Crisis, change and the future for teaching and learning in general practice.

OBJECTIVES: The aim of this study was to explore the decisions and decision-making strategies employed by academic GPs tasked with adapting the delivery of undergraduate general practice education curricula to virtual platforms during the Covid-19 pandemic. We sought to investigate how their experiences of this adaptation might influence the development of future curricula. METHODS: Recognising our 'insider' positions and constructivist paradigm preferences, we approached the study from a constructivist grounded theory (CGT) perspective and participants participated in semi-structured interviews. RESULTS: Nine participants from three university GP departments in Ireland described the transition to online delivery of the curriculum as a 'response approach'. Participants described seeking collaboration both within and between institutions. The value and limitations of student feedback as a driver for change differed between participants and recognised the impact of limited social engagement between peers on social determinants of learning. Participants with prior experience in e-learning were inclined to recommend some level of continuation. Two institutions plan to continue to incorporate aspects of blended learning. CONCLUSION AND IMPLICATIONS: All participants recognised a level of value (efficiency, social engagement and continuity) in online learning, they were less clear on the specific educational value and impact of this (e.g. on knowledge, skills and attributes). We need to consider which elements of undergraduate education can be delivered effectively online. Maintaining the socio-cultural learning environment is of critical importance but must be balanced by efficient, informed and strategic educational design.

Educational change in a crisis: what has changed and what is here to stay in undergraduate teaching and learning in General Practice.

OBJECTIVES: The aim of the study was to explore the decisions and decision-making strategies employed by academic GPs tasked with adapting the delivery of undergraduate general practice education curricula to virtual platforms during the COVID-19 pandemic and to investigate how their experiences of this adaptation might influence the development of future curricula. METHODS: Approaching the study from a constructivist grounded theory (CGT) perspective, we recognised that experiences shape perception, and an individual's 'truths' are socially constructed. Nine academic GPs from three university GP departments participated in semistructured interviews conducted via Zoom©. Anonymised transcripts were iteratively analysed, generating codes, categories, and concepts using a constant comparative approach. The study was approved by the Royal College of Surgeons in Ireland (RCSI) Research Ethics Committee. RESULTS: Participants described the transition to online delivery of the curriculum as a 'response approach'. The elimination of in-person delivery necessitated the changes rather than any strategic development process. With varying levels of experience in eLearning, participants described the need for and engagement with collaboration both internally within institutions and externally between institutions. Virtual patients were developed to replicate learning in a clinical environment. How these adaptions were evaluated by learners differed across the institutions. The value and limitations of student feedback as a driver for change differed between participants. Two institutions plan to incorporate aspects of blended learning going forward. Participants recognised the impact of limited social engagement between peers on social determinants of learning. CONCLUSION AND IMPLICATIONS: Prior experience in eLearning appeared to colour participants' perceptions of its value; those experienced in online delivery were inclined to recommend some level of continuation post-pandemic. We now need to consider which elements of undergraduate education can be delivered effectively online into the future. Maintaining the socio-cultural learning environment is of critical importance but must be balanced by efficient, informed and strategic educational design.

Myths and legends in workplace-based assessment; it's all about perspective?

Based on internationally published literature and the experience of the project team, we understood that already established beliefs and perceptions could influence the implementation of new workplace-based assessment (WBA) tools and processes. At the start of a project to design new WBA tools, we, therefore, attempted to understand the perspectives and perceptions of our GP training community and inform the communication strategy for the project. Online and paper surveys were disseminated to GP trainers, trainees and programme directors. Data were extracted from SurveyMonkey, added to paper-based data in an Excel spreadsheet and analysed using descriptive statistics. While it was generally acknowledged that trainers provide regular feedback to trainees, perceptions of the quality of feedback varied between the groups. The majority of participants agreed that WBA would be of value in learning but expressed concerns over increased workload. There were also some misconceptions about the purpose of WBA, with trainees stating they understood WBAs to be valid and reliable as a single-event sign-off tool. Differences in trainer, trainee and programme director perceptions of the use and usefulness of WBA may be attributed to many factors, not least of all (lack of) experience, perspective and position.

Is the learning value of workplace-based assessment being realised? A qualitative study of trainer and trainee perceptions and experiences.

