Understanding underperformance in a high-stakes clinical-based simulation assessment in physiotherapy: a descriptive analysis.

BACKGROUND: High-stakes assessments are often used as a 'gate-keeper' activity for entry into the health professions by ensuring that the minimum core competency thresholds of the profession are met. The aim of the study was to explore if common areas of underperformance existed in international candidates assessed with a high-stakes clinical-based simulation assessment for entry into the physiotherapy profession in Australia. METHODS: A retrospective mixed methods analysis of the clinical assessments completed by international candidates over a one-month period in 2021 that were deemed as not meeting competency. The clinical assessments were completed in one of the three practice areas: cardiorespiratory, musculoskeletal, or neurological rehabilitation. Each assessment was scored by two independent assessors, who discussed the performance and then completed a moderated assessment form. The assessment form used to score competency included seven domains such as initial assessment, effective treatment, communication skills, and risk management. RESULTS: Fifty-one clinical assessments graded as not competent were analysed. Across the practice areas, a high failure rate was found in domains related to interpreting assessment findings and developing a treatment plan. This trend was also observed in the qualitative data, suggesting candidates struggled to meet competency in areas of planning and prioritisation, interpretation and implementation of the information gathered, and selection and evaluation of effective treatment. CONCLUSION: These findings align with published data on the underperformance of Australian physiotherapy students in clinical placement settings, suggesting these issues are not specific to high stakes assessment of overseas physiotherapists, and that education needs to focus on improving these skills within the profession at all levels. With the identified areas of underperformance aligning with the ability to use higher order thinking and skills integral to clinical reasoning, improvements in the education and implementation of clinical reasoning may be a place to start.

"Attending lectures in your pyjamas": student agency in constrained circumstances.

COVID-19 forced the digitalisation of teaching and learning in a response often described as emergency remote teaching (ERT). This rapid response changed the social, spatial, and temporal arrangements of higher education and required important adaptations from educators and students alike. However, while the literature has examined the constraints students faced (e.g. availability of the internet) and the consequences of the pandemic (e.g. student mental health), students' active management of these constraints for learning remains underexplored. This paper aims to "think with" COVID-19 to explore student agency in home learning under constrained circumstances. This qualitative study used semi-structured interviews to understand the day-to-day actions of nineteen undergraduate students managing their learning during the COVID-19 lockdowns in Victoria, Australia. Emirbayer and Mische's multiple dimensions of agency - iterative, projective, and practical-evaluative - are used to explore student experience. The findings illustrate students' adaptability and agency in navigating life-integrated learning, with most of their actions oriented to their present circumstances. This practical evaluative form of agency was expressed through (1) organising self, space, time, and relationships; (2) self-care; and (3) seeking help. Although this study took place in the context of ERT, it has implications beyond the pandemic because higher education always operates under constraints, and in other circumstances, many students still experience emotionally and materially difficult times.

Teaching and learning under COVID-19 public health edicts: the role of household lockdowns and prior technology usage.

Public health edicts necessitated by COVID-19 prompted a rapid pivot to remote online teaching and learning. Two major consequences followed: households became students' main learning space, and technology became the sole medium of instructional delivery. We use the ideas of "digital disconnect" and "digital divide" to examine, for students and faculty, their prior experience with, and proficiency in using, learning technology. We also explore, for students, how household lockdowns and digital capacity impacted learning. Our findings are drawn from 3806 students and 283 faculty instructors from nine higher education institutions across Asia, Australia, Europe, and North America. For instructors, we find little evidence of a digital divide but some evidence of a digital disconnect. However, neither made a difference to self-reported success in transitioning courses. Faculty instructors were impacted in a myriad of diverse ways. For students, we show that closure and confinement measures which created difficult living situations were associated with lower levels of confidence in learning. The digital divide that did exist among students was less influential than were household lockdown measures in undermining student learning.

Invoking culture in medical education research: A critical review and metaphor analysis.

