in medical education by seeking them out in the U.S.

APPROACH

We conducted group concept mapping (GCM), a research method that involves brainstorming ideas, sorting them according to conceptual similarity, generating a point map that represents consensus among sorters, and interpreting the cluster maps to arrive at a final concept map. Participants in this study were stakeholders from the U.S. medical education system (i.e., learners, educators, administrators, regulators, researchers, and commercial resource producers) and those from the broader U.S. health system (i.e., patients, nurses, public health professionals, and health system administrators). All participants brainstormed ideas to the focus prompt: "To educate physicians who can meet the health needs of patients in the U.S. health system, medical education should become less blind to (or pay more attention to) …" Responses to this prompt were reviewed and synthesized by our study team to prepare them for sorting, which was done by a subset of participants from the medical education system. GCM software combined sorting solutions using a multidimensional scaling analysis to produce a point map and performed cluster analyses to generate cluster solution options. Our study team reviewed and interpreted all cluster solutions from five to 25 clusters to decide upon the final concept map.

FINDINGS

Twenty-seven stakeholders shared 298 blind spots during brainstorming. To decrease redundancy, we reduced these to 208 in preparation for sorting. Ten stakeholders independently sorted the blind spots, and the final concept map included 9 domains and 72 subdomains of blind spots that related to (1) admissions processes; (2) teaching practices; (3) assessment and curricular designs; (4) inequities in education and health; (5) professional growth and identity formation; (6) patient perspectives; (7) teamwork and leadership; (8) health systems care models and financial practices; and (9) government and business policies.

INSIGHTS

Soliciting perspectives from diverse stakeholders to identify blind spots in medical education uncovered a wide array of issues that deserve more attention. The concept map may also be used to help prioritize resources and direct interventions that can stimulate change and bring medical education into better alignment with the health needs of patients and communities.

When theory meets reality- a mismatch in communication: a qualitative study of clinical transition from communication skills training to the surgical ward

BACKGROUND

Communication skills training in patient centered communication is an integral part of the medical undergraduate education and has been shown to improve various components of communication. While the effects of different educational interventions have been investigated, little is known about the transfer from theoretical settings to clinical practice in the context of communication skills courses not integrated in the clinical curriculum. Most studies focus on single factors affecting transfer without considering the comprehensive perspective of the students themselves. The aim of this study is to explore how the students experience the transition to clinical practice and what they perceive as challenges in using patient centered communication.

METHODS

Fifteen 4th year medical students were interviewed 3 weeks after the transition from an advanced communication skills course to surgical internship using semi-structured interviews. Qualitative content analysis was used to analyze the interviews.

RESULTS

The analysis resulted in a theme 'When theory meets reality- a mismatch in communication'. It was comprised of four categories that encompassed the transfer process, from theoretical education, practical communication training and surgical internship to students' wishes and perceived needs.

CONCLUSIONS

We concluded that preparing the students through theoretical and practical training should reflect the reality they will face when entering clinical practice. When educating medical students as a group, their proclivity for perfectionism, high performance environment and achievement-related stress should be taken into consideration. The role of tutors being role models, offering guidance, giving feedback and providing support plays a major part in facilitating transfer of communication skills. To enable transfer to a larger extent, the environment needs to promote patient centeredness and students need more opportunities to practice communication with their patients.

Factors That Enhance and Hinder the Retention and Transfer of Online Pre-Clinical Skills Training to Facilitate Blended Learning

Purpose

During the SARS-CoV-2 pandemic, various online instructional strategies in clinical skills training were piloted. The sudden transition to the remote platform circumvented the rigorous planning associated with curriculum reform. This study aimed to explore students' and tutors' perceptions of factors that promoted or hindered successful learning transfer and to propose a blended conceptual model to guide affective, cognitive, and psychomotor clinical skills training in the pre-clinical phase of medical education.

Methods

A mixed-method quasi-experimental study assessed third-year students' transfer of clinical skills and knowledge following online learning in 2021. Students and their tutors completed online surveys that included open and closed-ended questions regarding factors influencing their experience of the adapted teaching methods. Descriptive statistical analysis was used for the quantitative data. Qualitative responses were thematically analyzed.

