Applying self-determination theory to stem medical schools' clinical teacher sustainability crisis.

THE PROBLEM: Medical schools require highly skilled and committed clinical faculty to teach, assess, supervise and mentor students' clinical care. Medical education is facing a crisis in recruiting and sustaining these clinical teachers. Faced with multiple demands and responsibilities in fast-paced clinical environments, teachers may not have the time, resources or stamina to sustain these critical roles. Medical school leaders must commit to and provide structures and processes to attract, sustain and retain clinical teachers. CONCEPTUAL FRAMEWORK: The authors use the lens of self-determination theory to frame approaches to support teacher sustainability. Self-determination theory describes sources of human motivation. The theory and its evidence base characterise three human psychological needs: autonomy, competence, and relatedness. This theory can bridge individual psychological and institutional leadership perspectives to help medical school leaders anticipate and respond to their clinical teachers' needs. The authors propose three practical steps: practices to advance employee-centredness, processes to align individual and institutional values, and restructuring education to support clinical teachers' needs alongside student and patient needs. The authors describe limitations to this relational approach that focuses on leadership actions and consider individual agency as another key factor for sustainability. DISCUSSION: Medical school leaders can develop and apply theory-driven approaches to advance sustainability. Sustainability now and in the future requires careful attention to the needs of clinical teachers and to their relationships with and within medical schools.

Sustainable healthcare education: A systematic review of the evidence and barriers to inclusion.

PURPOSE OF THE ARTICLE: Health professions education is failing to prepare students to practice sustainable healthcare despite the climate crisis an urgent provision of educational opportunities is required. This systematic review aimed to synthesise educational approaches applied to sustainable healthcare education within health professions curricula and critically evaluate their impact. MATERIALS AND METHODS: Databases searched: APA PsycInfo, BEI, CINAHL, Embase, ERIC, Medline, Scopus, Cochrane Library, Web of Science, BASE, DART-Europe, EThOS and ProQuest. Secondary searching techniques were also utilised, with searching conducted October 2021. Eligible studies included healthcare professional students/trainees, exposed to sustainable healthcare education, and evaluated through impact on knowledge, attitudes or skills. Empirical studies of any publication status were included. Non-English language studies were excluded. Eligible studies were quality assessed using JBI (2022) critical appraisal checklists and synthesised narratively. RESULTS: Twenty-three studies were included, comprising 3343 participants and seven health professions. Studies primarily adopted a quasi-experimental design and demonstrated variable quality. Most common educational approaches were workshops and clinical skills sessions, though eight different approaches were observed. Positive impacts were achieved for knowledge, attitudes and skills. CONCLUSIONS: Diverse approaches have been applied to sustainable healthcare education, though no superior approach is evident. Instead, many effective approaches are outlined, to be adopted in alignment with the learning outcomes.

A realist evaluation of a London general practitioner trainer course.

Clinicians with teaching and training roles should be adequately trained and assessed. However, some debate exists as to what the nature of this training should be. Historically, a postgraduate certificate in education was a pre-requisite to becoming a GP trainer but this is changing with growing concern that such a pre-requisite might act as a deterrent to potential GP trainers. This research examines the impact of a scheme designed to provide an alternative, more practical and focused, pathway to becoming a GP trainer. We interviewed 26 course participants and stakeholders of the London GP Training Course (LGPTC), observed teaching sessions, and analysed course materials. We asked what elements of the course were and weren't effective, for whom, and under what circumstances. Here, we present a summary of our main findings - that GP trainers want to know practically, not theoretically, how to be a trainer; formative assessment boosts trainees' confidence in their own skills and abilities; short, practical GP training courses can help enhance the numbers of GP trainers; important questions remain about the role and value of educational theory in education faculty development.

What makes a model prescriber? A documentary analysis.

INTRODUCTION: In recent years, the authority to prescribe medications in healthcare has expanded to include pharmacists, nurses and Allied Healthcare Professionals. Subsequently, the quantity of guidelines describing appropriate prescribing practice has increased. Despite this, the literature notes a lack of consensus regarding the overall qualities of a good prescriber. The aim of this study was to attempt to define what makes a model prescriber in practice, regardless of professional background. METHODS: A documentary analysis of UK-based and international prescribing practice guidelines was performed. Data analysis was conducted through a constructivist grounded theory approach to enable concepts to be identified from the data itself without the use of pre-defined categories. RESULTS: A total of 13 guideline documents were analysed. Overall, four core categories of a model prescriber in practice were identified: Knowledgeable: including that of disease and drug properties; Safe: relating to appropriate drug quantities and treatment-monitoring; Good Communicators: with both patients and colleagues; Contemporary: through enhancing knowledge and skills. CONCLUSIONS: These four categories can serve as a definition of a high-level prescriber and as an additional tool for prescribing educators to evaluate the extent their curriculum develops and assesses the core qualities needed by their students to be high-level prescribers in practice.

