Feedback learning opportunities from medical student logs of paediatric patients.

BACKGROUND: Feedback can alter medical student logging practices, although most learners feel feedback is inadequate. A varied case mix in rural and urban contexts offers diverse clinical encounters. Logs are an indicator of these clinical experiences, and contain opportunities for feedback, which can greatly influence learning: we labelled these 'feedback learning opportunities' (FLOs). We asked: How often do FLOs occur? What are the case complexities of rural compared to urban paediatric logs? Do more complex cases result in more FLOs? METHODS: In Western Australia, 25% of medical students are dispersed in a Rural Clinical School (RCSWA) up to 2175 miles (3500 km) from the city. Urban students logged 20 written cases; rural students logged a minimum of 25 paediatric cases electronically. These were reviewed to identify FLOs, using a coding convention. FLO categories provided a structure for feedback: medical, professionalism, insufficient, clinical reasoning, student wellbeing, quality and safety, and sociocultural. Each log was assigned an overall primary, secondary or tertiary case complexity. RESULTS: There were 76 consenting students in each urban and rural group, providing 3034 logs for analysis after exclusions. FLOs occurred in more than half the logs, with significantly more rural (OR 1.35 95% CI 1.17, 1.56; p < 0.0001). Major FLOs occurred in over a third of logs, but with no significant difference between rural and urban (OR 1.10 95% CI 0.94, 1.28; p = 0.24). Medical FLOs were the most common, accounting for 64.0% of rural and 75.2% of urban FLOs (OR 1.71 95% CI 1.37, 2.12; p < 0.0001). Students logged cases with a variety of complexities. Most cases logged by urban students in a tertiary healthcare setting were of primary and secondary complexity. Major medical FLOs increased with increasing patient complexity, occurring in 32.1% of tertiary complexity cases logged by urban students (p < 0.001). CONCLUSIONS: Case logs are a valuable resource for medical educators to enhance students' learning by providing meaningful feedback. FLOs occurred often, particularly in paediatric cases with multiple medical problems. This study strengthens recommendations for regular review and timely feedback on student logs. We recommend the FLOs categories as a framework for medical educators to identify FLOs.

Paediatric case mix in a rural clinical school is relevant to future practice.

BACKGROUND: Exposure to a representative case mix is essential for clinical learning, with logbooks established as a way of demonstrating patient contacts. Few studies have reported the paediatric case mix available to geographically distributed students within the same medical school. Given international interest in expanding medical teaching locations to rural contexts, equitable case exposure in rural relative to urban settings is topical. The Rural Clinical School of Western Australia locates students up to 3500 km from the urban university for an academic year. There is particular need to examine paediatric case mix as a study reported Australian graduates felt unprepared for paediatric rotations. We asked: Does a rural clinical school provide a paediatric case mix relevant to future practice? How does the paediatric case mix as logged by rural students compare with that by urban students? METHODS: The 3745 logs of 76 urban and 76 rural consenting medical students were categorised by presenting symptoms and compared to the Australian Institute of Health and Welfare (AIHW) database Major Diagnostic Categories (MDCs). RESULTS: Rural and urban students logged core paediatric cases, in similar order, despite the striking difference in geographic locations. The pattern of overall presenting problems closely corresponded to Australian paediatric hospital admissions. Rural students logged 91% of cases in secondary healthcare settings; urban students logged 90% of cases in tertiary settings. The top four presenting problems were ENT/respiratory, gastrointestinal/urogenital, neurodevelopmental and musculoskeletal; these made up 60% of all cases. Rural and urban students logged similar proportions of infants, children and adolescents, with a variety of case morbidity. CONCLUSIONS: Rural clinical school students logged a mix of core paediatric cases relevant to illnesses of Australian children admitted to public hospitals, with similar order and pattern by age group to urban students, despite major differences in clinical settings. Logged cases met the curriculum learning outcomes of graduates. Minor variations were readily addressed via recommendations about logging. This paper provides evidence of the legitimacy of student logs as useful tools in affirming appropriate paediatric case mix. It validates the rural clinical school context as appropriate for medical students to prepare for future clinical paediatric practice.

"Helping someone with a skill sharpens it in your own mind": a mixed method study exploring health professions students experiences of Peer Assisted Learning (PAL).

