Learning patient-centredness with simulated/standardized patients: A realist review: BEME Guide No. 68.

BACKGROUND: Given the positive outcomes of patient-centred care on health outcomes, future doctors should learn how to deliver patient-centred care. The literature describes a wide variety of educational interventions with standardized patients (SPs) that focus on learning patient-centredness. However, it is unclear which mechanisms are responsible for learning patient-centredness when applying educational interventions with SPs. OBJECTIVE: This study aims to clarify how healthcare learners and professionals learn patient-centredness through interventions involving SPs in different healthcare educational contexts. METHODS: A realist approach was used to focus on what works, for whom, in what circumstances, in what respect and why. Databases were searched through 2019. Nineteen papers were included for analysis. Through inductive and deductive coding, CIC'MO configurations were identified to build partial program theories. These CIC'MOs describe how Interventions with SPs change the Context (C→C') such that Mechanisms (M) are triggered that are expected to foster patient-centredness as Outcome. RESULTS: Interventions with SPs create three contexts which are 'a safe learning environment,' 'reflective practice,' and 'enabling people to learn together.' These contexts trigger the following seven mechanisms: feeling confident, feeling a sense of comfort, feeling safe, self-reflection, awareness, comparing & contrasting perspectives, combining and broadening perspectives. A tentative final program theory with mechanisms belonging to three main learning components (cognitive, regulative metacognitive and affective) is proposed: Interventions with SPs create a safe learning environment (C') in which learners gain feelings of confidence, comfort and safety (affective M). This safe learning environment enables two other mutual related contexts in which learners learn together (C'), through comparing & contrasting, combining and broadening their perspectives (cognitive M) and in which reflective practice (C') facilitates self-reflection and awareness (metacognitive M) in order to learn patient-centeredness. CONCLUSION: These insights offer educators ways to deliberately use interventions with SPs that trigger the described mechanisms for learning patient-centredness.

Towards best practice in developing motor skills: a systematic review on spacing in VR simulator-based psychomotor training for surgical novices.

OBJECTIVE: Repeated practice, or spacing, can improve various types of skill acquisition. Similarly, virtual reality (VR) simulators have demonstrated their effectiveness in fostering surgical skill acquisition and provide a promising, realistic environment for spaced training. To explore how spacing impacts VR simulator-based acquisition of surgical psychomotor skills, we performed a systematic literature review. METHODS: We systematically searched the databases PubMed, PsycINFO, Psychology and Behavioral Sciences Collection, ERIC and CINAHL for studies investigating the influence of spacing on the effectiveness of VR simulator training focused on psychomotor skill acquisition in healthcare professionals. We assessed the quality of all included studies using the Medical Education Research Study Quality Instrument (MERSQI) and the risk of bias using the Cochrane Collaboration's risk of bias assessment tool. We extracted and aggregated qualitative data regarding spacing interval, psychomotor task performance and several other performance metrics. RESULTS: The searches yielded 1662 unique publications. After screening the titles and abstracts, 53 publications were retained for full text screening and 7 met the inclusion criteria. Spaced training resulted in better performance scores and faster skill acquisition when compared to control groups with a single day (massed) training session. Spacing across consecutive days seemed more effective than shorter or longer spacing intervals. However, the included studies were too heterogeneous in terms of spacing interval, obtained performance metrics and psychomotor skills analysed to allow for a meta-analysis to substantiate our outcomes. CONCLUSION: Spacing in VR simulator-based surgical training improved skill acquisition when compared to massed training. The overall number and quality of available studies were only moderate, limiting the validity and generalizability of our findings.

Learning from patients about patient-centredness: A realist review: BEME Guide No. 60.

