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Kikukawa M, Stalmeijer R, Matsuguchi T, Oike M, Sei E, Schuwirth LWT, Scherpbier AJJA. How culture affects validity: understanding Japanese residents' sense-making of evaluating clinical teachers. BMJ Open 2021; 11:e047602. [PMID: 34408039 PMCID: PMC8375773 DOI: 10.1136/bmjopen-2020-047602] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/29/2022] Open
Abstract
OBJECTIVES Traditionally, evaluation is considered a measurement process that can be performed independently of the cultural context. However, more recently the importance of considering raters' sense-making, that is, the process by which raters assign meaning to their collective experiences, is being recognised. Thus far, the majority of the discussion on this topic has originated from Western perspectives. Little is known about the potential influence of an Asian culture on raters' sense-making. This study explored residents' sense-making associated with evaluating their clinical teachers within an Asian setting to better understand contextual dependency of validity. DESIGN A qualitative study using constructivist grounded theory. SETTING The Japanese Ministry of Health, Labour and Welfare has implemented a system to monitor the quality of clinical teaching within its 2-year postgraduate training programme. An evaluation instrument was developed specifically for the Japanese setting through which residents can evaluate their clinical teachers. PARTICIPANTS 30 residents from 10 Japanese teaching hospitals with experience in evaluating their clinical teachers were sampled purposively and theoretically. METHODS We conducted in-depth semistructured individual interviews. Sensitising concepts derived from Confucianism and principles of response process informed open, axial and selective coding. RESULTS Two themes and four subthemes were constructed. Japanese residents emphasised the awareness of their relationship with their clinical teachers (1). This awareness was fuelled by their sense of hierarchy (1a) and being part of the collective society (1b). Residents described how the meaning of evaluation (2) was coloured by their perceived role as senior (2a) and their experienced responsibility for future generations (2b). CONCLUSIONS Japanese residents' sense-making while evaluating their clinical teachers appears to be situated and affected by Japanese cultural values. These findings contribute to a better understanding of a culture's influence on residents' sense-making of evaluation instruments and the validity argument of evaluation.
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Affiliation(s)
- Makoto Kikukawa
- Department of Medical Education, Kyushu University, Fukuoka, Japan
| | - Renée Stalmeijer
- Department of Educational Development and Research, Maastricht University Faculty of Health, Medicine and Life Sciences, Maastricht, The Netherlands
| | - Takahiro Matsuguchi
- Department of Gastroenterology, Kitakyushu Minicipal Medical Center, Fukuoka, Japan
| | - Miyako Oike
- Department of Nursing, Fukuoka International University of Health and Welfare, Fukuoka, Japan
| | - Emura Sei
- Saga Medical Career Support Center, Saga University Hospital, Saga, Japan
| | - Lambert W T Schuwirth
- Department of Educational Development and Research, Maastricht University Faculty of Health, Medicine and Life Sciences, Maastricht, The Netherlands
- Prideaux Centre for Research in Health Professions Education, Flinders University, Adelaide, South Australia, Australia
| | - Albert J J A Scherpbier
- Institute for Medical Education, Faculty of Health, Medicine and Life Sciences, Maastricht University, Maastricht, The Netherlands
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Bressers G, Wallenburg I, Stalmeijer R, Oude Egbrink M, Lombarts K. Patient safety in medical residency training: Balancing bravery and checklists. Health (London) 2020; 25:494-512. [PMID: 31960708 DOI: 10.1177/1363459319899444] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
Distributing responsibility for patient safety between individual professionals and organisational systems is a pressing issue in contemporary healthcare. This article draws on Habermas' distinction between 'lifeworld' and 'system' to explore patient-safety culture in medical residency training. Sociological accounts of medical training have indicated that applying systemic solutions in patient-safety training and practice may conflict with residents' needs. Residents would navigate safety systems to get their work done and safeguard learning opportunities, acting 'in between' the system and traditional processes of socialisation and learning on the job. Our ethnographic study reveals how residents seek to connect system and professional-based learning, and do them together in situated manners that evolve in the course of medical training. We reveal three themes that closely align with the residents' developmental process of maturing during training and on the job to become 'real' physicians: (1) coming to grips with the job; (2) working around safety procedures; and (3) moving on to independence. A more explicit focus on learning to deal with uncertainty may enable residents to become more skilled in balancing safety systems.
