Bridging the Gap Between Educator and Learner: The Role of Psychological Safety in Medical Education

Reframing morning report: Cognitive simulation in a safe space

BACKGROUND

Various purposes for morning report (MR), in addition to education, have been cited in the literature. Learners can find traditional MR challenging secondary to a perceived lack of psychological safety, the sense that they are being evaluated. Despite the recognition of unsafe learning environments, there is a paucity of literature on how to promote psychological safety in the MR setting.

APPROACH

Our aim was to create an MR format utilizing scientifically proven teaching strategies to enhance its educational value. The creation of a safe learning environment was at the forefront of this initiative. Using Kern's six steps of curriculum development, we describe one institution's experience in reframing the morning report experience.

RESULTS

We conducted a pilot trial of the new MR with 35 paediatric residents beginning in July 2020 and followed the resident experience over 2 years. The primary outcome was attitudinal data as measured via a Likert scale. We found that by the second-year post-curricular implementation, greater than 50% of residents were less hesitant to participate in conference, increased their practice of retrieval and perceived feeling more prepared for examinations as the curriculum progressed.

IMPLICATIONS

We believe the use of proven teaching strategies based in the cognitive psychology of learning can enhance the quality of education. Furthermore, we believe that central to the success of learning is the perception that the classroom is a safe space to be wrong. This model can serve as a steppingstone for institutions that look to improve their MR series.

Cased-based education rounds-the eternal heart of an international training program

Case-based teaching or "Morning Rounds" have been used in medical education for more than a century and remain a cornerstone for teaching in many training programs. Our Pediatric Critical Care Medicine (PCCM) program was established forty years ago and has retained this form of teaching since its inception. Case-based rounds have consistently had the highest evaluation of all curricula in our program. Here we review the history of how these rounds were introduced in medical education, provide data from the learners' evaluation of these case-based rounds, and discuss the strengths and potential drawbacks of this form of teaching from an educational theories perspective with the hope that they can be used by other Pediatric Critical Care training programs.

What the experts see: A qualitative analysis of the behaviors of master adaptive learners in emergency medicine

Objectives

The Master Adaptive Learner (MAL) model postulates that learners develop adaptive expertise through cycles of self-regulated learning. Despite a robust theoretical basis, the actual observable behaviors of MALs are not well characterized. We sought to define behaviors that characterize MALs within emergency medicine (EM) training.

Methods

Using a constructivist grounded theory approach, we analyzed semistructured interviews with expert EM educators. These experts reflected on observable behaviors as well as factors in the clinical learning environment that may modulate these behaviors. We recruited using purposive sampling until thematic saturation.

Results

We identified four overall themes, of which three described groups of learner behaviors and a fourth described modifiers of these behaviors. Learner behaviors include: (1) critical interrogation of practice, (2) intellectual risk-taking, and (3) intentional curation of a learning network. Critical interrogation of practice encompasses several observable behaviors including learner-driven feedback conversations, independent synthesis of clinical information, appropriate deviation from algorithms based on their conceptual understanding of core principles, intentional use of case variation and hypothetical questioning, and continuous refinement of decisions. MALs also engage in intellectual risk-taking for their development by communicating clinical decision-making processes even at the risk of being wrong, openly addressing errors and gaps, and intentionally seeking out uncomfortable experiences. Intentional curation of a learning network is the deliberate development of a consortium of trusted individuals who serve as mentors and sounding boards. We also identified a fourth theme related to the expression of learner behaviors: learning environment modulates behaviors. Active promotion of psychological safety is necessary for learners to express these behaviors. This safety is mediated through trusting relationships and expert supervisors who serve as colearners and role models.

Conclusions

We present several behaviors that allow identification of MALs among EM trainees. These data expand our understanding of MALs and the critical influence of the learning environment. Identification of these behaviors may allow for more precise categorization of targeted curricular interventions and meaningful learning outcomes.