Background: Patient-centred work is an essential part of contemporary medicine. Literature shows that educational interventions contribute to developing patient-centredness, but there is a lack of insight into the associated learning processes.Objective: Through reviewing articles about educational interventions involving patients, we aspire to develop a program theory that describes the processes through which the educational interventions are expected to result in change. The processes will clarify contextual elements (called contexts) and mechanisms connected to learning patient-centredness.Methods: In our realist review, an initial, rough program theory was generated during the scoping phase, we searched for relevant articles in PubMed, PsycINFO, ERIC, CINAHL and Embase for all years before and through 2016. We included observational studies, case reports, interviews, and experimental studies in which the participants were students, residents, doctors, nurses or dentists. The relevance and rigour of the studies were taken into account during analysis. With deductive as well as inductive coding, we extended the rough program theory.Results: In our review, we classified five different contexts which affect how upcoming professionals learn patient-centredness. These aspects are influenced through components in the intervention(s) related to the learner, the teacher, and the patient. We placed the mechanisms together in four clusters - comparing and combining as well as broadening perspectives, developing narratives and engagement with patients, self-actualisation, and socialisation - to show how the development of (dimensions of) patient-centredness occurs. Three partial-program-theories (that together constituting a whole program theory) were developed, which show how different components of interventions within certain contexts will evoke mechanisms that contribute to patient-centredness.Translation into daily practice: These theories may help us better understand how the roles of patients, learners and teachers interact with contexts such as the kind of knowledge that is considered legitimate or insight in the whole illness trajectory. Our partial program theories open up potential areas for future research and interventions that may benefit learners, teachers, and patients.

How students and specialists appreciate the mini-clinical evaluation exercise (mini-CEX) in Indonesian clerkships.

BACKGROUND: Cultural differences might challenge the acceptance of the implementation of assessment formats that are developed in other countries. Acceptance of assessment formats is essential for its effectiveness; therefore, we explored the views of students and specialists on the practicality and impact on learning of these formats. This study was conducted to explore Indonesian students' and specialists' appreciation of the implementation of the Mini-Clinical Evaluation Exercise (Mini-CEX) in Indonesian clerkships. METHODS: This study was conducted at the Universitas Gadjah Mada, Indonesia. Participants were 52 students and 21 specialists in neurology and 78 students and 50 specialists in internal medicine. They were asked to complete a 19-item questionnaire that covered the characteristics of the mini-CEX such as its practicality, and the impact on learning and professional development. We used a Mann-Whitney U test to analyse the data. RESULTS: In total, 124 students (46 from neurology and 78 from internal medicine) and 38 specialists (13 from neurology and 25 from internal medicine) participated in this study. Students and specialists were positive about the practicality of the mini-CEX and the impact of this assessment format on learning and on professional development. The Mann-Whitney U test showed that there were no significant differences between students' and specialists' opinions on the mini-CEX, except for 2 items: specialists' appreciation of direct observation (mean rank = 93.16) was statistically significantly higher than students' appreciation of it (mean rank = 77.93; z = 2.065; p < 0.05), but students' appreciation of the item that students' past mini-CEX results affected their recent mini-CEX outcomes (mean rank = 85.29) was significantly higher than specialists' appreciation of it (mean rank = 69.12; z = 2140; p < 0.05). CONCLUSION: Students and specialists were positive about the mini-CEX in Indonesian clerkships, although it was developed and validated in another culture. We found only small differences between their appreciations, which could be explained by the patterns of specialist-student interaction in Indonesian culture as large power distance and low individualism country.

Reliability of residents' assessments of their postgraduate medical education learning environment: an observational study.