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Levis-Peralta M, González MDR, Stalmeijer R, Dolmans D, de Nooijer J. Organizational Conditions That Impact the Implementation of Effective Team-Based Models for the Treatment of Diabetes for Low Income Patients-A Scoping Review. Front Endocrinol (Lausanne) 2020; 11:352. [PMID: 32760344 PMCID: PMC7375199 DOI: 10.3389/fendo.2020.00352] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/16/2019] [Accepted: 05/05/2020] [Indexed: 11/13/2022] Open
Abstract
Background: Team-based care models (TBC) have demonstrated effectiveness to improve health outcomes for vulnerable diabetes patients but have proven difficult to implement in low income settings. Organizational conditions have been identified as influential on the implementation of TBC. This scoping review aims to answer the question: What is known from the scientific literature about how organizational conditions enable or inhibit TBC for diabetic patients in primary care settings, particularly settings that serve low-income patients? Methods: A scoping review study design was selected to identify key concepts and research gaps in the literature related to the impact of organizational conditions on TBC. Twenty-six articles were finally selected and included in this review. This scoping review was carried out following a directed content analysis approach. Results: While it is assumed that trained health professionals from diverse disciplines working in a common setting will sort it out and work as a team, co-location, and health professions education alone do not improve patient outcomes for diabetic patients. Health system, organization, and/or team level factors affect the way in which members of a care team, including patients and caregivers, collaborate to improve health outcomes. Organizational factors span across seven categories: governance and policies, structure and process, workplace culture, resources, team skills and knowledge, financial implications, and technology. These organizational factors are cited throughout the literature as important to TBC, however, research on the organizational conditions that enable and inhibit TBC for diabetic patients is extremely limited. Dispersed organizational factors are cited throughout the literature, but only one study specifically assesses the effect of organizational factors on TBC. Thematic analysis was used to categorize organizational factors in the literature about TBC and diabetes and a framework for analysis and definitions for key terms is presented. Conclusions: The review identified significant gaps in the literature relating to the study of organizational conditions that enable or inhibit TBC for low-income patients with diabetes. Efforts need to be carried out to establish unifying terminology and frameworks across the field to help explain the relationship between organizational conditions and TBC for diabetes. Gaps in the literature include research be based on organizational theories, research carried out in low-income settings and low and middle income countries, research explaining the difference between the organizational conditions that impact the implementation of TBC vs. maintaining or sustaining TBC and the interaction between organizational factors at the micro, meso and macro level and their impact on TBC. Few studies include information on patient outcomes, and fewer include information on low income settings. Further research is necessary on the impact of organizational conditions on TBC and diabetic patient outcomes.
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Affiliation(s)
| | | | - Renée Stalmeijer
- Department of Educational Development and Research, School of Health Professions Education, Maastricht University, Maastricht, Netherlands
| | - Diana Dolmans
- Department of Educational Development and Research, School of Health Professions Education, Maastricht University, Maastricht, Netherlands
| | - Jascha de Nooijer
- Department of Health Promotion, School of Health Professions Education, Maastricht University, Maastricht, Netherlands
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Stammen L, Slootweg I, Stalmeijer R, Janssen L, Stassen L, Scheele F, Driessen E. The Struggle Is Real: How Residents Learn to Provide High-Value, Cost-Conscious Care. Teach Learn Med 2019; 31:402-411. [PMID: 30909747 DOI: 10.1080/10401334.2019.1583566] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 06/09/2023]
Abstract
Phenomenon: Rising healthcare expenditures threaten the accessibility and affordability of healthcare systems. Research has demonstrated that teaching (junior) physicians to deliver high-value, cost-conscious care can be effective when learning is situated in a supportive environment. This study aims to offer insight into how residents learn to provide high-value, cost-conscious care in the workplace and how the postgraduate training environment influences this learning. Approach: Six homogeneous focus groups were held between August 2015 and July 2016 with 36 residents from six residency programs (dermatology, n = 5; elderly care, n = 8; family medicine, n = 5; internal medicine, n = 6; orthopedic surgery, n = 6; surgery, n = 6). An iterative grounded theory approach was used to analyze the qualitative data. Findings: Influential factors in learning of high-value, cost-conscious care delivery operated on three levels: individual resident, training program, and the workplace. On the individual level, we discerned three types of beliefs regarding HV3C. At the training program level, perceived determinants of learning included resident-supervisor interactions, involvement in decision-making over time, and exposure to variation in care delivery. At the workplace level, learning depended on the availability of professional healthcare expertise and the presence of institutional policy. Insights: Residents struggle to seize high-value, cost-conscious care learning opportunities in the workplace setting. Both residency training programs and workplaces can contribute to creating these learning opportunities. An important starting point is being aware of the different personal beliefs of residents and the approaches to high-value, cost-conscious care on the level of the training program and workplace.