BACKGROUND: Peer assisted learning (PAL) has been described as "the development of knowledge and skill through active help and support among status equals or matched companions". To enhance the learning experience of health professions students and improve collaborative and collegial learning, six pilot Peer Assisted Learning (PAL) projects were conducted across a health science faculty. METHODS: A responsive mixed method evaluation design was applied to explore the adequacy of the preparation for PAL, the impact PAL had on student attainment of examination, consultation, communication and feedback skills and to explore students' learning experiences through PAL. RESULTS: The 149 participants agreed the training programme was well organised, offered a safe learning environment and prepared the participant for the PAL activity. The impact of PAL included improvements in students' confidence and ability to give feedback and developed students' teaching, clinical and communication skills. Qualitative analysis revealed participants experienced deeper learning through teaching and learning from their peers, became more open to giving and receiving feedback and valued the comfortable/safe learning environment offered through PAL. CONCLUSION: Providing appropriate training in peer teaching and feedback and the schools engagement and openness to peer learning in the classroom and clinical setting enhances students' peer assisted learning experience.

International trial of online auditory training programme for distinguishing innocent and pathological murmurs.

AIM: Recognition of normal and abnormal heart sounds and murmurs is an important but declining clinical skill among practitioners. Current teaching methods are often ineffective. This may result from inadequate repetition and normal-abnormal comparisons needed for auditory recognition. This paper describes a rapid new method of teaching murmur recognition using principles of auditory training. METHODS: Participants were 120 Australian and 42 Canadian medical students. The medical students were randomised to intervention and control (no intervention) groups. The 1-h online programme structured like a computer game used auditory training methodology to teach students to distinguish between innocent and pathological murmurs. Participants underwent pre- and post-testing on 20 paediatric murmurs. Post-testing occurred immediately following training and after 2 months. Twenty-two Canadian medical students were retested 1 year later with a brief mastery-style reinforcement programme. RESULTS: Median pre- and post-test scores improved in about 1 h from 75-95% (P < 0.001) for Australian students and 85-95% (P = 0.004) for Canadian students. Two-month post-test scores declined for Australian students to 85% (P = 0.001), and for Canadian students to 85% (P = 0.02). Australian controls had no significant change during the study period, whereas Canadian controls improved slightly. The group receiving reinforcement after 1 year had a median final score of 90%. CONCLUSIONS: This auditory training programme rapidly teaches students to distinguish innocent and pathological murmurs with at least 90% accuracy. The skill declines within 2 months but can be restored with brief mastery reinforcement 1 year later.

Looking to the future: Framing the implementation of interprofessional education and practice with scenario planning.

BACKGROUND: Adapting to interprofessional education and practice requires a change of perspective for many health professionals. We aimed to explore the potential of scenario planning to bridge the understanding gap and framing strategic planning for interprofessional education (IPE) and practice (IPP), as well as to implement innovative techniques and technology for large-group scenario planning. METHODS: A full-day scenario planning workshop incorporating innovative methodology was designed and offered to participants. The 71 participants included academics from nine universities, as well as service providers, government, students and consumer organisations. The outcomes were evaluated by statistical and thematic analysis of a mixed method survey questionnaire. RESULTS: The scenario planning method resulted in a positive response as a means of collaboratively exploring current knowledge and broadening entrenched attitudes. It was perceived to be an effective instrument for framing strategy for the implementation of IPE/IPP, with 81 percent of respondents to a post-workshop survey indicating they would consider using scenario planning in their own organisations. DISCUSSION: The scenario planning method can be used by tertiary academic institutions as a strategy in developing, implementing and embedding IPE, and for the enculturation of IPP in practice settings.

Interprofessional health education in Australia: three research projects informing curriculum renewal and development.

PURPOSE: This paper reports on three interrelated Australian studies that provide a nationally coherent and evidence-informed approach to interprofessional education (IPE). Based on findings from previous studies that IPE tends to be marginalized in mainstream health curriculum, the three studies aspired to produce a range of resources that would guide the sustainable implementation of IPE across the Australian higher education sector. METHOD: Nine national universities, two peak industry bodies and a non-government organization constituted the study team. Data were gathered via a mixture of stakeholder consultations, surveys and interviews and analyzed using quantitative and qualitative methods. RESULTS & CONCLUSION: An important outcome was a curriculum renewal framework which has been used to explore the implications of the study's findings on Australian nursing. While the findings are pertinent to all health professions, nursing is well placed to take a leading role in establishing IPE as a central element of health professional education.