Optimizing clinical care and training in the neonatal intensive care unit: the relationship between front line providers and physician trainees

Changes in neonatal intensive care unit (NICU) coverage models, restrictions in trainee work hours, and alterations to the training requirements of pediatric house staff have led to a rapid increase in utilization of front-line providers (FLPs) in the NICU. FLP describes a provider who cares for neonates and infants in the delivery room, nursery, and NICU, and includes nurse practitioners, physician assistants, and/or hospitalists. The increasing presence and responsibility of FLPs in the NICU have fundamentally changed the way patient care is provided as well as the learning environment for trainees. With these changes has come confusion over role clarity with resulting periodic conflict. While staffing changes have addressed a critical clinical gap, they have also highlighted areas for improvement amongst the teams of NICU providers. This paper describes the current landscape and summarizes improvement opportunities with a dynamic neonatal interprofessional provider team.

Faculty bridging individual and organizational resilience: results of a qualitative analysis

BACKGROUND

Medical student burnout and anxiety has received growing attention in the past decade. The culture of competition and assessment has resulted in increasing stress levels amongst medical students, causing a decline in their academic performance and overall mental health. The objective of this qualitative analysis was to characterize recommendations from educational experts to aid students' academic progress.

METHODS

At an international meeting in 2019, worksheets were completed by medical educators during a panel discussion. Participants responded to four scenarios representing common challenges medical students face in school (eg. Postponing Step 1, failing clerkships, etc.). For each case, participants addressed what students, faculty and medical schools could do to mitigate the challenge. Inductive thematic analysis was conducted by two authors followed by deductive categorization using an individual-organizational resilience model.

RESULTS

Across the four cases, common suggestions made for students, faculty and medical schools were aligned to a resilience model representing the complex interplay between individuals and organizations and the impact on student wellbeing.

DISCUSSION

Using suggestions from medical educators from across the US, we were able to identify recommendations for students, faculty, and medical schools to help students succeed in medical school. By applying a model of resilience, faculty serve as a critical bridge to connect students to the medical school administration. Our findings also support a pass/fail curriculum to ease the competition and burden students place on themselves.

Shared Reading as a Community of Practice for Overcoming the Generation Gap and Improving Psychological Safety in Rural Family Medicine Education: A Grounded-Theory Approach

Background A community of practice (CoP) is essential for continuous professional development in family medicine. A CoP in medical education comprises a group of individuals who share common interests and learn and share knowledge, skills, and attitudes. The generation gap between teachers and learners can influence their effective collaboration in family medicine education. To address this issue, shared reading, which involves group discussions on medical texts, effectively promotes intergenerational learning within a CoP. Shared reading is particularly beneficial in rural contexts, where medical resources are scarce, and the generation gap between teachers and learners is wide. This study examines how shared reading facilitates learning and practice among family medicine trainees in rural areas. Methods This qualitative study utilized a grounded-theory approach. It involved the participation of eight family medicine residents, five junior residents, and seven medical students from Unnan City Hospital, Japan, in shared reading sessions between August 2022 and March 2023. Semi-structured interviews were conducted with all participants after the sessions. Results Data analysis using the grounded-theory approach yielded three themes: facilitating learning and motivation, respectful collaboration with teachers, and developing a relationship that fosters psychological safety. First, through shared reading, the participants had opportunities to learn about medical issues and engage in continual dialogues with colleagues and teachers. Second, the participants felt motivated to apply their newly acquired knowledge at work and collaborate with teachers. Third, they acquired self-regulated learning skills by adapting their motivations to their interests and experiences. Increased interaction between participants and teachers during the sessions helped mitigate the generation gap and enhanced psychological safety. Conclusions Shared reading effectively promotes continuous learning and motivates medical learners to apply their knowledge and collaborate with teachers. It facilitates the development of self-regulated learning skills, helps mitigate the generation gap, and enhances psychological safety among educators and learners in rural medical education.