BACKGROUND: Even in anonymous evaluations of a postgraduate medical education (PGME) program, residents may be reluctant to provide an honest evaluation of their PGME program, because they fear embarrassment or repercussions from their supervisors if their anonymity as a respondent is endangered. This study was set up to test the hypothesis that current residents in a PGME program provide more positive evaluations of their PGME program than residents having completed it. We therefore compared PGME learning environment evaluations of current residents in the program to leaving residents having completed it. METHODS: This observational study used data gathered routinely in the quality cycle of PGME programs at two Dutch teaching hospitals to test our hypothesis. At both hospitals, all current PGME residents are requested to complete the Scan of Postgraduate Education Environment Domains (SPEED) annually. Residents leaving the hospital after completion of the PGME program are also asked to complete the SPEED after an exit interview with the hospital's independent residency coordinator. All SPEED evaluations are collected and analysed anonymously. We compared the residents' grades (on a continuous scale ranging from 0 (poor) to 10 (excellent)) on the three SPEED domains (content, atmosphere, and organization of the program) and their mean (overall department grade) between current and leaving residents. RESULTS: Mean (SD) overall SPEED department grades were 8.00 (0.52) for 287 current residents in 39 PGME programs and 8.07 (0.48) for 170 leaving residents in 39 programs. Neither the overall SPEED department grades (t test, p = 0.53, 95% CI for difference - 0.16 to 0.31) nor the department SPEED domain grades (MANOVA, F(3, 62) = 0.79, p = 0.51) were significantly different between current and leaving residents. CONCLUSIONS: Residents leaving the program did not provide more critical evaluations of their PGME learning environment than current residents in the program. This suggests that current residents' evaluations of their postgraduate learning environment were not affected by social desirability bias or fear of repercussions from faculty.

Clinical workplace learning: perceived learning value of individual and group feedback in a collectivistic culture.

BACKGROUND: Feedback is essential for workplace learning. Most papers in this field concern individual feedback. In collectivistic cultures, however, group feedback is common educational practice. This study was conducted to investigate the perceived learning value and characteristics of individual and group feedback in a collectivistic culture. METHODS: During two weeks, on a daily basis, clerkship students (n = 215) from 12 clinical departments at Faculty of Medicine, Universitas Gadjah Mada, Yogyakarta, Indonesia, recorded individual and group feedback moments by using a structured form: the providers, focus and perceived learning value of feedback. Data were analysed with logistic regression and multilevel techniques. RESULTS: Students reported 2687 group and 1535 individual feedback moments. Group feedback more often focused on history taking, clinical judgment, patient management, patient counselling, and professional behaviour (OR ranging from 1.232, p < .01, to 2.152, p < .001), but less often on physical examination (OR = .836, p < .01). Group feedback less often aimed at correcting performance deficiencies (OR = .523, p < .001) and more often at comparing performance to the standard (OR = 2.447, p < .001) and planning action to improve performance (OR = 1.759, p < .001). Group feedback was perceived as more valuable than individual feedback (M = 4.08 and 3.96, respectively, ß group = .065, SE = .026, p < .01). CONCLUSION: In collectivistic cultures, group feedback may add to the array of educational measures that optimize student learning. Congruence between culture and type of feedback may be important for the effectiveness of feedback.

Physician job satisfaction related to actual and preferred job size.

BACKGROUND: Job satisfaction is essential for physicians' well-being and patient care. The work ethic of long days and hard work that has been advocated for decades is acknowledged as a threat for physicians' job satisfaction, well-being, and patient safety. Our aim was to determine the actual and preferred job size of physicians and to investigate how these and the differences between them influence physicians' job satisfaction. METHOD: Data were retrieved from a larger, longitudinal study among physicians starting medical training at Groningen University in 1982/83/92/93 (N = 597). Data from 506 participants (85%) were available for this study. We used regression analysis to investigate the influence of job size on physicians' job satisfaction (13 aspects) and ANOVA to examine differences in job satisfaction between physicians wishing to retain, reduce or increase job size. RESULTS: The majority of the respondents (57%) had an actual job size less than 1.0 FTE. More than 80% of all respondents preferred not to work full-time in the future. Respondents' average actual and preferred job sizes were .85 FTE and .81 FTE, respectively. On average, respondents who wished to work less (35% of respondents) preferred a job size reduction of 0.18 FTE and those who wished to work more (12%) preferred an increase in job size of 0.16 FTE. Job size influenced satisfaction with balance work-private hours most (ß = -.351). Physicians who preferred larger job sizes were - compared to the other groups of physicians - least satisfied with professional accomplishments. CONCLUSIONS: A considerable group of physicians reported a gap between actual and preferred job size. Realizing physicians' preferences as to job size will hardly affect total workforce, but may greatly benefit individual physicians as well as their patients and society. Therefore, it seems time for a shift in work ethic.