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Affiliation(s)
- Lorette Stammen
- a School of Health Professions Education (SHE), Department of Educational Research and Development, Maastricht University , Maastricht , Limburg , The Netherlands
| | - Irene Slootweg
- b Department of Public Health and Primary Care, Leiden University Medical Centre , Leiden , The Netherlands
| | - Renée Stalmeijer
- a School of Health Professions Education (SHE), Department of Educational Research and Development, Maastricht University , Maastricht , Limburg , The Netherlands
| | - Linda Janssen
- a School of Health Professions Education (SHE), Department of Educational Research and Development, Maastricht University , Maastricht , Limburg , The Netherlands
| | - Laurents Stassen
- c Department of Surgery, Maastricht University Medical Center , Maastricht , The Netherlands
| | - Fedde Scheele
- d VU School of Medical Sciences, Amsterdam UMC, Athena Institute , Amsterdam , The Netherlands
- e OLVG Amsterdam , Amsterdam , The Netherlands
| | - Erik Driessen
- a School of Health Professions Education (SHE), Department of Educational Research and Development, Maastricht University , Maastricht , Limburg , The Netherlands
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Hill E, Solomon Y, Dornan T, Stalmeijer R. 'You become a man in a man's world': is there discursive space for women in surgery? Med Educ 2015; 49:1207-18. [PMID: 26611186 DOI: 10.1111/medu.12818] [Citation(s) in RCA: 17] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 07/31/2014] [Revised: 09/09/2014] [Accepted: 06/16/2015] [Indexed: 05/19/2023]
Abstract
CONTEXT The UK set a target of 20% of the surgical consultant workforce to be represented by women by 2009; in 2012, it remains 7%. Studies have attributed this shortfall to the nature of careers in surgery and differing career aspirations among women. OBJECTIVES Rather than exploring barriers to participation, this study aims to explore the self-narratives of those women who do undertake surgical careers and who do come to see themselves as surgeons. METHODS The study comprises 15 individual interviews with women in surgical careers, from those aspiring to be surgeons, to senior and retired surgeons. Data were explored using discourse analysis with a priori themes derived from the literature on women in surgery and Holland et al.'s theoretical framework of Figured Worlds. RESULTS Discourses of being a surgeon and discourses of being a woman, existed in competition. Female surgeons figured surgery as a career requiring 100% dedication, as they did motherhood, although the demands of the two roles differed and consequently the roles were not discursively compatible. Many related powerfully negative experiences in which their gender had marked them out as 'other' within surgery. Women described how they were expected to show masculine traits as surgeons and the ways to consequently become legitimate in the surgical world as a 'woman surgeon'. They found creative ways to articulate how women in general, and feminine qualities in particular, enhanced surgery. Finally, some women engaged in identity work, termed 'world making', - the creative orchestration of discourses of surgeonhood and motherhood to be mutually sustaining. CONCLUSIONS There is little discursive space in which to be both a successful woman and a successful surgeon. Those who combine these roles must either be innovative in refiguring what it means to be a woman or what it means to be a surgeon, or they must author a new space for themselves, a powerful discursive process termed 'world making'.
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Affiliation(s)
- Elspeth Hill
- Department of Educational Development and Research, School of Health Professions Education, Faculty of Health, Medicine and Life Sciences, Maastricht University, Maastricht, the Netherlands
- Division of Plastic and Reconstructive Surgery, Washington University in St Louis, St Louis, Missouri, USA
| | - Yvette Solomon
- Education and Social Research Institute, Manchester Metropolitan University, Manchester, UK
| | - Tim Dornan
- Department of Educational Development and Research, School of Health Professions Education, Faculty of Health, Medicine and Life Sciences, Maastricht University, Maastricht, the Netherlands
- Department of Medicine, School of Medicine, Dentistry and Biomedical Sciences, Queen's University, Belfast, UK
| | - Renée Stalmeijer
- Department of Educational Development and Research, School of Health Professions Education, Faculty of Health, Medicine and Life Sciences, Maastricht University, Maastricht, the Netherlands
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van den Eertwegh V, van der Vleuten C, Stalmeijer R, van Dalen J, Scherpbier A, van Dulmen S. Exploring residents' communication learning process in the workplace: a five-phase model. PLoS One 2015; 10:e0125958. [PMID: 26000767 PMCID: PMC4441458 DOI: 10.1371/journal.pone.0125958] [Citation(s) in RCA: 30] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/12/2014] [Accepted: 03/27/2015] [Indexed: 11/18/2022] Open
Abstract
Context Competency-based education is a resurgent paradigm in professional medical education. However, more specific knowledge is needed about the learning process of such competencies, since they consist of complex skills. We chose to focus on the competency of skilled communication and want to further explore its learning process, since it is regarded as a main competency in medical education. Objective This study aims to explore in more detail the learning process that residents in general practice go through during workplace-based learning in order to become skilled communicators. Methods A qualitative study was conducted in which twelve GP residents were observed during their regular consultations, and were interviewed in-depth afterwards. Results Analysis of the data resulted in the construction of five phases and two overall conditions to describe the development towards becoming a skilled communicator: Confrontation with (un)desired behaviour or clinical outcomes was the first phase. Becoming conscious of one’s own behaviour and changing the underlying frame of reference formed the second phase. The third phase consisted of the search for alternative behaviour. In the fourth phase, personalization of the alternative behaviour had to occur, this was perceived as difficult and required much time. Finally, the fifth phase concerned full internalization of the new behaviour, which by then had become an integrated part of the residents’ clinical repertoire. Safety and cognitive & emotional space were labelled as overall conditions influencing this learning process. Conclusions Knowledge and awareness of these five phases can be used to adjust medical working and learning environments in such a way that development of skilled medical communication can come to full fruition and its benefits are more fully reaped.
