Exploring perspectives on health professions education scholarship units from sub-Saharan Africa.

INTRODUCTION: There has been a marked increase in institutional structures developed to support health professions education scholarship recently. These health professions education scholarship units (HPESUs) engage in a diverse range of activities. Previous work provided insight into factors that influence the functioning of such units, but data from European, Asian, Latin American, and African contexts was absent, potentially leading to a single world-view informing international standards for HPESUs. This aim of this study was to explore perspectives from sub-Saharan Africa (SSA) in response to this omission. METHODS: Situated within an interpretivist paradigm, the research team conducted semi-structured interviews with nine HPESU leaders in SSA, exploring how participants experienced and understood the functioning of their units. Despite efforts to have representation from across the region, most participants were from South Africa. The researchers analysed data thematically using the theory of institutional logics as an analytical frame. RESULTS: Several aspects of the HPESUs aligned with the previously identified logics of academic research, service and teaching; and of a cohesive education continuum. By contrast, leaders described financial sustainability as a more prominent logic than financial accountability. DISCUSSION: The similarities identified in this study may reflect isomorphism-a process which sees institutions within a similar field becoming more alike, particularly as newer institutions seek to acquire legitimacy within that field. An important caveat, however, is that isomorphism tends to occur across similar institutional contexts, which was not the case in this study. Understanding these differences is key as these HPESUs move to foster scholarship that can respond to the region's unique context.

Human resources for health interventions in high- and middle-income countries: findings of an evidence review.

Many high- and middle-income countries face challenges in developing and maintaining a health workforce which can address changing population health needs. They have experimented with interventions which overlap with but have differences to those documented in low- and middle-income countries, where many of the recent literature reviews were undertaken. The aim of this paper is to fill that gap. It examines published and grey evidence on interventions to train, recruit, retain, distribute, and manage an effective health workforce, focusing on physicians, nurses, and allied health professionals in high- and middle-income countries. A search of databases, websites, and relevant references was carried out in March 2019. One hundred thirty-one reports or papers were selected for extraction, using a template which followed a health labor market structure. Many studies were cross-cutting; however, the largest number of country studies was focused on Canada, Australia, and the United States of America. The studies were relatively balanced across occupational groups. The largest number focused on availability, followed by performance and then distribution. Study numbers peaked in 2013-2016. A range of study types was included, with a high number of descriptive studies. Some topics were more deeply documented than others-there is, for example, a large number of studies on human resources for health (HRH) planning, educational interventions, and policies to reduce in-migration, but much less on topics such as HRH financing and task shifting. It is also evident that some policy actions may address more than one area of challenge, but equally that some policy actions may have conflicting results for different challenges. Although some of the interventions have been more used and documented in relation to specific cadres, many of the lessons appear to apply across them, with tailoring required to reflect individuals' characteristics, such as age, location, and preferences. Useful lessons can be learned from these higher-income settings for low- and middle-income settings. Much of the literature is descriptive, rather than evaluative, reflecting the organic way in which many HRH reforms are introduced. A more rigorous approach to testing HRH interventions is recommended to improve the evidence in this area of health systems strengthening.

The US Health Provider Workforce: Determinants and Potential Paths to Enhancement.

The health provider workforce is shaped by factors collectively influencing the education, training, licensing, and certification of physicians and allied health professionals, through professional organizations with interlocking and often opaque governance relationships within a state-based licensing system. This system produces a workforce is that is insufficiently responsive to current needs and opportunities, including those created by new technologies. This lack of responsiveness reflects the complex, nontransparent, and cautious nature of the controlling organizations, influenced by the economic interests of the organized professions, which seek protection from competitors both local and international. The first step in addressing this is to comprehensively examine the organizational complexity and conflicted interests within this critical ecosystem. Doing so suggests areas ripe for change, to enhance the health workforce and benefit public health.

Examinee Cohort Size and Item Analysis Guidelines for Health Professions Education Programs: A Monte Carlo Simulation Study.