Influence of feedback characteristics on perceived learning value of feedback in clerkships: does culture matter?

BACKGROUND: Various feedback characteristics have been suggested to positively influence student learning. It is not clear how these feedback characteristics contribute to students' perceived learning value of feedback in cultures classified low on the cultural dimension of individualism and high on power distance. This study was conducted to validate the influence of five feedback characteristics on students' perceived learning value of feedback in an Indonesian clerkship context. METHODS: We asked clerks in Neurology (n = 169) and Internal Medicine (n = 132) to assess on a 5-point Likert scale the learning value of the feedback they received. We asked them to record whether the feedback provider (1) informed the student what went well, (2) mentioned which aspects of performance needed improvement, (3) compared the student's performance to a standard, (4) further explained or demonstrated the correct performance, and (5) prepared an action plan with the student to improve performance. Data were analyzed using multilevel regression. RESULTS: A total of 250 students participated in this study, 131 from Internal Medicine (response rate 99%) and 119 from Neurology (response rate 70%). Of these participants, 225 respondents (44% males, 56% females) completed the form and reported 889 feedback moments. Students perceived feedback as more valuable when the feedback provider mentioned their weaknesses (ß = 0.153, p < 0.01), compared their performance to a standard (ß = 0.159, p < 0.01), explained or demonstrated the correct performance (ß = 0.324, p < 0.001) and prepared an action plan with the student (ß =0.496, p < 0.001). Appraisal of good performance did not influence the perceived learning value of feedback. No gender differences were found for perceived learning value. CONCLUSIONS: In Indonesia, we could validate four out of the five characteristics for effective feedback. We argue that our findings relate to culture, in particular to the levels of individualism and power distance. The recognized characteristics of what constitutes effective feedback should be validated across cultures.

Supervisor leadership in relation to resident job satisfaction.

BACKGROUND: Research from outside the medical field shows that leadership behaviours influence job satisfaction. Whether the same is true for the medical training setting needs to be explored. The aim of this study was to investigate the influence of residents' overall appreciation of their supervisor's leadership and observation of specific supervisor leadership behaviours on job satisfaction. METHODS: We invited residents (N = 117) to rate how often they observed certain task and relation-oriented leadership behaviours in their supervisor and overall appreciation of their supervisor's leadership. Furthermore, they rated their satisfaction with 13 different aspects of their jobs on a 10-point scale. Using exploratory factor analysis we identified four factors covering different types of job satisfaction aspects: personal growth, autonomy, affective, and instrumental job satisfaction aspects. Influence of overall appreciation for supervisor leadership and observation of certain leadership behaviours on these job satisfaction factors were analysed using multiple regression analyses. RESULTS: The affective aspects of job satisfaction were positively influenced by overall appreciation of leadership (B = 0.792, p = 0.017), observation of specific instructions (B = 0.972, p = 0.008) and two-way communication (B = 1.376, p = 0.008) and negatively by mutual decision-making (B = -1.285, p = 0.007). No effects were found for the other three factors of job satisfaction. CONCLUSIONS: We recommend that supervisors become more aware of whether and how their behaviours influence residents' job satisfaction. Especially providing specific instructions and using two-way communication seem important to help residents deal with their insecurities and to offer them support.

Student distress in clinical workplace learning: differences in social comparison behaviours.