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Affiliation(s)
| | - Cees van der Vleuten
- Department of Educational Development and Research, Maastricht University, Maastricht, the Netherlands
| | - Renée Stalmeijer
- Department of Educational Development and Research, Maastricht University, Maastricht, the Netherlands
| | - Jan van Dalen
- Skillslab, Maastricht University, Maastricht, the Netherlands
| | - Albert Scherpbier
- Faculty of Health, Medicine and Life Sciences, Maastricht University, Maastricht, the Netherlands
| | - Sandra van Dulmen
- NIVEL (Netherlands institute for health services research), Utrecht, the Netherlands
- Radboud University Medical Centre, Nijmegen, the Netherlands
- Buskerud and Vestfold University College, Drammen, Norway
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Hill E, Bowman K, Stalmeijer R, Hart J. You've got to know the rules to play the game: how medical students negotiate the hidden curriculum of surgical careers. Med Educ 2014; 48:884-894. [PMID: 25113115 DOI: 10.1111/medu.12488] [Citation(s) in RCA: 27] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 10/24/2013] [Revised: 02/19/2014] [Accepted: 03/14/2014] [Indexed: 05/28/2023]
Abstract
OBJECTIVES The hidden curriculum may be framed as the culture, beliefs and behaviours of a community that are passed to students outside formal course offerings. Medical careers involve diverse specialties, each with a different culture, yet how medical students negotiate these cultures has not been fully explored. Using surgery as a case study, we aimed to establish, first, whether a specialty-specific hidden curriculum existed for students, and second, how students encountered and negotiated surgical career options. METHODS Using a constructivist grounded theory approach, we explored students' thoughts, beliefs and experiences regarding career decisions and surgery. An exploratory questionnaire informed the discussion schedule for semi-structured individual interviews. Medical students were purposively sampled by year group, gender and career intentions in surgery. Data collection and analysis were iterative: analysis followed each interview and guided the adaptation of our discussion schedule to further our evolving model. RESULTS Students held a clear sense of a hidden curriculum in surgery. To successfully negotiate a surgical career, students perceived that they must first build networks because careers information flows through relationships. They subsequently enacted what they learned by accruing the accolades ('ticking the boxes') and appropriating the dispositions ('walking the talk') of 'future surgeons'. This allowed them to identify themselves and to be identified by others as 'future surgeons' and to gain access to participation in the surgical world. Participation then enabled further network building and access to careers information in a positive feedback loop. For some, negotiating the hidden curriculum was more difficult, which, for them, rendered a surgical career unattractive or unattainable. CONCLUSIONS Students perceive a clear surgery-specific hidden curriculum. Using a constructivist grounded theory approach, we have developed a model of how students encounter, uncover and enact this hidden curriculum to succeed. Drawing on concepts of Bourdieu, we discuss unequal access to the hidden curriculum, which was found to exclude many from the possibility of a surgical career.