Early career doctors' experiences of psychiatry placements: A qualitative study.

INTRODUCTION: On completion of a medical degree, junior doctors in the UK undergo a 2 year Foundation Programme. Since 2016, 45% of Foundation Programme doctors are required to undertake a psychiatry placement during foundation training. During this time, recruitment to Core Psychiatry Training has fluctuated, dropping to a 69% fill rate in 2017. METHODS: With the support of the Royal College of Psychiatrists, Health Education England and the UK Foundation Programme Office, a large-scale study was formulated utilising semi-structured focus groups. These exploring participant experiences help to understand how and if the psychiatry foundation placements are valuable, and their potential influence on a trainee choosing psychiatry as a career. A framework analysis was used to analyse data. RESULTS: Seventy-four participants across 10 foundation schools in England participated. Experiences and perceptions were split into three broad themes; pre-placement, during placement, and post-placement. Within these, 12 sub-themes emerged. Doctors valued independence and responsibility especially if accompanied by a level of support from seniors. They also enjoyed working as part of a multi-disciplinary team. However, there were clear issues around staffing levels, stigma attached to psychiatry, and out of hours working. DISCUSSION: The pre-placement perceptions of psychiatry as a specialty as well as the trainees' personal priorities for career selection were influenced by psychiatry placement experiences. The results have important implications for the recruitment to the specialty and need to be considered when designing and constructing placement aims.

Not all who wander are lost: evaluation of the Hull York medical school longitudinal integrated clerkship.

Longitudinal integrated clerkships (LICs) are increasingly available within the United Kingdom, but gaps in knowledge remain regarding their efficacy and the influence of local context. In 2019-20, the Hull York Medical School ran a pilot LIC for 6 fourth-year medical students. This work describes the longitudinal qualitative programme evaluation. LIC students participated in two focus groups, one after four months, and another at the end of the programme. In total, 16 faculty were also interviewed regarding their experiences in developing, implementing and running the LIC. Students' GP supervisors were difficult to engage in detailed evaluation due to the COVID-19 pandemic, and so were briefly surveyed at the end of the LIC. All data were pooled and analysed together using reflexive thematic analysis. Two major themes were identified: 'Trajectory of the LIC', describing the learning curve students and faculty encounter, and 'Institutional decision making', describing the need for clarity regarding the programme's purpose. The programme was largely positively received, but areas for improvement locally, and transferrable recommendations, were identified. Aligning assessment to programme aims is an important area for future development, alongside balancing structured with unstructured time, and supporting students as they navigate a J-shaped learning curve.

Situational judgement test validity for selection: A systematic review and meta-analysis.

CONTEXT: Situational judgement tests (SJTs) are widely used to evaluate 'non-academic' abilities in medical applicants. However, there is a lack of understanding of how their predictive validity may vary across contexts. We conducted a systematic review and meta-analysis to synthesise existing evidence relating to the validity of such tools for predicting outcomes relevant to interpersonal workplace performance. METHODS: Searches were conducted in relevant databases to June 2019. Study quality and risk of bias were assessed using the Quality In Prognosis Studies (QUIPS) tool. Results were pooled using random effects meta-analysis and meta-regressions. RESULTS: Initially, 470 articles were identified, 218 title or abstracts were reviewed, and 44 full text articles were assessed with 30 studies meeting the final inclusion criteria and were judged, overall, to be at moderate risk of bias. Of these, 26 reported correlation coefficients relating to validity, with a pooled estimate of 0.32 (95% confidence interval 0.26 to 0.39, P < .0001). Considerable heterogeneity was observed (I2  = 96.5%) with the largest validity coefficients tending to be observed for postgraduate, rather than undergraduate, selection studies (ß = 0.23, 0.11 to 0.36, P < .001). The correction of validity coefficients for attenuation was also independently associated with larger effects (ß = 0.13, 0.03 to 0.23, P = .01). No significant associations with test medium (video vs text format), cross-sectional study design, or period of assessment (one-off vs longer-term) were observed. Where reported, the scores generally demonstrated incremental predictive validity, over and above tests of knowledge and cognitive ability. CONCLUSIONS: The use of SJTs in medical selection is supported by the evidence. The observed trend relating to training stage requires investigation. Further research should focus on developing robust criterion-relevant outcome measures that, ideally, capture interpersonal aspects of typical workplace performance. This will facilitate additional work identifying the optimal place of SJTs within particular selection contexts and further enhancing their effectiveness.