In medical education, student distress is known to hamper learning and professional development. To address this problem, recent studies aimed at helping students cope with stressful situations. Undergraduate students in clinical practice frequently use experiences of surrounding peers to estimate their abilities to master such challenging situations. This use of the experiences of others, known as social comparison, may affect student distress both positively and negatively. To find characteristics of a beneficial use of social comparison, we examined differences in comparison behaviours between students expressing low and high levels of distress. The participants in our study, response rate 93% (N = 301/321), were all medical students in their first year in clinical practice. They completed the General Health Questionnaire (GHQ-12) to measure distress, and three separate questionnaires to measure: (1) orientation to comparison, (2) motive for comparison, and (3) interpretation of comparison. Differences were analysed using multivariate analysis of variance. Although all students were oriented towards social comparison, the analyses showed that this orientation was less apparent among low-distress students. Besides, the low-distress students were less inclined to use motives indicative for comparisons with peers perceived as performing worse and were less negative in the interpretations of their comparisons. As social comparison is frequently used among all students, we recommend to make them aware of their comparison behaviours and inform them about the pros and cons of the distinguished aspects of the comparison process.

The transferability of Western concepts to other cultures: validation of the Zuckerman-Kuhlman Personality Questionnaire in a Saudi Arabic context.

BACKGROUND: The importance of medical education research in Saudi Arabia has been acknowledged increasingly and a lot of concepts used have been derived from the Western world. The question arises, however, whether Western concepts and questionnaires are transferable to societies with different cultures. The aim of this study was to investigate the instrument structure and the reliability of the Arabic version of the Zuckerman-Kuhlman Personality Questionnaire-medium (ZKPQ-m). METHODS: Three statistical methods with decreased amount of strictness were used to analyse our data: Confirmatory Factor Analysis, Procrustes rotation and Principal Component Analysis. RESULTS: Our outcomes did not confirm the original instrument structure. Instead, we found four interpretable components: Emotional Instability, Impulse-seeking, Activeness and Self-Control. However, the amount of explained variance was not very high and the internal consistencies ranged from unsatisfactory to only moderate. The data showed a high percentage of respondents agreeing with more than three items of the Infrequency scale, which may be attributable to the collectivistic culture in Saudi Arabia. CONCLUSION: We did not succeed in replicating the ZKPQ structure in the Arabic context. Social desirability, a common characteristic in collectivistic cultures, may have reduced the replicability of the internal structure of the ZKPQ-m. Different methods to measure concepts in collectivistic cultures may help to get round social desirability.

Leadership in the clinical workplace: what residents report to observe and supervisors report to display: an exploratory questionnaire study.

BACKGROUND: Within the current health care system, leadership is considered important for physicians. leadership is mostly self-taught, through observing and practicing. Does the practice environment offer residents enough opportunities to observe the supervisor leadership behaviours they have to learn? In the current study we investigate which leadership behaviours residents observe throughout their training, which behaviours supervisors report to display and whether residents and supervisors have a need for more formal training. METHODS: We performed two questionnaire studies. Study 1: Residents (n = 117) answered questions about the extent to which they observed four basic and observable Situational Leadership behaviours in their supervisors. Study 2: Supervisors (n = 201) answered questions about the extent to which they perceived to display these Situational Leadership behaviours in medical practice. We asked both groups of participants whether they experienced a need for formal leadership training. RESULTS: One-third of the residents did not observe the four basic Situational Leadership behaviours. The same pattern was found among starting, intermediate and experienced residents. Moreover, not all supervisors showed these 4 leadership behaviours. Both supervisors and residents expressed a need for formal leadership training. CONCLUSION: Both findings together suggest that current practice does not offer residents enough opportunities to acquire these leadership behaviours by solely observing their supervisors. Moreover, residents and supervisors both express a need for more formal leadership training. More explicit attention should be paid to leadership development, for example by providing formal leadership training for supervisors and residents.

The influence of achievement before, during and after medical school on physician job satisfaction.