Informing a culturally appropriate approach to oral health and dental care for pre-school refugee children: a community participatory study.

BACKGROUND: Pre-school children in families of recently settled refugees often have very high rates of early childhood caries (ECC). ECC is associated with a high level of morbidity and is largely preventable, however effective culturally appropriate models of care are lacking. This study aimed to provide a deeper understanding of the refugee experience related to early oral health by exploring pre-school refugee families (i) understanding of ECC and child oral health, (ii) experiences of accessing dental services and (iii) barriers and enablers for achieving improved oral health. The knowledge gained will be critical to the development of effective early oral health programs in refugee children. METHODS: Community based participatory qualitative methodology using focus groups of resettled refugee families and community refugee nurse interviews. A community reference group was established and a bi-lingual community research associate was employed. Transcripts were analysed for thematic content using NVivo software. RESULTS: There were 44 participants: eight focus groups (nine countries of origin) and five interviews. Emergent themes were (i) the major influence of parents' previous experience, including their beliefs about deciduous (baby) teeth, traditional feeding practices and poverty; and a consequent lack of understanding of the importance of early oral health and early dental caries, (ii) the burden of resettlement including prioritising, parenting, learning about new foods and how to assimilate into the community, and (iii) refugees' difficulties in accessing both information and dental services, and the role of schools in addressing these issues. An Opportunities for Change Model was proposed. CONCLUSIONS: The main implication of the study is the demonstration of how enhanced understanding of the refugee experience can inform improvement in early oral prevention and treatment. The community participatory methodology of the study provided a basis for cross-cultural understanding and has already assisted in translating the findings and raising awareness in the provision of targeted refugee oral health services.

Tertiary paediatric hospital health professionals' attitudes to lesbian, gay, bisexual and transgender parents seeking health care for their children.

AIMS AND OBJECTIVES: To ascertain health professionals' knowledge, attitudes and beliefs towards lesbian, gay, bisexual and transgender parents seeking health care for their children in a paediatric tertiary hospital setting which practises family-centred care. BACKGROUND: Lesbian, gay, bisexual and transgender parents are often reluctant to disclose their sexual orientation to health professionals for fear of discrimination and compromised quality of care. Staff knowledge, attitudes and beliefs can influence disclosure by parents, but little is known about knowledge, attitudes and beliefs in paediatric tertiary hospital staff towards lesbian, gay, bisexual and transgender parents accessing care for their children. DESIGN: Descriptive comparative study of health staff using a cross-sectional survey. METHODS: A set of validated anonymous questionnaires was used to assess knowledge about homosexuality, attitudes towards lesbians and gay men, and gay affirmative practice. Three open-ended questions were also used to assess beliefs about encouraging disclosure of lesbian, gay, bisexual and transgender parenting roles and how this may impact on care. RESULTS: Of the 646 staff surveyed, 212 (32.8%) responded. Knowledge and attitudes were significantly associated with professional group, gender, Caucasian race, political voting behaviour, presence of religious beliefs, the frequency of attendance at religious services, the frequency of praying, and having a friend who was openly lesbian, gay, bisexual and transgender. CONCLUSION: This study highlighted that staff working in a tertiary paediatric hospital setting, with family-centred care models in place, held attitudes and beliefs that may impact on the experience of hospitalisation for lesbian, gay, bisexual and transgender parents, and the quality of care received by their children. RELEVANCE TO CLINICAL PRACTICE: To promote equitable care to all families, organisations should ensure that family-centred care policies and guidelines are adopted and appropriately implemented. In addition to formal education, affirmative health service action and innovative methods may be required.

Nursing and medical students' attitude, knowledge and beliefs regarding lesbian, gay, bisexual and transgender parents seeking health care for their children.