Student dignity during work-integrated learning: a qualitative study exploring student and supervisors' perspectives.

While University students increasingly participate in work-integrated learning (WIL), their dignity is often violated during WIL. The current literature is limited in so far as it typically focuses on student perspectives within healthcare contexts and does not use the concept of 'dignity'. Instead, this study explored student and supervisor perspectives on student dignity during WIL across healthcare and non-healthcare disciplines. Research questions included: What are: (1) types of student dignity experiences and patterns by groups; (2) factors contributing to experiences; (3) consequences of experiences? Sixty-five semi-structured interviews were conducted using narrative interviewing techniques with 30 supervisors and 46 students from healthcare (medicine, nursing and counselling) and non-healthcare (business, law and education) disciplines. Data were analyzed using framework analysis. Nine common narrative types were identified within 344 stories: verbal abuse, right for learning opportunities, care, inclusion, reasonable expectations, right for appropriate feedback, equality, trust, and right to be informed. Factors contributing to dignity experiences and consequences were often at the individual level (e.g. student/supervisor characteristics). We found some salient differences in perceptions of experiences between students and supervisors, but few differences between healthcare and non-healthcare disciplines. This study extends WIL research based on student perspectives in healthcare, and provides practice and further research guidance to enhance student dignity during WIL.

Teaching medical professionalism: a qualitative exploration of persuasive communication as an educational strategy.

BACKGROUND: Across the world, local standards provide doctors with a backbone of professional attitudes that must be embodied across their practice. However, educational approaches to develop attitudes are undermined by the lack of a theoretical framework. Our research explored the ways in which the General Medical Council's (GMC) programme of preventative educational workshops (the Duties of a Doctor programme) attempted to influence doctors' professional attitudes and examined how persuasive communication theory can advance understandings of professionalism education. METHODS: This qualitative study comprised 15 ethnographic observations of the GMC's programme of preventative educational workshops at seven locations across England, as well as qualitative interviews with 55 postgraduate doctors ranging in experience from junior trainees to senior consultants. The sample was purposefully chosen to include various geographic locations, different programme facilitators and doctors, who varied by seniority. Data collection occurred between March to December 2017. Thematic analysis was undertaken inductively, with meaning flowing from the data, and deductively, guided by persuasive communication theory. RESULTS: The source (educator); the message (content); and the audience (participants) were revealed as key influences on the persuasiveness of the intervention. Educators established a high degree of credibility amongst doctors and worked to build rapport. Their message was persuasive, in that it drew on rational and emotional communicative techniques and made use of both statistical and narrative evidence. Importantly, the workshops were interactive, which allowed doctors to engage with the message and thus increased its persuasiveness. CONCLUSIONS: This study extends the literature by providing a theoretically-informed understanding of an educational intervention aimed at promoting professionalism, examining it through the lens of persuasive communication. Within the context of interactive programmes that allow doctors to discuss real life examples of professional dilemmas, educators can impact on doctors' professional attitudes by drawing on persuasive communication techniques to enhance their credibility to demonstrate expertise, by building rapport and by making use of rational and emotional appeals.

Student and clinician identities: how are identities constructed in interprofessional narratives?