In this longitudinal study, we investigated the relationship between physicians' prior achievements (before, during and after medical school) and job satisfaction, and tested the two lines of reasoning that prior achievements influence job satisfaction positively or negatively, respectively. The participants were graduates who started their medical training in 1982 (n = 147), 1983 (n = 154), 1992 (n = 143) and 1993 (n = 153). We operationalised job satisfaction as satisfaction (on a 10-point scale) with 13 cognitive, affective and instrumental aspects of the participants' jobs. The measures of achievement before, during and after medical school included pre-university grade point average, study progress and a residency position in the specialty of first choice, respectively. We included the effect of curriculum type (problem-based learning versus traditional), gender and years of experience as moderator variables. Higher achievers before and during medical school were more satisfied about their income (ß = .152, p < .01 and ß = .149, p < .05), but less satisfied with their opportunities for personal development (ß = -.159, p < .05). High achievers after medical school were more satisfied with professional accomplishments (ß = .095, p < .05), with appreciation from support personnel (ß = .154, p < .01) and from patients (ß = .120, p < .05). Effect sizes were small. Prior achievements influenced job satisfaction. The direction of the influences depended on the job satisfaction aspect in question, which indicates that it is important to distinguish between aspects of job satisfaction. To optimize job satisfaction of high achievers, it is important for graduates to obtain their preferred specialty. Furthermore, it is vital to provide them with enough opportunities for further development.

Meeting international standards: a cultural approach in implementing the mini-CEX effectively in Indonesian clerkships.

UNLABELLED: Abstract Background: Medical schools all over the world try to adapt their programs to meet international standards. However, local culture might hamper innovation attempts. AIMS: To describe challenges in implementing the mini-CEX in Indonesia and investigate its effect on students' clinical competence. METHODS: The study was conducted in the Internal Medicine and Neurology departments of the Universitas Gadjah Mada, Indonesia. Implementing the mini-CEX into the existing curriculum, while taking the Indonesian culture into account, implied a shift from group to individual feedback. We compared students' final clinical competence before (Internal Medicine n = 122, Neurology n = 183) and after (n = 183 and 186, respectively) the implementation of the mini-CEX, using a modified Objective Structured Long Examination Record (OSLER). The Mann-Whitney test was used to analyze the data. RESULTS: We took power distance and individualism into account to facilitate the implementation process. After implementing the mini-CEX, the OSLER results were significant higher in Internal Medicine (p < 0.05). However, no differences were found in Neurology. CONCLUSION: By managing the innovation process carefully and taking culture and local context into account, the mini-CEX can be implemented without changing the underlying concept. The shift from group to individual feedback seems to have a positive effect on student learning.

Patterns of Medical Residents' Preferences for Organizational Socialization Strategies to Facilitate Their Transitions: A Q-study.

Introduction: To facilitate various transitions of medical residents, healthcare team members and departments may employ various organizational socialization strategies, including formal and informal onboarding methods. However, residents' preferences for these organizational socialization strategies to ease their transition can vary. This study identifies patterns (viewpoints) in these preferences. Methods: Using Q-methodology, we asked a purposeful sample of early-career residents to rank a set of statements into a quasi-normal distributed grid. Statements were based on previous qualitative interviews and organizational socialization theory. Participants responded to the question, 'What are your preferences regarding strategies other health care professionals, departments, or hospitals should use to optimize your next transition?' Participants then explained their sorting choices in a post-sort questionnaire. We identified different viewpoints based on by-person (inverted) factor analysis and Varimax rotation. We interpreted the viewpoints using distinguishing and consensus statements, enriched by residents' comments. Results: Fifty-one residents ranked 42 statements, among whom 36 residents displayed four distinct viewpoints: Dependent residents (n = 10) favored a task-oriented approach, clear guidance, and formal colleague relationships; Social Capitalizing residents (n = 9) preferred structure in the onboarding period and informal workplace social interactions; Autonomous residents (n = 12) prioritized a loosely structured onboarding period, independence, responsibility, and informal social interactions; and Development-oriented residents (n = 5) desired a balanced onboarding period that allowed independence, exploration, and development. Discussion: This identification of four viewpoints highlights the inadequacy of one-size-fits-all approaches to resident transition. Healthcare professionals and departments should tailor their socialization strategies to residents' preferences for support, structure, and formal/informal social interaction.