Results

One hundred fourteen students (48%) and seven tutors (100%) responded to the surveys. The questionnaires' internal consistency and construct validity were determined using Cronbach's α-Coefficient. There was an overall positive response (86%) to the acceptability of the online platform in clinical skills training. Using online simulations with targeted onsite practice was reported as effective in clinical skills training. Tutors perceived students as well-prepared for the skills laboratory. Five emergent themes, qualified by a linear model of asynchronous and synchronous online and onsite teaching with the evaluation of the instructional design and institutional support, informed the proposed blended learning guide for clinical skills training in the pre-clinical phase.

Conclusion

Blended clinical skills learning that included the flipped classroom concept was well-accepted. Virtual patients proved a convenient cognitive preparation tool for skills training and potentially optimized teaching delivery. The study found that the adapted teaching frameworks incorporating an online clinical skills component into a modified onsite curriculum augmented learners' ability to transfer knowledge to the clinical skills laboratory. An integrated five-step blended model is proposed for future interventions.

Examining the nexus between medical education and complexity: a systematic review to inform practice and research

BACKGROUND

Medical education is a multifarious endeavour integrating a range of pedagogies and philosophies. Complexity as a science or theory ('complexity') signals a move away from a reductionist paradigm to one which appreciates that interactions in multi-component systems, such as healthcare systems, can result in adaptive and emergent outcomes. This examination of the nexus between medical education and complexity theory aims to discover ways that complexity theory can inform medical education and medical education research.

METHODS

A structured literature review was conducted to examine the nexus between medical education and complexity; 5 databases were searched using relevant terms. Papers were included if they engaged fully with complexity as a science or theory and were significantly focused on medical education. All types of papers were included, including conceptual papers (e.g. opinion and theoretical discussions), case studies, program evaluations and empirical research. A narrative and thematic synthesis was undertaken to create a deep understanding of the use of complexity in medical education.

RESULTS

Eighty-three papers were included; the majority were conceptual papers. The context and theoretical underpinnings of complexity as a relevant theory for medical education were identified. Bibliographic and temporal observations were noted regarding the entry of complexity into medical education. Complexity was relied upon as a theoretical framework for empirical studies covering a variety of elements within medical education including: knowledge and learning theories; curricular, program and faculty development; program evaluation and medical education research; assessment and admissions; professionalism and leadership; and learning for systems, about systems and in systems.

DISCUSSION

There is a call for greater use of theory by medical educators. Complexity within medical education is established, although not widespread. Individualistic cultures of medicine and comfort with reductionist epistemologies challenges its introduction. However, complexity was found to be a useful theory across a range of areas by a limited number of authors and is increasingly used by medical educators and medical education researchers. This review has further conceptualized how complexity is being used to support medical education and medical education research.

CONCLUSION

This literature review can assist in understanding how complexity can be useful in medical educationalists' practice.

Flipped Classroom to Facilitate Deeper Learning in Veterinary Undergraduate Students: An Educational Change Pilot Study Limited to the Imaging Module Bones

In a flipped classroom, learners study at home and do the 'homework' in class. This approach respects the limitations of memory and allows more interaction between learners. The overall vision is self-paced activities for learners with decreased boredom and greater task value, which should facilitate deeper learning. To implement a flipped classroom, a bumpy incremental change process characterized by periods of relative stillness punctuated by the acceleration of pace was planned. All veterinary undergraduate students used an existing eLearning platform to access relevant text and selected image examples before class. Only for the randomly selected students in the flipped classroom (FC) was this content amended with purposeful audio content and concrete tasks. Further, FC learners discussed their opinions in an online class forum. To measure the educational change, a pre- and post-class formative test and a standardized questionnaire for students in the FC versus in the traditional classroom (TC) were performed. To assess engagement, students were invited to measure all learning activities, categorized into attendance, or self-study. The educational change project resulted in more commitment and less resistance from teachers. The FC consisted of 20 students, while the TC had 40. The mean pre-class scores difference between FC students and TC students was +1.7/20 points, and the mean post-class scores difference was +3/20 points. The chance of answering item 10 of the formative test (describe site of the fracture) correctly was about seven times higher for FC compared to TC learners (OR = 6.96; p = 0.002). The questionnaire revealed more satisfaction and greater task value in the FC compared to TC (p = 0.048). FC students invested 21 h into the course on average, while TC students invested 16 h. The results of this pilot agree with previous reports: A transparent process was helpful to initiate mainly positive interactions between teachers and students. Higher scores, higher chance to give the correct answer, greater task value, and more positive emotions are observed in the FC compared to the TC. Higher measures of learning time are not expected to affect exam results but indicate more engagement.