CONTEXT: Although the literature on professional identity formation in medical education is increasing, it is scant by comparison on student and clinician identities within interprofessional contexts. We therefore adopt a novel discursive approach to identities to explore how soon-to-become graduates and workplace-based clinicians construct their own and others' identities in interprofessional student-clinician (IPSC) interaction narratives. METHODS: We conducted a qualitative narrative interview study with 38 students and 23 clinicians representing the fields of medicine, midwifery, nursing, occupational therapy, paramedicine and physiotherapy. Through framework analysis, we identified the breadth of student and clinician identity constructions across 208 IPSC interaction narratives, and explored how common constructions differed by narrative and narrator. Through in-depth positioning analysis, we explored how student and clinician identities are discursively positioned within two selected IPSC interaction narratives. RESULTS: We identified 11 common constructions of student identities and eight common constructions of clinician identities across all 208 narratives. We found differences in identity constructions across positively versus negatively evaluated narratives, and student versus clinician narrators, highlighting the rhetorical nature of narratives. Our in-depth positioning analysis of two narratives illustrates how one student and one clinician discursively positioned theirs and others' identities during interprofessional interactions, and how identities vary depending on narrators' evaluations of their stories. Although both positioning analyses illustrate how the narrators' language serves to reproduce the common societal discourse of interprofessional conflict, the clinician narrative also draws on the competing discourse of interprofessional collaboration. CONCLUSIONS: Although some of the identities support previous uniprofessional research, our findings illustrate greater breadth and depth in terms of student and clinician identities within interprofessional contexts. We encourage educators to embed identities curricula into existing workplace learning for students and clinicians to help them make sense of their developing professional and interprofessional identities. Workplace educators should facilitate meaningful IPSC interactions to promote interprofessional learning and collaboration.

Setting priorities for health education research: A mixed methods study.

Introduction: Identifying priority research topics that meet the needs of multiple stakeholders should maximize research investment. Aim: To identify priorities for health education research. Methods: A three-stage sequential mixed methods study was conducted. Priorities for health education research were identified through a qualitative survey with 104 students, patients, academics, and clinicians across five health sciences and 12 professions (stage 1). These findings were analyzed using framework analysis and transposed into a quantitative survey whereby 780 stakeholders rated and ranked the identified priorities. Descriptive statistics identified priorities, exploratory factor analysis grouped priorities and differences between stakeholders were determined using Mann-Whitney U tests (stage 2). Six individual or group interviews with 16 participants (stage 3) further explicated the results from previous stages. Results: Of 30 priorities identified, the top were: how best to ensure students develop the required skills for work; how to promote resiliency and well-being in students; and ensuring the curriculum prepares students for work. For the majority of priorities, no significant differences were found between different stakeholder groups. Conclusions: These findings will be used to inform health educational research strategy both locally and nationally. Further research should explore if setting priorities can be translated effectively into education research policy and practice.

A postgraduate curriculum for integrated care: a qualitative exploration of trainee paediatricians and general practitioners' experiences.

BACKGROUND: Integrated care unites funding, administrative, organisational, service delivery and clinical levels to create connectivity, alignment and collaboration within and between care delivery and prevention sectors. It aims to improve efficiency by avoiding unnecessary duplication of resources. Consequently, implementing integrated care is increasingly important; however, there are many barriers and how we teach healthcare practitioners to work across systems is under-researched. This paper explores an innovative educational curriculum, the Programme for Integrated Child Health (PICH). METHODS: The PICH involved an experiential learning approach supported by taught sessions on specific issues relevant to integrated care. A qualitative study was conducted by interviewing 23 participants using semi-structured one-to-one interviews. Participants included trainees (general practice, paediatrics) and programme mentors. Data was thematically analysed. RESULTS: Results are coded under three main themes: integrated care curriculum components, perceptions of a curriculum addressing integrated care and organisational change, and personal and professional learning. The data highlights the importance of real-world projects, utilising healthcare data, and considering patient perspectives to understand and develop integrated practices. Trainees received guidance from mentors but, more crucially learnt from, with, and about one another. They learnt about the context in which GPs and paediatricians work and developed a deeper understanding through which integrated services could be meaningfully developed. CONCLUSIONS: This study explored participants' experiences and can be taken forward by educationalists to design curricula to better prepare healthcare practitioners to work collaboratively. The emergence of integrated care brings about challenges for traditional pedagogical approaches as learners have to re-align their discipline-specific approaches with evolving healthcare structures. PICH demonstrated that trainees acquired knowledge through real-word projects and experiential learning; and that this facilitated integration, empowering doctors to become leaders of organisational change. However, there are also many challenges of implementing integrated curricula which need to be addressed, including breaking down professional silos and integrating resourceful healthcare. This study begins to demonstrate the ability of an integrated curriculum to support trainees to work collaboratively, but further work is needed to develop the wider efficacy of the programme incorporating other professional groups, and to assess its longer term impact.

What really matters for successful research environments? A realist synthesis.