INTRODUCTION: 'Culture' is a word frequently invoked within medical education literature to explain challenges faced by learners in practice. While social settings and practices are widely acknowledged as critical influences on medical education, there is vast variability in how the term 'culture' is employed. This may lead to confusion, resulting in assumptions and oversights. OBJECTIVE: This critical literature review aims to characterise how the term 'culture' is explicitly and implicitly conceptualised in medical education research. METHODS: Four leading English language journals in the medical education field were searched in a twelve-month period for research papers or reviews that mentioned culture in title or abstract in a substantive way. A content analysis was undertaken of extracted definitions. In addition, metaphor analysis was used to identify conceptual metaphors, which were subsequently clustered thematically. RESULTS: Our search yielded 26 papers, 8 of which contained definitions, mostly from the organisational literature. We interpreted nine conceptual metaphors related to how the term culture was employed (terroir, divider, dominant force, toxic force, obstacle, microclimate, object, brand and holdall) in four categories (unchanging, powerful, can adapt around, can be used). DISCUSSION: This critical review reveals that medical education as a field: 1) draws most explicitly from the organisational literature; 2) invokes culture in multiple means but in ways that privilege either acontextual human agency or all-powerful social forces; and 3) regards culture as a negative or neutral force but rarely a positive one. There is a notable absence around conceptualisations of 'culture' that allow educator, student and administrator agency but at the same time acknowledge the deep forces that various social settings and practices exert. Other literatures investigating learning cultures and cultural reflexivity focus on this nexus and may provide possible means to advance considerations of culture within medical education research.

Conversation Starter: Advancing the Theory of Peer-Assisted Learning.

This Conversation Starter article uses four selected abstracts, one each from the four regional Association of American Medical Colleges (AAMC) Group on Educational Affairs (CGEA) 2018 spring meetings, as a springboard for unpacking the definition of peer-assisted learning (PAL). The aim of this article is to prompt deeper reflection on this phenomenon and, in so doing, to foster scholarly program evaluation of this widely adopted instructional approach. This analysis calls for a more nuanced definition of PAL, one that emphasizes process over structure, one that stimulates examination of "doing" PAL and how this affects the personal and professional development of all involved.

What should we teach the teachers? Identifying the learning priorities of clinical supervisors.

Clinicians who teach are essential for the health workforce but require faculty development to improve their educational skills. Curricula for faculty development programs are often based on expert frameworks without consideration of the learning priorities as defined by clinical supervisors themselves. We sought to inform these curricula by highlighting clinical supervisors own requirements through answering the research question: what do clinical supervisors identify as relative strengths and areas for improvement in their teaching practice? This mixed methods study employed a modified version of the Maastricht Clinical Teaching Questionnaire (mMCTQ) which included free-text reflections. Descriptive statistics were calculated and content analysis was conducted on textual comments. 481 (49%) of 978 clinical supervisors submitted their mMCTQs and associated reflections for the research study. Clinical supervisors self-identified relatively strong capability with interpersonal skills or attributes and indicated least capability with assisting learners to explore strengths, weaknesses and learning goals. The qualitative category 'establishing relationships' was the most reported strength with 224 responses. The qualitative category 'feedback' was the most reported area for improvement, with 151 responses. Key areas for curricular focus include: improving feedback practices; stimulating reflective and agentic learning; and managing the logistics of a clinical education environment. Clinical supervisors' self-identified needs provide a foundation for designing engaging and relevant faculty development programs.

Identifying Opportunities for Peer Learning: An Observational Study of Medical Students on Clinical Placements.