PURPOSE: Workplace-based assessments (WBAs) were originally intended to inform learning and development by structuring effective observation-based feedback. The success of this innovation has not yet been established due in part to the widely varied tools, implementation strategies and research approaches. Using a conceptual framework of experience, trajectories and reifications in workplace learning, we aimed to explore trainer and trainee experiences and perceptions of the learning value of WBAs. STUDY DESIGN: Trainers and trainees who had used at least one WBA in the previous year were invited to participate in semistructured interviews for this phenomenological study. We used a template analysis method to explore and compare the experiences of the two groups, using the emergent themes to develop an understanding of the impact of these experiences on perceptions of learning value. RESULTS: Nine trainers and eight trainees participated in the study. Common themes emerged among the two groups around issues of responsibility and engagement along with (mis)understandings of the purpose of the individual tools. Trainer-specific themes emerged related to the concurrent implementation of a new e-portfolio and perceptions of increased workload. Trainees associated WBA with a training structure support value but could not translate experiences into learning values. CONCLUSIONS: WBAs provide trainees with a justified reason to approach trainers for feedback. WBAs, however, are not being reified as the formative assessments originally intended. A culture change may be required to change the focus of WBA research and reconceptualise this set of tools and methods as a workplace learning practice.

A BEME (Best Evidence in Medical Education) review of the use of workplace-based assessment in identifying and remediating underperformance among postgraduate medical trainees: BEME Guide No. 43.

INTRODUCTION: The extent to which workplace-based assessment (WBA) can be used as a facilitator of change among trainee doctors has not been established; this is particularly important in the case of underperforming trainees. The aim of this review is to examine the use of WBA in identifying and remediating performance among this cohort. METHODS: Following publication of a review protocol a comprehensive search of eight databases took place to identify relevant articles published prior to November 2015. All screening, data extraction and analysis procedures were performed in duplicate or with quality checks and necessary consensus methods throughout. Given the study-level heterogeneity, a descriptive synthesis approach informed the study analysis. RESULTS: Twenty studies met the inclusion criteria. The use of WBA within the context of remediation is not supported within the existing literature. The identification of underperformance is not supported by the use of stand-alone, single-assessor WBA events although specific areas of underperformance may be identified. Multisource feedback (MSF) tools may facilitate identification of underperformance. CONCLUSION: The extent to which WBA can be used to detect and manage underperformance in postgraduate trainees is unclear although evidence to date suggests that multirater assessments (i.e. MSF) may be of more use than single-rater judgments (e.g. mini-clinical evaluation exercise).

Interprofessional ethics and professionalism debates: findings from a study involving physiotherapy and pharmacy students.

Ethics is a core component of healthcare curricula and may provide ideal content for interprofessional education (IPE). An IPE debate in ethics and professionalism was developed for first year undergraduate pharmacy and physiotherapy students. A controlled "before-and-after" study was conducted. The opinion of students on IPE, the debate topics and debating was determined before and after the debate. While there was no impact on attitudes to IPE or healthcare professionals, students agreed that debating ethics through IPE was a valid teaching modality. Students found the debates challenging. They stimulated critical thinking and interest in complex and controversial issues. Students also found it of benefit to work as a team. We conclude that in-class debate is a useful way of learning together.

'Rules of engagement': Does competition drive engagement in faculty development.

INTRODUCTION: Faculty development (FD) is integral to the implementation of educational programmes. However, attracting new faculty is challenging. Competition is a motivator for learning at an undergraduate level; however, incorporating competition to engage faculty in continued FD has not been explored. In the context of a new strategy to embed in situ simulation in postgraduate education across our healthcare group, and drawing on motivational theory, we asked 'does competition drive engagement in new FD initiatives?' METHODS: We conducted semi-structured interviews with nine healthcare professionals (HCPs) who had participated in an in situ simulation 'SimStars' competition. Guided by thematic analysis and borrowing from constructivist grounded theory, we explored participants' motivations for entering a competition, their experiences of competition throughout their education and how this process impacted on their engagement in FD. RESULTS: Three overarching concepts arose and challenged our understanding of the role of competition as a motivator: (1) 'Competition is a necessary evil'; (2) 'It really is the taking part that counts'; and (3) 'Teamwork makes the dream work'. In contrast to previously published work, our results suggest participants view competition negatively and as a means to career progression. However, the opportunity to work as part of an (interprofessional) team towards a goal, and to develop a new skill (i.e. the process), was more motivating for participants than 'winning' a competition. CONCLUSION: Competition may not provide a motivation for HCPs to engage in FD and may be a barrier. Providing collaboration opportunities, faculty coaching and the chance to develop new skills could enhance engagement.

The Modified Rivermead Mobility Index: reliability and convergent validity in a mixed neurological population.