CONTEXT: Research environments, or cultures, are thought to be the most influential predictors of research productivity. Although several narrative and systematic reviews have begun to identify the characteristics of research-favourable environments, these reviews have ignored the contextual complexities and multiplicity of environmental characteristics. OBJECTIVES: The current synthesis adopts a realist approach to explore what interventions work for whom and under what circumstances. METHODS: We conducted a realist synthesis of the international literature in medical education, education and medicine from 1992 to 2016, following five stages: (i) clarifying the scope; (ii) searching for evidence; (iii) assessing quality; (iv) extracting data, and (v) synthesising data. RESULTS: We identified numerous interventions relating to research strategy, people, income, infrastructure and facilities (IIF), and collaboration. These interventions resulted in positive or negative outcomes depending on the context and mechanisms fired. We identified diverse contexts at the individual and institutional levels, but found that disciplinary contexts were less influential. There were a multiplicity of positive and negative mechanisms, along with three cross-cutting mechanisms that regularly intersected: time; identity, and relationships. Outcomes varied widely and included both positive and negative outcomes across subjective (e.g. researcher identity) and objective (e.g. research quantity and quality) domains. CONCLUSIONS: The interplay among mechanisms and contexts is central to understanding the outcomes of specific interventions, bringing novel insights to the literature. Researchers, research leaders and research organisations should prioritise the protection of time for research, enculturate researcher identities, and develop collaborative relationships to better foster successful research environments. Future research should further explore the interplay among time, identity and relationships.

A systematic literature review of undergraduate clinical placements in underserved areas.

CONTEXT: The delivery of undergraduate clinical education in underserved areas is increasing in various contexts across the world in response to local workforce needs. A collective understanding of the impact of these placements is lacking. Previous reviews have often taken a positivist approach by only looking at outcome measures. This review addresses the question: What are the strengths and weaknesses for medical students and supervisors of community placements in underserved areas? METHODS: A systematic literature review was carried out by database searching, citation searching, pearl growing, reference list checking and use of own literature. The databases included MEDLINE, EMBASE, PsycINFO, Web of Science and ERIC. The search terms used were combinations and variations of four key concepts exploring general practitioner (GP) primary care, medical students, placements and location characteristics. The papers were analysed using a textual narrative synthesis. FINDINGS: The initial search identified 4923 results. After the removal of duplicates and the screening of titles and abstracts, 185 met the inclusion criteria. These full articles were obtained and assessed for their relevance to the research question; 54 were then included in the final review. Four main categories were identified: student performance, student perceptions, career pathways and supervisor experiences. CONCLUSIONS: This review reflects the emergent qualitative data as well as the quantitative data used to assess initiatives. Underserved area placements have produced many beneficial implications for students, supervisors and the community. There is a growing amount of evidence regarding rural, underserved areas, but little in relation to inner city, deprived areas, and none in the UK.

Responsibility with a Safety Net: Exploring the Medical Student to Junior Doctor Transition During COVID-19.

INTRODUCTION: The Foundation Interim Year-one (FiY1) Programme was part of a UK strategy to increase the medical workforce in response to the COVID-19 pandemic. However, the strategy was introduced urgently without evidence. We sought to explore the transition experience of medical student to FiY1 to foundation doctor, with a view to inform future undergraduate education. METHODS: In this hermeneutic phenomenology study, semi-structured individual interviews were completed with nine foundation doctors who had experience of an FiY1 placement. A template analysis approach was taken, and themes reported. RESULTS: Participants reported that FiY1 tended to offer a positive experience of transition as a stepping stone to becoming a foundation doctor. Having a degree of clinical responsibility including the right to prescribe medication with supervision was highly valued, as was feeling a core member of the healthcare team. Participants perceived that FiY1 made them more prepared for the foundation transition, and more resilient to the challenges they faced during their first foundation job. DISCUSSION: The FiY1 fostered many opportunities for junior doctors to bridge the transition to foundation doctor. Aspects of the FiY1 programme, such as early licencing and increased team membership, should be considered for final-year students in the future.

Tips to Support the Recruitment, Retention, and Progression of Clinical Academics.

Training to become a clinical academic is a long and arduous process with many obstacles. Many potential candidates fall by the wayside both during and following completion of the combined clinical and academic training pathway with negative implications for clinical and translational research and teaching. Findings from a recent national multi-funder study, alongside clinical academic experiences and current literature, have led to the creation of this 12-tip paper. The tips are targeted at supervisors and employers of clinical academics, aiming to improve recruitment, experiences, retention, and progression through the career path.