Phenomenon: Peer assisted learning (PAL) is frequently employed and researched in preclinical medical education. Fewer studies have examined PAL in the clinical context: These have focused mainly on the accuracy of peer assessment and potential benefits to learner communication and teamwork skills. Research has also examined the positive and negative effects of formal, structured PAL activities in the clinical setting. Given the prevalence of PAL activities during preclinical years, and the unstructured nature of clinical placements, it is likely that nonformal PAL activities are also undertaken. How PAL happens formally and informally and why students find PAL useful in this clinical setting remain poorly understood. APPROACH: This study aimed to describe PAL activities within the context of clinical placement learning and to explore students' perceptions of these activities. An ethnographic study was conducted to gather empirical data on engagement in clinical placement learning activities, including observations and interviews with students in their 1st clinical year, along with their supervising clinicians. Thematic analysis was used to interrogate the data. FINDINGS: On average, students used PAL for 5.19 hours per week in a range of activities, of a total of 29.29 hours undertaking placements. PAL was recognized as a means of vicarious learning and had greater perceived value when an educator was present to guide or moderate the learning. Trust between students was seen as a requirement for PAL to be effective. Students found passive observation a barrier to PAL and were able to identify ways to adopt an active stance when observing peers interacting with patients. For example, learners reported that the expectation that they had to provide feedback to peers after task observation, resulted in them taking on a more critical gaze where they were encouraged to consider notions of good practice. Insights: Students use PAL in formal (i.e., tutorial) and nonformal (e.g., peer observation and feedback on the ward; discussion during lunch) situations in clinical education and find it useful. The educator is crucial in fostering PAL through providing opportunities for learners to practice together and in helping to moderate discussions about quality of performance. Student engagement in PAL may reduce passivity commonly reported in clinical rotations. Further directions for research into PAL in clinical education are identified along with potential strategies that may maximize the benefits of peer to peer learning.

Implementing Peer Learning in Clinical Education: A Framework to Address Challenges In the "Real World".

Phenomenon: Peer learning has many benefits and can assist students in gaining the educational skills required in future years when they become teachers themselves. Peer learning may be particularly useful in clinical learning environments, where students report feeling marginalized, overwhelmed, and unsupported. Educational interventions often fail in the workplace environment, as they are often conceived in the "ideal" rather than the complex, messy real world. This work sought to explore barriers and facilitators to implementing peer learning activities in a clinical curriculum. APPROACH: Previous peer learning research results and a matrix of empirically derived peer learning activities were presented to local clinical education experts to generate discussion around the realities of implementing such activities. Potential barriers and limitations of and strategies for implementing peer learning in clinical education were the focus of the individual interviews. FINDINGS: Thematic analysis of the data identified three key considerations for real-world implementation of peer learning: culture, epistemic authority, and the primacy of patient-centered care. Strategies for peer learning implementation were also developed from themes within the data, focusing on developing a culture of safety in which peer learning could be undertaken, engaging both educators and students, and establishing expectations for the use of peer learning. Insights: This study identified considerations and strategies for the implementation of peer learning activities, which took into account both educator and student roles. Reported challenges were reflective of those identified within the literature. The resultant framework may aid others in anticipating implementation challenges. Further work is required to test the framework's application in other contexts and its effect on learner outcomes.

Same-level peer-assisted learning in medical clinical placements: a narrative systematic review.

BACKGROUND: Peer-assisted learning (PAL) is increasingly used in medical education, and the benefits of this approach have been reported. Previous reviews have focused on the benefits of peer tutoring of junior students by senior students. Forms of PAL such as discussion groups and role-playing have been neglected, as have alternative teacher-learner configurations (e.g. same-level PAL) and the effects on other stakeholders, including clinician educators and patients. This review examines the benefits of same-level PAL for students, clinician educators and patients in pre-registration clinical medical education. METHODS: Medline, PsycINFO, CINAHL and ERIC were searched in March 2014. A total of 1228 abstracts were retrieved for review; 64 full-text papers were assessed. Data were extracted from empirical studies describing a same-level PAL initiative in a clinical setting, focusing on effects beyond academic performance and student satisfaction. Qualitative thematic analysis was employed to identify types of PAL and to cluster the reported PAL effects. RESULTS: Forty-three studies were included in the review. PAL activities were categorised into role-play, discussion, teaching and assessment. Only 50% of studies reported information beyond self-report and satisfaction with the PAL intervention. Benefits for students (including development of communication and professional skills) and clinician educators (developing less-used facilitation skills) were reported. Direct patient outcomes were not identified. Caveats to the use of PAL emerged, and guidelines for the use of PAL were perceived as useful. CONCLUSION: Many student-related benefits of PAL were identified. PAL contributes to the development of crucial skills required for a doctor in the workplace. Vertical integration of learning and teaching skills across the curriculum and tools such as feedback checklists may be required for successful PAL in the clinical environment. Benefits for patients and educators were poorly characterised within the included studies. Future work should evaluate the use of PAL with regards to student, clinician educator and patient outcomes.