Learning Clinical Reasoning: The Experience of Postgraduate Psychiatry Trainee Doctors in Qatar

Phenomenon: As a core competency in medical education, clinical reasoning is a pillar for reducing medical errors and promoting patient safety. Clinical reasoning is a complex phenomenon studied through the lens of multiple theories. Although cognitive psychology theories transformed our understanding of clinical reasoning, the theories fell short of explaining the variations in clinical reasoning influenced by contextual factors. Social cognitive theories propose a dynamic relationship between learners' cognitive process and their social and physical environments. This dynamic relationship highlights the essential role of formal and informal learning environments for learning clinical reasoning. Approach: My research aimed to explore the personal experience of learning clinical reasoning in a sample of postgraduate psychiatry trainee doctors using cognitive psychology and social cognitive theories. A stratified convenience sample of seven psychiatry trainee doctors working in the Mental Health Services in Qatar completed semi-structured interviews in 2020. I analyzed the data manually using theoretical thematic analysis. Findings: I identified three overarching themes with multiple subthemes. The first theme was the hierarchical cultural impact on perceived learning opportunities and learning behavior. The first theme had two subthemes that explored the relationship with team members and the expected hierarchy roles. The second theme was the impact of emotions on the learning and execution of clinical reasoning.The second theme had three subthemes that explored the personal approach to managing emotions related to perceived self-efficacy and professional image. The third theme was characteristics of learning environments and their role in learning clinical reasoning. The last theme included three subthemes that explored stressful, autonomous, and interactive environments. Insights: The results accentuate the complexity of clinical reasoning. Trainees' experience of learning clinical reasoning was influenced by factors not controlled for in the curricula. These factors constitute a hidden curriculum with a significant influence on learning. Our local postgraduate training programmes will benefit from addressing the points raised in this study for effective and culturally sensitive clinical reasoning learning.

Investigating preceptor experiences with cultural intelligence in pharmacy education

BACKGROUND

A culturally intelligent pharmacy workforce is critical for addressing health disparities and ensuring that healthcare teams are equipped to support the medication needs of patients. Despite the critical role of preceptors in developing aspiring pharmacists, little is known about how they create or manage cross-cultural situations for students.

OBJECTIVE

The objective of this study was to explore preceptor experiences teaching cultural intelligence within experiential pharmacy settings.

METHODS

A convergent parallel mixed methods approach was used with a 10-item survey measuring preceptor teaching self-efficacy (measured from 0-cannot do at all to 10-highly certain can do) and interviews/focus groups to further understand cultural intelligence teaching experiences. Data were analyzed according to the 4 domains of the cultural intelligence framework (i.e., cultural awareness, cultural knowledge, cultural practice, and cultural desire). Survey data were analyzed descriptively and qualitative data were analyzed deductively.

RESULTS

Participants (n = 24) were most confident Discussing factors underlying health and healthcare disparities (e.g., access, socioeconomic status, environment, racial/ethnic) (7.54 ± 2.04) and least confident in Understanding the importance of cultural desire in teaching students to be culturally intelligent healthcare practitioners (5.21 ± 2.72). All four cultural intelligence domains were identified in the qualitative data (n = 315 codes), with preceptors providing evidence of cultural awareness (n = 38, 12.1%), cultural knowledge (n = 54, 17.1%), cultural practice (n = 183 codes, 58.1%), and cultural desire (n = 40, 12.7%). Preceptors described various pedagogical strategies, such as case discussions, reflection, and simulation.

CONCLUSIONS

Participants provided insight into pedagogical strategies for cultural intelligence that could promote student learning in experiential settings and help explicate curricular gaps. Further research regarding applicability of the cultural intelligence framework is needed, including application of these strategies and opportunities for preceptor development.

A Qualitative Study of Pediatric Residents' Experiences at Morning Report

Objectives

Morning Report is a prevalent classroom learning activity in residency programs. Yet, its contribution to resident education remains unclear. Our objective was to explore pediatric residents' perceptions of the purpose of Morning Report as well as their experiences at Morning Report both as learners and resident presenters.

Methods

We performed a qualitative study with a grounded theory approach using semi-structured focus groups of pediatric residents (November 2016-July 2017) from a large academic health center. We analyzed data with the constant comparative method, generating codes using an iterative approach and collecting data until reaching saturation. We identified major themes and resolved disagreements by consensus.