PURPOSE: Using item analyses is an important quality-monitoring strategy for written exams. Authors urge caution as statistics may be unstable with small cohorts, making application of guidelines potentially detrimental. Given the small cohorts common in health professions education, this study's aim was to determine the impact of cohort size on outcomes arising from the application of item analysis guidelines. METHOD: The authors performed a Monte Carlo simulation study in fall 2015 to examine the impact of applying 2 commonly used item analysis guidelines on the proportion of items removed and overall exam reliability as a function of cohort size. Three variables were manipulated: Cohort size (6 levels), exam length (6 levels), and exam difficulty (3 levels). Study parameters were decided based on data provided by several Canadian medical schools. RESULTS: The analyses showed an increase in proportion of items removed with decreases in exam difficulty and decreases in cohort size. There was no effect of exam length on this outcome. Exam length had a greater impact on exam reliability than did cohort size after applying item analysis guidelines. That is, exam reliability decreased more with shorter exams than with smaller cohorts. CONCLUSIONS: Although program directors and assessment creators have little control over their cohort sizes, they can control the length of their exams. Creating longer exams makes it possible to remove items without as much negative impact on the exam's reliability relative to shorter exams, thereby reducing the negative impact of small cohorts when applying item removal guidelines.

Considerations that will determine if competency-based assessment is a sustainable innovation.

Educational assessment for the health professions has seen a major attempt to introduce competency based frameworks. As high level policy developments, the changes were intended to improve outcomes by supporting learning and skills development. However, we argue that previous experiences with major innovations in assessment offer an important road map for developing and refining assessment innovations, including careful piloting and analyses of their measurement qualities and impacts. Based on the literature, numerous assessment workshops, personal interactions with potential users, and our 40 years of experience in implementing assessment change, we lament the lack of a coordinated approach to clarify and improve measurement qualities and functionality of competency based assessment (CBA). To address this worrisome situation, we offer two roadmaps to guide CBA's further development. Initially, reframe and address CBA as a measurement development opportunity. Secondly, using a roadmap adapted from the management literature on sustainable innovation, the medical assessment community needs to initiate an integrated plan to implement CBA as a sustainable innovation within existing educational programs and self-regulatory enterprises. Further examples of down-stream opportunities to refocus CBA at the implementation level within faculties and within the regulatory framework of the profession are offered. In closing, we challenge the broader assessment community in medicine to step forward and own the challenge and opportunities to reframe CBA as an innovation to improve the quality of the clinical educational experience. The goal is to optimize assessment in health education and ultimately improve the public's health.

Health Sciences cultural safety education in Australia, Canada, New Zealand, and the United States: a literature review.

OBJECTIVES: To review the research literature on cultural safety education within post-secondary health science programs. METHODS: We conducted health and social science database searches from 1996-2016, using combined keywords: cultural competence or safety; teaching or curriculum; universities, polytechnics or professional programs; and Aboriginal or Indigenous. In dyads, authors selected, and reviewed studies independently followed by discussion and consensus to identify thematic linkages of major findings. RESULTS: A total of 1583 abstracts and 122 full-text articles were reviewed with 40 selected for final inclusion. Publications from Australia, Canada, New Zealand and the United States described curriculum development and delivery. A variety of evaluation approaches were used including anecdotal reports, focus groups, interviews, course evaluations, reflective journals, pre-post surveys, critical reflective papers, and exam questions. Duration and depth of curricular exposure ranged from one day to integration across a six-year program.  Changes in student knowledge, attitude, self-confidence, and behaviour when working with Indigenous populations were reported. Cultural safety education and application to practice were shown to be linked to improved relationships, healthier outcomes, and increased number of Indigenous people entering health education programs and graduates interested in working in diverse communities. CONCLUSIONS: This review provides a summary of multidisciplinary didactic and experiential instructional approaches to cultural safety education and the impact on students, educators and Indigenous people.  Institutional support, strategic planning and cultural safety curriculum policy within post-secondary settings and community engagement are imperative for positive student experiences, advocacy, and actions toward health equity and improved health for Indigenous people and communities.

Core Entrustable Professional Activities in Clinical Pharmacology for Entering Residency: Value of Interprofessional Health-Care Teams in Medication Prescribing and Medication Error Prevention.