The role of peer-assisted learning in building evaluative judgement: opportunities in clinical medical education.

This study explored the contribution of peer-assisted learning (PAL) in the development of evaluative judgement capacity; the ability to understand work quality and apply those standards to appraising performance. The study employed a mixed methods approach, collecting self-reported survey data, observations of, and reflective interviews with, the medical students observed. Participants were in their first year of clinical placements. Data were thematically analysed. Students indicated that PAL contributed to both the comprehension of notions of quality, and the practice of making comparisons between a given performance and the standards. Emergent themes included peer story-telling, direct observation of performance, and peer-based feedback, all of which helped students to define 'work quality'. By participating in PAL, students were required to make comparisons, therefore using the standards of practice and gaining a deeper understanding of them. The data revealed tensions in that peers were seen as less threatening than supervisors with the advantage of increasing learners' appetites for thoughtful 'intellectual risk taking'. Despite this reported advantage of peer engagement, learners still expressed a preference for feedback from senior teachers as more trusted sources of clinical knowledge. While this study suggests that PAL already contributes to the development of evaluative judgement, further steps could be taken to formalise PAL in clinical placements to improve learners' capacity to make accurate judgements on the performance of self and others. Further experimental studies are necessary to confirm the best methods of using PAL to develop evaluative judgement. This may include both students and educators as instigators of PAL in the workplace.

Inclusivity in health professional education: how can virtual simulation foster attitudes of inclusion?

Disparities in accessing quality healthcare persist among diverse populations. Health professional education should therefore promote more diversity in the health workforce, by fostering attitudes of inclusion. This paper outlines the potential of virtual simulation (VS), as one method in a system of health professional education, to promote inclusion and diversity. We conceptualise how VS can allow learners to experience an alternative to what HPE currently is by drawing on two social justice theorists, Paulo Freire, and Nancy Fraser and their ideas about 'voice' and 'representation'. We present two principles for VS design and implementation: (1) giving voice to learners has the power to transform; and (2) representation in VS builds inclusion. We provide practical means of building voice and representation into VS learning activities, followed by an example. Purposeful and thoughtful integration of these principles paves the way for a more diverse and inclusive healthcare workforce.

Honesty in critically reflective essays: an analysis of student practice.

In health professional education, reflective practice is seen as a potential means for self-improvement from everyday clinical encounters. This study aims to examine the level of student honesty in critical reflection, and barriers and facilitators for students engaging in honest reflection. Third year physiotherapy students, completing summative reflective essays on clinical encounters using the modified Gibbs cycle, were invited to participate in an anonymous online survey. Student knowledge and beliefs about reflective practice, and disclosure of the truthfulness of their reflections, were assessed using a mixed method approach. A total of 34 students, from a maximum possible of 48 (71 %), participated in the study activities. A total of 68 % stated that they were at least 80 % truthful about their experiences. There was general student consensus that reflective practice was important for their growth as a clinician. Students questioned the belief that the reflection needed to be based on a factual experience. Reflective practice can be a valuable addition to the clinical education of health care professionals, although this value can be diminished through dishonest reflections if it is not carefully implemented. Student influences on honest reflection include; (1) the design of any assessment criteria, and (2) student knowledge and competency in applying critical reflection.

A vertical study programme for medical students: peer-assisted learning in practice.