Results

Twenty-six residents participated in five focus groups. Data analysis yielded four themes: Morning Report is Multipurpose, Socialization and Engagement Influence the Learning Environment, Potential for Emotional Discomfort, and Barriers to Prioritizing Morning Report Attendance. Residents felt the primary purpose of Morning Report was acquiring medical knowledge, but also acknowledged Morning Report's added benefits of providing an opportunity for socialization and a mental reprieve before work rounds. Residents felt Morning Report was educational when engaged in interactive discussion; however, it was challenging to meet the differing needs in this mixed learner level format. Some resident learners were hesitant to participate due to fears of being judged, and some resident presenters perceived a need to be topic experts. Clinical responsibilities and exhaustion following busy service rotations often precluded Morning Report attendance.

Conclusion

Pediatric residents described numerous purposes of Morning Report, including opportunities for valuable learning. Self-perceived learning was positively influenced by engagement and a sense of connection and challenged by emotional discomfort at times. Future work can explore how to best promote engagement and foster a safe learning environment.

The Influence of Psychological Safety on Students' Creativity in Project-Based Learning: The Mediating Role of Psychological Empowerment

Creative-oriented new educational model will shape the direction and appearance of world development. This study focuses on the role of psychological safety and psychological empowerment in improving students' creativity in the context of project-based learning from the perspective of student empowerment. Based on self-determination theory, we propose that psychological safety positively affects students' creativity through psychological empowerment, and fault-tolerant culture plays a positive role in it. In this study, 238 students who participated in project-based learning were randomly selected to conduct a questionnaire survey. The results show that there is a positive correlation between psychological safety and creativity, and psychological empowerment plays an intermediary role in the relationship between them. The fault-tolerant culture enhances the direct influence of psychological safety on psychological empowerment and the indirect influence of psychological safety on creativity. Theoretical and practical implications were also discussed.

The science of education: using learning theory to solve teaching problems in medical education

Although theories do not play a major role in clinical medicine, the application of established theories of education can improve medical teaching. By understanding and harnessing learning theories, clinician educators can solve common teaching problems, thoughtfully craft their teaching sessions, determine whether learners or residents have achieved the intended learning objectives, and even earn higher course ratings. Key theories to be aware of include cognitive load theory, social learning theory, experiential learning, constructivism, humanism, behaviourism and connectivism. Various teaching problems are presented, along with explanations rooted in educational theory and possible solutions for use in the clinical educational setting.

Students-As-Teachers: Fostering medical educators

BACKGROUND

While mounting evidence supports various benefits of Students-As-Teachers (SAT) curricula in preparing students to teach, limited SAT electives are offered across Canada. We developed a 4-week SAT selective for fourth-year medical students at the University of Toronto to enhance medical education knowledge and teaching skills. This study aimed to evaluate the SAT programme and its impact on students' development as educators, their experience as learners and educators, and their future plans for involvement with medical education.

APPROACH

Students participated in highly interactive small group seminars and teaching opportunities in nonclinical and clinical environments. Course evaluation consisted of pre-selective and post-selective surveys and written reflections on the selective experience and future career aspirations. A theory-based evaluation approach was utilized to compare the SAT programme's theory with course outcomes.

EVALUATION

Post-SAT selective, students self-reported greater knowledge and confidence in teaching methods, provision of feedback, medical education scholarship, and interest in further medical education training. Student reflections highlighted three key themes. Identity formation as educators and the importance of mentorship in medical education aligned with our programme theory, while an unexpected outcome included a shifting perception on teaching and feedback from a learner to an educator lens.

IMPLICATIONS

This study's findings demonstrate the ability of SAT curricula to build capacity for future medical educators. Positive factors contributing to the programme's outcomes included cohort size, course and seminar structure, and active group participation. Future iterations may explore use of flipped classroom models, additional clinical teaching opportunities, and near-peer teaching.