BACKGROUND: Little research has been conducted to investigate students' attitudes, knowledge and beliefs regarding lesbian, gay, bisexual and transgender parents seeking health care for their children. DESIGN: Descriptive, comparative study. Validated scales were used to assess students' attitudes, knowledge and beliefs and gay affirmative practice. Three open ended questions assessed beliefs regarding lesbian, gay, bisexual and transgender parents accessing health care for their children. METHOD: Nursing and medical students completed questionnaires about attitudes to homosexuality. Associations between variables were assessed using chi-square tests of independence, and differences between nursing and medical student groups were assessed using the Mann-Whitney U-test or the Kruskal-Wallis one-way analysis of variance test. Responses to the open ended questions were evaluated, coded and described. RESULTS: Knowledge and attitudes about homosexuality were significantly associated with students' race, political voting behaviour, religious beliefs and having a friend who is openly lesbian, gay, bisexual and transgender. CONCLUSIONS: It is important to develop strategies to address the existence of prejudicial attitudes among student health professionals and prevent discriminatory practices towards lesbian, gay, bisexual and transgender parents when seeking health care for their children. RELEVANCE TO CLINICAL PRACTICE: Educators can develop programs that provide students with knowledge and skills to ensure lesbian, gay, bisexual and transgender families receive effective health care when they access services for their children.

A prospective large-scale study of methods for the detection of latent Mycobacterium tuberculosis infection in refugee children.

BACKGROUND Diagnosis of latent tuberculosis infection (LTBI) is a cornerstone of the health assessment of resettled high incidence populations, particularly in children. Two blood-based interferon gamma release assays (IGRAs), T-SPOT.TB and QFT-Gold in-tube (QFT-GIT), have greater sensitivity and specificity than the tuberculin skin test (TST), but their performance as screening tools for LTBI in children, especially refugee children, remains unclear. METHODS 524 African and ethnic Burmese children, including 107 under 3 years of age, were prospectively enrolled in a comparison of the T-SPOT.TB and QFT-GIT. The TST was also performed in 342 of the children. RESULTS The T-SPOT.TB and QFT-GIT had similar rates of positivity (8% and 10%, respectively) and showed good concordance when both tests gave definitive results (kappa=0.78; p<0.0001). However, the IGRAs had significant failure rates: 15% of QFT-GIT gave indeterminate results due to failed mitogen response and 14% of T-SPOT.TB results were inconclusive, largely because of insufficient mononuclear leucocyte yields. Failure of the QFT-GIT mitogen response was associated with African ethnicity and co-morbid infections, particularly with helminths. The TST results showed poor concordance ( approximately 50%) with both IGRAs. CONCLUSIONS It is reasonable to screen using either IGRA with follow-up by the alternative if the test fails. In general, the QFT-GIT is the preferred option for non-African populations but the T-SPOT.TB is recommended when there are epidemiological and/or clinical high risk factors for TB infection. However, both IGRAs have methodological and performance characteristics that limit their usefulness in refugee children, highlighting the need for continued development of screening strategies.

Using the Ages and Stages Questionnaire to teach medical students developmental assessment: a descriptive analysis.

BACKGROUND: After a survey of medical graduates' skills found a lack of confidence in developmental assessment, a program was introduced with the broad aims of increasing medical student confidence and respect for the parents' role in childhood developmental assessment. Research has shown that parents' concerns are as accurate as quality screening tests in assessing development, so the program utilised the Ages and Stages Questionnaire, a parent completed, child development assessment tool. METHOD: To evaluate the program, an interpretative analysis was completed on the students' reports written during the program and a questionnaire was administered to the parents to gain their perception of the experience. As well, student confidence levels in assessing growth and development were measured at the end of the paediatric term. RESULTS: Although there was an increase in student confidence in developmental assessment at the end of the term, it was not statistically significant. However the findings indicated that students gained increased understanding of the process and enhanced recognition of the parental role, and the study suggested there was increased confidence in some students. Parents indicated that they thought they should be involved in the teaching of students. CONCLUSION: The ASQ was shown to have been useful in an education program at the level of advanced beginners in developmental assessment.

The effect of an enrolled nursing registration pathway program on undergraduate nursing students' confidence level: A pre- and post-test study.