Chameleon Leadership and Innovative Behavior in the Health Sector: The Mediation Role of Job Security

The primary aim of the current study is to identify the effect of chameleon leadership behaviors on the innovative behavior of staff in the health sector in the Sultanate of Oman, and examining if job security plays a mediating role in the relationship between chameleon leadership and innovative behavior. Data were collected using a questionnaire consisting of 282 employees working in healthcare organizations in Oman. The PLS-SEM methodology was performed used to test the proposed hypotheses. The results indicated that chameleon leadership behaviors (external control, and relativistic beliefs) have no effect on innovative behavior but have a positive effect of external control on job security. Moreover, job security has a direct positive impact on innovative behavior. In addition, the results showed that job security is not a factor in the relationship between chameleon leadership behaviors and innovative behavior. The study contributes to providing a deferent perspective to explore the behaviors of chameleon leadership in the Omani health sector to provide security and accelerating innovative systems to support a stable work environment.

Faculty development participants' experiences of working with change in clinical settings

OBJECTIVES

Many universities offer faculty development to support teachers in developing and improving clinical education in the health professions. Although research shows outcomes on individual levels after faculty development, little is known about its contribution to change within the organisation. To advance current faculty development and ensure that it can support wider educational change in healthcare organisations, a better understanding of educational change practices in these settings is needed. This study therefore explores the experiences of working with educational change in clinical workplaces from the perspective of clinical educators that have undergone faculty development training. The study adopts perspectives on change as influenced by context to include the impact from clinical workplaces on individuals' change work.

METHODS

A collective case study design with a multi-institutional approach was applied and individual interviews with 14 clinical educators from two universities, one in Sweden and one in South Africa, were conducted. Data were analysed separately before a cross-case analysis was performed, synthesising the findings from both sites.

FINDINGS

Participants shared experiences of having limited opportunities to work with educational change beyond their own individual teaching practices within their clinical workplaces. Also, participants appeared to refrain from leading change and rather pursued change on their own or relied on indirect approaches to change. They described several workplace aspects influencing their work, including the organisation and management of teaching, the resources and incentives for teaching and the attitudes and beliefs about teaching within the clinical community.

CONCLUSIONS

The study shows that clinical educators are part of communities and contexts that shape their approaches to educational change and influence which changes are feasible and which ones are not. It thus adds to the understanding of change as contextual and dynamic and contributes with implications for how to advance faculty development to better support change in practice.

A comparative analysis of the impact of online, blended, and face-to-face learning on medical students' clinical competency in the affective, cognitive, and psychomotor domains

BACKGROUND

The Coronavirus Disease-2019 (COVID-19) pandemic in South Africa compelled medical schools to switch to a purely online curriculum. The innovative changes transformed the standard clinical skills curriculum to increase learning transfer to bridge the theory-practice gap. The efficacy of this intervention remains unknown. This study aims to measure medical students' clinical competency in the affective, cognitive, and psychomotor domains by assessing clinical skills knowledge retention and transfer from the online platform compared to face-to-face and blended learning.

METHODS

A non-random cross-sectional quasi-experimental study assessed third-year medical students' knowledge retention and learning transfer in three domains of clinical skills competence. Data were obtained using a score sheet during a directly observed formative and a trial online summative assessment. One hundred and one third-year medical students volunteered for the formative onsite assessment that tested the psychomotor domain. Two hundred and thirty-nine students were evaluated on the affective and cognitive domains in the summative online trial mini-objective structured clinical examination (tm-OSCE). The OSCE scores were analysed using descriptive statistics. The significance of the findings was evaluated by comparing OSCE scores with the pre-pandemic 2019 third-year medical students.