'What would my classmates say?' An international study of the prediction-based method of course evaluation.

OBJECTIVES: Traditional student feedback questionnaires are imperfect course evaluation tools, largely because they generate low response rates and are susceptible to response bias. Preliminary research suggests that prediction-based methods of course evaluation - in which students estimate their peers' opinions rather than provide their own personal opinions - require significantly fewer respondents to achieve comparable results and are less subject to biasing influences. This international study seeks further support for the validity of these findings by investigating: (i) the performance of the prediction-based method, and (ii) its potential for bias. METHODS: Participants (210 Year 1 undergraduate medical students at McGill University, Montreal, Quebec, Canada, and 371 Year 1 and 385 Year 3 undergraduate medical students at the University Medical Center Groningen [UMCG], University of Groningen, Groningen, the Netherlands) were randomly assigned to complete course evaluations using either the prediction-based or the traditional opinion-based method. The numbers of respondents required to achieve stable outcomes were determined using an iterative process. Differences between the methods regarding the number of respondents required were analysed using t-tests. Differences in evaluation outcomes between the methods and between groups of students stratified by four potentially biasing variables (gender, estimated general level of achievement, expected test result, satisfaction after examination completion) were analysed using multivariate analysis of variance (manova). RESULTS: Overall response rates in the three student cohorts ranged from 70% to 94%. The prediction-based method required significantly fewer respondents than the opinion-based method (averages of 26-28 and 67-79 respondents, respectively) across all samples (p < 0.001), whereas the outcomes achieved were fairly similar. Bias was found in four of 12 opinion-based condition comparisons (three sites, four variables), and in only one comparison in the prediction-based condition. CONCLUSIONS: Our study supports previous findings that prediction-based methods require significantly fewer respondents to achieve results comparable with those obtained through traditional course evaluation methods. Moreover, our findings support the hypothesis that prediction-based responses are less subject to bias than traditional opinion-based responses. These findings lend credence to prediction-based as an accurate and efficient method of course evaluation.

The development and validation of a short form of the STERLinG: a practical, valid and reliable tool to evaluate teacher competencies to encourage reflective learning.

BACKGROUND: To optimize response rates, it is important to have brief, comprehensive instruments. AIMS: We have developed and validated a short form of an instrument for measuring students' perceptions of teachers' competencies to encourage students' reflective learning in small groups (the STERLinG). METHODS: Based on statistical and content criteria, the original 36-item STERLinG was reduced to 15 items: three scales with five items each. This mini-STERLinG was validated. Confirmatory factor analysis was performed and internal consistencies were calculated. RESULTS: The instrument was completed by 501 respondents (63%). The original instrument structure was confirmed with 62.6% explained variance. Reliabilities were high with 0.91 for the entire mini-STERLinG and 0.87, 0.85 and 0.81 for its subscales. CONCLUSIONS: The mini-STERLinG was found to be a feasible, valid and reliable instrument.

Which characteristics of written feedback are perceived as stimulating students' reflective competence: an exploratory study.