In recent years, health care has been increasingly delivered by interprofessional teams in the inpatient, outpatient, and transition-of-care arenas. For many reasons, effective communication between patient-centered care teams and patients is critically important in order to optimize care, ensure patient safety, and prevent medical and medication misadventures. In rapid-paced, high-stress medical environments, it is especially important to carefully evaluate the causes of all misadventures in a manner that avoids assigning blame and identifies the root causes and, through team activity, leads to development of remedies that reduce the likelihood of future misadventures. Using a series of illustrative cases, this paper seeks to bring attention to these issues and provide insights regarding some tools developed to assist in improving patient safety and effective team communication.

Using the multiple mini interview as an assessment strategy within the first year of a health professions curriculum.

BACKGROUND: The multiple mini-interview (MMI) is a common assessment strategy used in student selection. The MMI as an assessment strategy within a health professions curriculum, however, has not been previously studied. This study describes the integration of a 5-station MMI as part of an end-of-year capstone following the first year of a health professions curriculum. The goal of the capstone MMI was to assess professional competencies of students and to offer formative feedback to prepare students for their upcoming clinical practice experiences. The purpose of this study was to evaluate the psychometric properties of an MMI integrated into a health professions curriculum. METHODS: Five capstone MMI stations were designed to each evaluate a single construct assessed by one rater. A principal component analysis (PCA) was used to evaluate the structure of the model and its ability to distinguish 5 separate constructs. A Multifaceted Rasch Measurement (MFRM) model assessed student performance and estimated the sources of measurement error attributed to 3 facets: student ability, rater stringency, and station difficulty. At the conclusion, students were surveyed about the capstone MMI experience. RESULTS: The PCA confirmed the MMI reliably assessed 5 unique constructs and performance on each station was not strongly correlated with one another. The 3-facet MFRM analysis explained 58.79% of the total variance in student scores. Specifically, 29.98% of the variance reflected student ability, 20.25% reflected rater stringency, and 8.56% reflected station difficulty. Overall, the data demonstrated an acceptable fit to the MFRM model. The majority of students agreed the MMI allowed them to effectively demonstrate their communication (80.82%), critical thinking (78.77%), and collaboration skills (70.55%). CONCLUSIONS: The MMI can be a valuable assessment strategy of professional competence within a health professions curriculum. These findings suggest the MMI is well-received by students and can produce reliable results. Future research should explore the impact of using the MMI as a strategy to monitor longitudinal competency development and inform feedback approaches.

Regulação das profissões de saúde nos Estados Unidos / The regulation of health professions by professional councils in the law of France and Europe

A regulação das profissões da área de saúde nos Estados Unidos é uma responsabilidade primária dos estados. A estrutura e o conteúdo das regulações específicas de cada estado impactam a prestação de serviços de saúde, afetando os custos, a qualidade e o acesso. Existe a preocupação de que as atuais estruturas regulatórias estaduais e específicas para cada profissão não poderão servir de base para as inovações na mão de obra necessárias à reforma do sistema de saúde. Este artigo revisa tanto os aspectos da regulação em nível estadual de profissões da área de saúde que limitam o uso efetivo dos profissionais de saúde como uma de suas principais vantagens: sua capacidade de providenciar soluções locais para enfrentar problemas de acesso. Descrevem-se elementos geradores de mudanças na demanda por serviços de saúde e prestadores de saúde. Por último, recomendam-se estratégias para melhorar as decisões em relação às práticas, incluindo: padronização de escopos da prática entre diferentes estados; atualização permanente de leis de prática profissional específicas em cada estado, de acordo com a evolução das competências profissionais; uso das melhores evidências para autorizar novas especialidades profissionais ou expandir o escopo das práticas já existentes e, quando não houver tais evidências, promover programas para testar novas modalidades de trabalho. Levando em conta o ritmo das transformações do sistema de saúde nos Estados Unidos, existe uma urgência crescente por reformas que assegurem uma força de trabalho adequadamente dimensionada e treinada para o futuro.