PURPOSE: To assess the inter-rater reliability, internal consistency and convergent validity of the Modified Rivermead Mobility Index (MRMI) in a mixed neurological population. METHOD: The MRMI was scored for 30 consecutive patients (mean age 54.5+/-15.6 years) by two individual testers. Reliability was examined using intraclass correlation coefficients (ICC3,1) and Bland and Altman plots; internal consistency reliability using Cronbach's alpha (alpha) and convergent validity using Spearman's correlation coefficient (rho) test to compare the MRMI to the 10-m walk test as a gold standard of mobility. As the majority of patients had bilateral deficits, the MRMI was measured and added independently for both sides. RESULTS: The inter-rater reliability was excellent: ICC (95% CI)=0.93(0.86, 0.96). The Bland and Altman plots contained most data points and there was perfect agreement between raters bilaterally in 27% of cases, with a difference of one point in 60% of cases on the left and 63% of cases on the right. Internal consistency was good at alpha=0.72 (Rater 1) and 0.80 (Rater 2). The Spearman rho between MRMI and the 10-m walk test was high at 0.86. CONCLUSIONS: The MRMI was shown to have high levels of reliability in a mixed neurological population but we recommend that its psychometric properties are further investigated to establish the true clinical utility of this measure.

How to synthesise qualitative data.

Methods of qualitative synthesis are an important component of the research toolbox. In this article, we introduce several ways to approach qualitative data synthesis and discuss how to choose between them. We use published examples throughout to illustrate how these methods are used to address research questions.

How to be reflexive when conducting qualitative research.

Reflexivity can be a complex concept to grasp when entering the world of qualitative research. In this article, we aim to encourage new qualitative researchers to become reflexive as they develop their critical research skills, differentiating between the familiar concept of reflection and reflective practice and that of reflexivity. Although reflection is, to all intents and purposes, a goal-oriented action with the aim of improving practice, reflexivity is a continual process of engaging with and articulating the place of the researcher and the context of the research. It also involves challenging and articulating social and cultural influences and dynamics that affect this context. As a hallmark of high-quality qualitative research, reflexivity is not only an individual process but one that needs to be considered a collective process within a research team, and communicated throughout the research process. In keeping with our previous articles in this series, we have illustrated the theoretical concept of reflexivity using practical examples of published research.

How to analyse qualitative data in different ways.

In this paper, the fifth in a series on qualitative research in medical education, we discuss approaches to analysing qualitative data. We focus primarily on analysing transcribed interview and focus group data. We also touch on the analysis of visual data, a potentially fruitful alternative approach.

How to choose between different types of data.

This article, on how to choose the types of data that are most appropriate to your study, is the third in a series that aims to support researchers within clinical education who are new to qualitative research. Although individual or focus group interviews may seem to be the most obvious source of data in qualitative research, we describe some alternative data sources and how they can be of value in answering certain research questions. We provide examples of how research participants may tell you about their experiences through audio diaries, how they may show you what is going on by drawing a picture, and how you can study what actually happens in practice by observing how people interact, move, dress and use space. By doing so, we hope to catch your interest and inspire you to think of all the different possibilities when setting up a qualitative study. In qualitative research, almost everything in the real world can serve as data.

How to do research interviews in different ways.

This article is the next instalment in our 'How to…' series about qualitative research, and focuses on interviews. In many ways, conducting research interviews can be compared with talking to a patient or a student, yet there are specific elements to consider if you want the interview data to be useful for a research study. In this article, we will reflect on what a 'good' research interview is. We will provide an overview of different types of interviews, both much used and more adventurous. Finally, we present a list of dilemmas and frequently asked questions, with tips, tricks and suggestions. This practical and concise article will be helpful when starting a qualitative research project using interviews. Getting access to participants' inner worlds is the real trick to acquiring rich data.

Development and Initial Psychometric Properties of a Questionnaire to Assess Competence in Palliative Care: Palliative Care Competence Framework Questionnaire.

BACKGROUND: Although the provision of palliative care (PC) is fundamental to the role of the physician, little research has assessed the competence of trainee and experienced physicians in PC. AIM: To describe the development of a competence questionnaire and assess the level of competence of medical doctors in Ireland to provide PC to individuals with life-limiting conditions and their families. DESIGN: A survey-based cohort study was employed using a questionnaire based on the Palliative Care Competence Framework, developed specifically for this study. SETTING: The sample was accessed via the Royal College of Physicians of Ireland. All specialties in adult medical care and direct patient contact were included. RESULTS: A pilot study demonstrated comprehensiveness and ensured face validity. In the main study, all subscales showed internal reliability and evidence of a normal distribution. Strong correlation was noted between knowledge and behavior while moderate correlations were noted between attitudes and behavior and attitudes and knowledge, respectively. As expected, palliative-trained participants scored significantly higher in attitudes, behavior, and knowledge. CONCLUSIONS: The study provides baseline data on the level of competence of PC of doctors working in Ireland. The study also offers a novel assessment tool that has the potential to be used for future research.