BACKGROUND: Monash University employs a vertically-integrated curriculum with cumulative knowledge testing throughout the course. To facilitate cross-year level revision, a vertical study programme (VESPA) was established using the principles of peer-assisted learning (PAL). AIM: To implement and evaluate VESPA in relation to defined objectives. METHODS: Following from a successful pilot, a working group organised five 2 h VESPA sessions over the course of 2009. Each was case-based and study materials were provided. Participants were allocated to a group of 10-15 students of all year levels, and pre-interns acted as facilitators. Sessions were evaluated using a 10-question survey. RESULTS: A total of 647 evaluation surveys were completed overall and participant numbers ranged from 79 to 182 per session. Of these, 624 (96%) agreed the case materials were easy to follow and 562 (87%) believed they allowed students from all year levels to contribute; 552 (85%) felt VESPA helped them understand curriculum content. There were no significant differences between sessions. CONCLUSIONS: VESPA represents an innovative application of PAL that has been well received by students. Potential benefits to participants include academic revision, the development of mentoring relationships and enhanced teaching and facilitation skills. This model of a structured revision programme would suit other settings with vertically-integrated curricula and assessment.

Preparing students for the future through developing evaluative judgement.

In today's environment, health students need to be prepared for an ever changing workplace and workforce. They need to understand what demonstrates good quality work and how to assess their standard of work. Evaluative judgement can contribute to student and graduate self-regulation and autonomy in their learning. This toolbox article describes how to implement strategies for developing evaluative judgement in allied health placements. These strategies were developed as part of an occupational therapy program in rural Western Australia, where experiential education is provided through service-learning with both direct and indirect supervision. Practical advice is provided on the use of peer-assisted learning, rubrics, self-assessment and feedback. Challenges and opportunities in implementing strategies to develop evaluative judgement, such as how to achieve effective feedback, are also discussed. The suggested toolbox may be adapted to various clinical placement contexts. Developing evaluative judgement can help to prepare our students to be lifelong learners. This article empowers educators to promote this capability in their students to create work ready graduates, who are able to operate independently and in rapidly evolving, technologically enabled environments.

Clinical supervision training across contexts.

BACKGROUND: Clinicians require specific skills to teach or supervise students in the workplace; however, there are barriers to accessing faculty member development, such as time, cost and suitability. The Clinical Supervision Support Across Contexts (ClinSSAC) programme was designed to provide accessible interprofessional educator training to clinical supervisors across a wide range of clinical settings. CONTEXT: In Australia there are increasing numbers of health care students, creating pressure on existing placements. Students are now increasingly learning in community settings, where clinicians have traditionally had less access to faculty member development. INNOVATION: An interprofessional team collaborated in the development and implementation of ClinSSAC. A total of 978 clinicians participated in a face-to-face, interactive, introductory module to clinical supervision; 672 people accessed the equivalent online core module, with 23 per cent completing all activities. Additional profession-and discipline-specific modules were also developed. IMPLICATIONS: Formal project evaluation found that most participants rated the workshops as helpful or very helpful for their roles as clinical supervisors. Interdisciplinary learning from the workshops was reported to enable cross-discipline supervision. Large participant numbers and favourable ratings indicate a continuing need for basic training in education. Key factors to workshop success included expert facilitators, the interprofessional context and interactive model. The online modules were an important adjunct, and provided context-specific resources, but the low online completion rate suggests protected face-to-face time for faculty member development is still required. Programmes such as ClinSSAC have the capacity to promote interprofessional education and practice. There are barriers to accessing faculty member development, such as time, cost and suitability.

Covert attention affects the psychometric function of contrast sensitivity.

We examined the effect of transient covert attention on the psychometric function for contrast sensitivity in an orientation discrimination task when the target was presented alone in the absence of distracters and visual masks. Transient covert attention decreased both the threshold (consistent with a contrast gain mechanism) and, less consistently, the slope of the psychometric function. We assessed performance at 8 equidistant locations (4.5 degrees eccentricity) and found that threshold and slope depended on target location-both were higher on the vertical than the horizontal meridian, particularly directly above fixation. All effects were robust across a range of spatial frequencies, and the visual field asymmetries increased with spatial frequency. Notwithstanding the dependence of the psychometric function on target location, attention improved performance to a similar extent across the visual field.Given that, in this study, we excluded all sources of external noise, and that we showed experimentally that spatial uncertainty cannot explain the present results, we conclude that the observed attentional benefit is consistent with signal enhancement.