A regulação das profissões de saúde na França / The regulation of health professions in France

A regulação jurídica das profissões de saúde faz parte de uma política de saúde pública e contribui para o estabelecimento de um sistema de saúde de qualidade e acessível a todos. No entanto, há muito tempo, as questões regulatórias são monopolizadas por entidades profissionais, principalmente pelos conselhos médicos, que defendem um sistema liberal e a autonomia jurídica das profissões. A regulação das profissões de saúde na França ainda é precária, porém, tende a se tornar cada vez mais um assunto de interesse de todos os cidadãos.

Regulação do exercício de profissões de saúde: fragmentação e complexidade do modelo regulatório brasileiro e desafios para seu aperfeiçoamento / Health professions regulation: Fragmentation and complexity of the Brazilian model and challenges for its improvement

A regulação jurídica das profissões de saúde no Brasil é composta por um conjunto normativo amplo, complexo e fragmentado, que encontra sua base na Constituição Federal de 1988 e se complementa por uma extensa quantidade de leis, decretos, portarias e, principalmente, resoluções editadas pelos conselhos profissionais. O presente artigo tem como objetivo identificar os principais marcos legais que estruturam a regulação do exercício profissional no setor da saúde brasileiro, delineando, a partir dos resultados obtidos, o modelo de regulação do exercício de profissões de saúde no Brasil. o método utilizado foi de pesquisa normativa e jurisprudencial, com análise qualitativa dos dados selecionados. A partir das leis atualmente vigentes, foram identificadas as diferentes instituições estatais com competência legal para regular as profissões de saúde no Brasil e as principais normas editadas para a regulação das profissões de saúde. Em seguida, buscaram-se conflitos regulatórios judicializados por essas instituições e levados até os tribunais superiores. A análise das leis e decisões selecionadas permitiu a caracterização do que denominamos Modelo de Regulação de Profissões de Saúde Brasileiro, com a identificação e análise das diferentes instituições estatais reguladoras e das principais normas vigentes que regulam as 14 profissões de saúde reconhecidas pelo Conselho Nacional de Saúde. Os resultados apresentados neste artigo delineiam o atual modelo de regulação de profissões de saúde vigente no Brasil e contribuem para o aprofundamento dos conhecimentos sobre o tema, possibilitando reflexões para o aperfeiçoamento do atual modelo jurídico-institucional brasileiro.

The legal regulation of health professions in Brazil is composed by a set of broad, complex and fragmented norms, based on the Federal Constitution of 1988 (CF 88) and complemented by an extensive amount of laws, decrees, ordinances, and mainly resolutions issued by the professional councils. This article aims to identify the main legal frameworks that structure the regulation of professional practice in the Brazilian health sector, using the results to outline a model of regulation of the Health Professions in Brazil. The method used was normative and jurisprudential research followed by a qualitative analysis of the selected data. Based on the current laws, we first identified the different state institutions with legal competence to regulate the health professions in Brazil and the main edited norms for that purpose. Next, we searched for the regulatory conflicts brought by these institutions before the higher courts. The analysis of the selected laws and decisions allowed the characterization of what we call the Brazilian Health Professions Regulation Model, with the identification and analysis of the different state regulatory institutions and the main current norms that regulate the 14 health professions recognized by the National Health Council. The results presented in this article outline the current Model of Regulation of Health Professions in force in Brazil and contribute to the deepening of knowledge on the subject, allowing reflections for the improvement of the current Brazilian legal-institutional model.

Defining Health Profession Regulators' Roles in the Canadian Healthcare System.

Health professions regulation today faces a myriad of challenges, due to both the perceived performance of regulatory colleges, how health systems have evolved, and even larger political and economic shifts such as the renegotiation of NAFTA. In this issue of Healthcare Papers, Wilkie and Tzountzouris (2017) describe the work of the College of Medical Laboratory Technologists of Ontario (CMLTO) to redefine professionalism in the context of these challenges. Their paper, and the comments of the responding authors in this issue highlight that there, is an overarching perception that health regulatory structures - across a range of professions - are not working as effectively as they should. Across this issue of Healthcare Papers, attention is drawn to the fact that more can be done to improve both the function and perception of professional regulatory bodies. However, each paper presents a different approach to how improvements in function and perception are possible.