RESULTS

Statistically significant differences were found between the two cohorts of medical students from both years (p < 0.05). The 2021 blended group's (n = 101) medians were 90%, 95%CI [86, 92], 82%, 95%CI [80, 85], and 87%, 95% CI [84, 90] for the psychomotor, affective, and cognitive skills, respectively. The e-learning group's affective and cognitive skills medians were 78%, 95%CI [73, 79] and 76%, 95%CI [71, 78], respectively. The 2019 face-to-face cohort (n = 249) achieved medians of 70%, 95% CI [69, 72] and 84%, 95%CI [82, 86] for the affective and psychomotor skills, respectively.

CONCLUSION

Medical students demonstrated near and far transfer bridging the theory-practice gap in three clinical skills domains. The blended group performed significantly better than the e-learning and face-to-face groups. Medical schools and educators play a vital role in overcoming learning challenges and achieving higher transfer levels by adopting multiple student-centered teaching delivery approaches and arranging immediate application opportunities. This study offers medical educators suggestions that encourage the transfer of online learning to face-to-face practice, decentralising medical education with a revised blended learning strategy.

Inpatient teaching with a clinical review game

BACKGROUND

Shortened preclinical curricula, social distancing policies and the fast-paced nature of inpatient medicine make clinical education challenging. Crowdsourced learning and a review game derived from real-time patient cases can offer an engaging solution for inpatient teaching.

APPROACH

We implemented a clinical review game with 67 participants (10 physician instructors, 40 residents and 17 medical students) rotating through the adult inpatient medicine service at an academic medical centre from July 2018 through July 2020. During 2-week rotations, participants identified shareable teaching points about their patients on rounds. Teaching points were compiled by an instructor into a 30-minute end-of-rotation review game formatted from a free gameshow-based PowerPoint template. After the review game was completed, learners were then asked to complete end-of-rotation evaluations.

EVALUATION

Learners were surveyed on their educational experience, and teaching point submissions were studied. After eight rotations, 39 participants (39/67 = 58.2% response rate) submitted a total of 268 teaching points, and nearly half of which were from learners (n = 131 [48.9%]). In the review game, 35 residents and 17 medical students participated and correctly answered 80% of questions. Learner evaluations highlighted the activity strengths including self-directed learning, peer teaching from primary literature and a warm, collaborative educational environment.

IMPLICATIONS

Our crowdsourced clinical review game approach helped to highlight clinically relevant content for teaching rounds, build a collaborative culture across trainee levels and encourage self-study for trainees to stay informed with current evidence-based practice, even during pandemic restrictions.

An international study on the implementation of programmatic assessment: Understanding challenges and exploring solutions

INTRODUCTION

Programmatic assessment is an approach to assessment aimed at optimizing the learning and decision function of assessment. It involves a set of key principles and ground rules that are important for its design and implementation. However, despite its intuitive appeal, its implementation remains a challenge. The purpose of this paper is to gain a better understanding of the factors that affect the implementation process of programmatic assessment and how specific implementation challenges are managed across different programs.

METHODS

An explanatory multiple case (collective) approach was used for this study. We identified 6 medical programs that had implemented programmatic assessment with variation regarding health profession disciplines, level of education and geographic location. We conducted interviews with a key faculty member from each of the programs and analyzed the data using inductive thematic analysis.

RESULTS

We identified two major factors in managing the challenges and complexity of the implementation process: knowledge brokers and a strategic opportunistic approach. Knowledge brokers were the people who drove and designed the implementation process acting by translating evidence into practice allowing for real-time management of the complex processes of implementation. These knowledge brokers used a 'strategic opportunistic' or agile approach to recognize new opportunities, secure leadership support, adapt to the context and take advantage of the unexpected. Engaging in an overall curriculum reform process was a critical factor for a successful implementation of programmatic assessment.

DISCUSSION

The study contributes to the understanding of the intricacies of implementation processes of programmatic assessment across different institutions. Managing opportunities, adaptive planning, awareness of context, were all critical aspects of thinking strategically and opportunistically in the implementation of programmatic assessment. Future research is needed to provide a more in-depth understanding of values and beliefs that underpin the assessment culture of an organization, and how such values may affect implementation.