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Affiliation(s)
- Elspeth Hill
- School of Health Professions Education, Faculty of Health, Medicine and Life Sciences, Maastricht University, Maastricht, The Netherlands; Manchester Medical School, Faculty of Medicine and Human Sciences, The University of Manchester, Manchester, UK; Division of Plastic Surgery, Washington University in St. Louis, St. Louis, MO, USA
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Duvivier R, Stalmeijer R, van Dalen J, van der Vleuten C, Scherpbier A. Influence of the workplace on learning physical examination skills. BMC Med Educ 2014; 14:61. [PMID: 24678562 PMCID: PMC3976051 DOI: 10.1186/1472-6920-14-61] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 05/03/2013] [Accepted: 03/13/2014] [Indexed: 05/10/2023]
Abstract
BACKGROUND Hospital clerkships are considered crucial for acquiring competencies such as diagnostic reasoning and clinical skills. The actual learning process in the hospital remains poorly understood. This study investigates how students learn clinical skills in workplaces and factors affecting this. METHODS Six focus group sessions with 32 students in Internal Medicine rotation (4-9 students per group; sessions 80-90 minutes). Verbatim transcripts were analysed by emerging themes and coded independently by three researchers followed by constant comparison and axial coding. RESULTS Students report to learn the systematics of the physical examination, gain agility and become able to recognise pathological signs. The learning process combines working alongside others and working independently with increasing responsibility for patient care. Helpful behaviour includes making findings explicit through patient files or during observation, feedback by abnormal findings and taking initiative. Factors affecting the process negatively include lack of supervision, uncertainty about tasks and expectations, and social context such as hierarchy of learners and perceived learning environment. CONCLUSION Although individual student experiences vary greatly between different hospitals, it seems that proactivity and participation are central drivers for learning. These results can improve the quality of existing programmes and help design new ways to learn physical examination skills.
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Affiliation(s)
- Robbert Duvivier
- Skillslab, Faculty of Health Medicine and Life Sciences, Maastricht University, Maastricht, The Netherlands
| | - Renée Stalmeijer
- Department of Educational Development and Research, Faculty of Health Medicine and Life Sciences, Maastricht University, Maastricht, The Netherlands
| | - Jan van Dalen
- Skillslab, Faculty of Health Medicine and Life Sciences, Maastricht University, Maastricht, The Netherlands
| | - Cees van der Vleuten
- Department of Educational Development and Research, Faculty of Health Medicine and Life Sciences, Maastricht University, Maastricht, The Netherlands
| | - Albert Scherpbier
- Institute for Medical Education, Faculty of Health Medicine and Life Sciences, Maastricht University, Maastricht, The Netherlands
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Dolmans D, Kamp R, Stalmeijer R, Whittingham J, Wolfhagen I. Biases in course evaluations: 'what does the evidence say?'. Med Educ 2014; 48:219-220. [PMID: 24528404 DOI: 10.1111/medu.12297] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 06/03/2023]
Affiliation(s)
- Diana Dolmans
- School of Health Professions Education, Maastricht University, Maastricht, The Netherlands
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Strand P, Sjöborg K, Stalmeijer R, Wichmann-Hansen G, Jakobsson U, Edgren G. Development and psychometric evaluation of the Undergraduate Clinical Education Environment Measure (UCEEM). Med Teach 2013; 35:1014-26. [PMID: 24050817 DOI: 10.3109/0142159x.2013.835389] [Citation(s) in RCA: 40] [Impact Index Per Article: 3.6] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 05/08/2023]
Abstract
BACKGROUND There is a paucity of instruments designed to evaluate the multiple dimensions of the workplace as an educational environment for undergraduate medical students. AIM The aim was to develop and psychometrically evaluate an instrument to measure how undergraduate medical students perceive the clinical workplace environment, based on workplace learning theories and empirical findings. METHOD Development of the instrument relied on established standards including theoretical and empirical grounding, systematic item development and expert review at various stages to ensure content validity. Qualitative and quantitative methods were employed using a series of steps from conceptualization through psychometric analysis of scores in a Swedish medical student population. RESULTS The final result was a 25-item instrument with two overarching dimensions, experiential learning and social participation, and four subscales that coincided well with theory and empirical findings: Opportunities to learn in and through work & quality of supervision; Preparedness for student entry; Workplace interaction patterns & student inclusion; and Equal treatment. Evidence from various sources supported content validity, construct validity and reliability of the instrument. CONCLUSION The Undergraduate Clinical Education Environment Measure represents a valid, reliable and feasible multidimensional instrument for evaluation of the clinical workplace as a learning environment for undergraduate medical students. Further validation in different populations using various psychometric methods is needed.
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Bergman E, de Feijter J, Frambach J, Godefrooij M, Slootweg I, Stalmeijer R, van der Zwet J. AM last page: A guide to research paradigms relevant to medical education. Acad Med 2012; 87:545. [PMID: 22452919 DOI: 10.1097/acm.0b013e31824fbc8a] [Citation(s) in RCA: 47] [Impact Index Per Article: 3.9] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 05/11/2023]
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