BACKGROUND: Teacher feedback on student reflective writing is recommended to improve learners' reflective competence. To be able to improve teacher feedback on reflective writing, it is essential to gain insight into which characteristics of written feedback stimulate students' reflection processes. Therefore, we investigated (1) which characteristics can be distinguished in written feedback comments on reflective writing and (2) which of these characteristics are perceived to stimulate students' reflection processes. METHODS: We investigated written feedback comments from forty-three teachers on their students' reflective essays. In Study 1, twenty-three medical educators grouped the comments into distinct categories. We used Multiple Correspondence Analysis to determine dimensions in the set of comments. In Study 2, another group of twenty-one medical educators individually judged whether the comments stimulated reflection by rating them on a five-point scale. We used t-tests to investigate whether comments classified as stimulating and not stimulating reflection differed in their scores on the dimensions. RESULTS: Our results showed that characteristics of written feedback comments can be described in three dimensions: format of the feedback (phrased as statement versus question), focus of the feedback (related to the levels of students' reflections) and tone of the feedback (positive versus negative). Furthermore, comments phrased as a question and in a positive tone were judged as stimulating reflection more than comments at the opposite side of those dimensions (t = (14.5) = 6.48; p = < .001 and t = (15) = -1.80; p < .10 respectively). The effect sizes were large for format of the feedback comment (r = .86) and medium for tone of the feedback comment (r = .42). CONCLUSIONS: This study suggests that written feedback comments on students' reflective essays should be formulated as a question, positive in tone and tailored to the individual student's reflective level in order to stimulate students to reflect on a slightly higher level. Further research is needed to examine whether incorporating these characteristics into teacher training helps to improve the quality of written feedback comments on reflective writing.

Development and evaluation of the Measure of the International Learning Environment Status (MILES) in international higher education.

The aim of this study was to develop and evaluate an instrument to assess international students' perceptions of the international learning environment called 'Measure of the International Learning Environment Status' (MILES). We based the development of the MILES on a solid theoretical framework from Moos by addressing three domains to measure the quality of the international learning environment, namely goal direction, relationships, and system change and system maintenance. We have designed and constructed the instrument in three steps. Firstly, we have collected items from relevant existing instruments and grouped them into the three domains via content analysis. Secondly, we applied a Delphi procedure involving international higher education experts from different stakeholder groups and from different cultural backgrounds to identify and reach consensus on the items comprehensively covering important elements of the international learning environment. Thirdly, we carried out an initial questionnaire evaluation. The final MILES consisted of 47 items with 13 in the first domain, 17 in the second and 17 in the third domain. The content of the domains was clearly in line with Moos theoretical framework and we interpreted the sets of items as goal direction, relationships, and supporting services, respectively. This study provides a comprehensive and systematically developed instrument for future research to better understand international students' perspectives towards the international learning environment that are supported by stakeholders from a range of cultures.

Influence of online collaborative learning on social network and academic performance of medical students: lessons learned from the COVID-19 pandemic.

Introduction: The social distancing restrictions due to the COVID-19 pandemic have changed students' learning environment and limited their social interactions. Therefore, the objective of this study was to investigate the influence of the social distancing restrictions on students' social networks, wellbeing, and academic performance. Methods: We performed a questionnaire study in which 102 students participated before and 167 students during the pandemic. They completed an online questionnaire about how they formed their five peer social networks (study-related support, collaboration, friendship, share information, and learn-from) out-of-class. We performed social network analysis to compare the sizes, structures, and compositions of students' five social networks before and during the pandemic, between first- and second-year students, and between international and domestic students. Additionally, we performed Kruskal-Wallis H test to compare students' academic performance before and during the pandemic. We performed thematic analysis to answers for two open-end questions in the online questionnaire to explore what difficulties students encountered during the COVID-19 pandemic and what support they needed. Results: The results showed that the size of students' social networks during the pandemic was significantly smaller than before the pandemic. Besides, the formation of social networks differed between first- and second-year students, and between domestic and international students. However, academic performance did not decline during the COVID-19 pandemic. Furthermore, we identified three key areas in which students experienced difficulties and needed support by thematic analysis: social connections and interactions, learning and studying, and physical and mental wellbeing. Conclusion: When institutions implement learning with social distancing, such as online learning, they need to consider changes in students' social networks and provide appropriate support.