Safeguarding fairness in assessments-How teachers develop joint practices

INTRODUCTION

In light of reforms demanding increased transparency of student performance assessments, this study offers an in-depth perspective of how teachers develop their assessment practice. Much is known about factors that influence assessments, and different solutions claim to improve the validity and reliability of assessments of students' clinical competency. However, little is known about how teachers go about improving their assessment practices. This study aims to contribute empirical findings about how teachers' assessment practice may change when shared criteria for assessing students' clinical competency are developed and implemented.

METHODS

Using a narrative-in-action research approach grounded in narrative theory about human sense-making, one group including nine health professions teachers was studied over a period of 1 year. Drawing upon data from observations, interviews, formal documents and written reflections from these teachers, we performed a narrative analysis to reveal how these teachers made sense of experiences associated with the development and implementation of joint grading criteria for assessing students' clinical performances.

RESULTS

The findings present a narrative showing how a shared assessment practice took years to develop and was based on the teachers changed approach to scrutiny. The teachers became highly motivated to use grading criteria to ensure fairness in assessments, but more importantly, to fulfil their moral obligation towards patients. The narrative also demonstrates how these teachers reasoned about dilemmas that arose when they applied standardised assessment criteria.

DISCUSSION

The narrative analysis shows clearly how teachers' development and application of assessment standards are embedded in local practices. Our findings highlight the importance of teachers' joint discussions on how to interpret criteria applied in formative and summative assessments of students' performances. In particular, teachers' different approaches to assessing 'pieces of skills' versus making holistic judgements on students' performances, regardless of whether the grading criteria are clear and well-articulated on paper, should be acknowledged. Understanding the journey that these teachers made gives new perspectives as to how faculty can be supported when assessments of professionalism and clinical competency are developed.

How can inhabited institutionalism inform the analysis of medical education?

CONTEXT

Medical schools are complex organisations existing at the intersection of higher education and healthcare services. This complexity is compounded by many competing pressures and drivers from professional and regulatory bodies, the wider political environment and public expectations, producing a range of challenges for those involved in all stages of medical education. There are established approaches that have been used to address research questions related to these challenges; some focus on organisational structures, characteristics and performance; others on the interactions that take place in a particular setting. Less common are approaches that integrate data on macro-level structures with the micro-level interactions of the people who inhabit those structures. Looking at the interaction of the macro and the micro opens up possibilities for the new insights.

FRAMEWORK

We propose using an approach with roots in social theory-Inhabited Institutionalism (II)-that is largely unexplored in medical education. II has been described as Janus-faced, looking both outwards, at the broader context of medical education, and inwards, at the ways in which meanings are constructed and re-constructed by participants within a particular setting.

METHODS

After describing the theoretical framework of II, we explain how it can be used to understand medical education as subject to both broader societal structures (the macro level) and interactions between people (the micro level), as well as-crucially-their mutual influence.

CONCLUSION

II offers the opportunity to combine macro- and micro-level perspectives, leading to a more expansive understanding of the operation of medical education which sees its form and function as neither entirely determined by structures nor a construction of individuals engaged in it. In doing so, it potentially offers a valuable way of considering the intractable problem of how to successfully manage change, offering a combined top-down and bottom-up perspective.

Main challenges to international student mobility in the European arena

This study analyses international student mobility (ISM) in Europe since the 1999 Bologna Declaration. International mobility of higher education students is both a driver and a consequence of the Bologna Process and emerges as a relevant issue in a wide range of research areas. This literature review develops a qualitative content analysis of the set of high-performance articles published between 2000 and 2018 and identified through a wide range of bibliometric tools: direct (first generation) citation counts; indirect or accumulated impact; early influence; adjusted impact with respect to year of publication, type of document, and discipline; and alternative metrics that measure interactions in the internet and social media. The content analysis focuses on the pending achievements and main challenges to ISM, among them: attracting non-European students to whole degree programs, the need for actual and further convergence in programs and systems to ensure real compatibility, the impact of HE ISM on the promotion of the European citizenship and consciousness, the sharp imbalance between credit and degree mobility, the need to strengthen the link between ISM and employability, the existing social selectivity in European ISM, the frequent social segregation problems faced by international students.