BACKGROUND: In the latter half of the 20th century, registered nurse education moved to university degree level. As a result, there has been a reduction in access for students to clinical experience. In numerous studies, nursing graduates have reported that they do not feel prepared for practice. The importance of maximising every learning opportunity during nursing school is paramount. At Edith Cowan University, a program was initiated that allows students to become enrolled nurses at the midway point of their degree to enable them to work and therefore gain experience in the clinical practice setting during their education. This study investigated the effect of the program on the nursing students' perception of their clinical abilities and explored their ability to link theory to practice. METHODS: The research design for this study was a quasi-experimental, prospective observational cohort study. The study included 39 second-year nursing students not enrolled in the program (Group 1), 45 second-year nursing students enrolled in the program (Group 2), and 28 third-year nursing students who completed the program and are working as enrolled nurses (Group 3). Participants were asked to complete a Five Dimension of Nursing Scale questionnaire. RESULTS: The quantitative analyses showed that students in Group 1 had statistically significant higher pre-questionnaire perceived abilities across all domains, except in two dimensions when compared to Group 2. The post-questionnaire analysis showed that Group 1 had statistically significant lower perceived abilities in four of the five dimensions compared to Group 2. Group 1 also had significantly lower abilities in all dimensions compared to Group 3. Group 3 had a significantly higher perception of their clinical abilities compared to Group 2. CONCLUSION: This study highlights the value of meaningful employment for undergraduate nursing students by providing opportunities to increase confidence in clinical abilities.

A student-centred feedback model for educators.

BACKGROUND: Effective feedback is instrumental to effective learning. Current feedback models tend to be educator driven rather than learner-centred, with the focus on how the supervisor should give feedback rather than on the role of the learner in requesting and responding to feedback. CONTEXT: An alternative approach emphasising the theoretical principles of student-centred and self-regulated learning is offered, drawing upon the literature and also upon the experience of the authors. INNOVATION: The proposed feedback model places the student in the centre of the feedback process, and stresses that the attainment of student learning outcomes is influenced by the students themselves. This model emphasises the attributes of the student, particularly responsiveness, receptiveness and reflection, whilst acknowledging the important role that the context and attributes of the supervisor have in influencing the quality of feedback. IMPLICATIONS: Educational institutions should consider strategies to encourage and enable students to maximise the many feedback opportunities available to them. As a minimum, educators should remind students about their central role in the feedback process, and support them to develop confidence in meeting this role. In addition, supervisors may need support to develop the skills to shift the balance of responsibility and support students in precipitating feedback moments. Research is also required to validate the proposed model and to determine how to support students to adopt self-regulatory learning, with feedback as a central platform.

Retention into internship of resuscitation skills learned in a medical student resuscitation program incorporating an Immediate Life Support course.

AIMS: This study describes the acquisition and retention of resuscitation skills by medical students during and following a vertically integrated training program incorporating an Immediate Life Support course (ILS): and the skills demonstrated by interns on entry to clinical practice. METHODS: Yearly resuscitation workshops were held in the final 3 years of a 6-year undergraduate medical curriculum. These consisted of a basic life support course in year 4; a resuscitation workshop including shock-advisory defibrillation in year 5; and an ILS course in year 6. A medical student cohort was tested during the course and at the beginning of internship. RESULTS: Before year 5 training, an average of 36.6% of students passed each criterion and this increased to 72.3% 10 weeks after training. Prior to the ILS course (approximately 6-18 months following year 5 training), this proportion had decreased to 35.2%; and on retesting as interns the proportion was 64.1%, with delay between ILS training and testing of between 3 and 9 months. The proportion of interns correctly performing airway opening, initial rescue breathing and ventilation technique was lower than other measured skills. Those with ILS training performed better in initial rescue breaths (p=0.03), ventilation technique (p=0.04), and recommencement of CPR without delay following defibrillation (p=0.02). CONCLUSIONS: A vertically integrated undergraduate resuscitation course appears to reinforce the maintenance of resuscitation skills until internship. Skills are maintained for at least 6-9 months following an ILS course. This may be due to the ILS course embedding the skills more thoroughly.

Sail training: an innovative approach to graduate nurse preceptor development.

A 1-day sail-training program that aims to increase graduate nurse preceptor skills was evaluated. Preliminary results suggest that this experiential learning is an effective way to develop graduate nurse preceptors. Awareness of graduate nurses' needs has been heightened, and skills in clinical teaching have been developed. It is indicated from the limited results that the outcomes are sustained over time, but further evaluation is needed.