A qualitative study to explore student learning and development of interprofessional collaboration during an online interprofessional education intervention.

Interprofessional education (IPE) during undergraduate education and training has been found to improve collaboration between health care students. This supports interprofessional working in clinical practice to enhance patient safety and care delivery.Undergraduate students from pharmacy and medical programmes worked online in pairs to review notes of hospital patients due to be discharged. Students were tasked to complete a discharge letter and undertake an online consultation with a simulated patient prior to discharge. Online interactions were recorded and assessed using a validated tool to measure interprofessional professionalism. Students undertook this intervention in different pairings with different patient cases for three iterations after receiving feedback and undertaking a reflective exercise.The aim was to investigate the student learning and development that could be used to inform intervention optimisation and scale-up.Qualitative data were collected from different sources. Method triangulation was employed to develop a comprehensive understanding of the student learning and development. Data was collected from written feedback provided by the assessment team, student reflections on their performance, and from semi-structured interviews conducted with the student pairs and one to one with the assessment team. Content and thematic analysis was used to analyse these data and the Kirkpatrick/Barr evaluation model provided a framework to organise the themes.Eighteen students (nine from each professional programme) completed the study and a total of 27 IPE sessions were conducted. The assessment team completed 54 assessment tools and 31 student reflections were received (from a maximum of 36). Students were interviewed in their interprofessional pairs to yield nine interview transcripts and one interview was conducted with the assessment team.Students reported and were observed to improve in interprofessional collaboration over the three iterations following feedback and rehearsal opportunities. Longitudinal observation and assessment of student interprofessional working in changing teams provided the opportunity to capture the influence of interdependence on student performance and assessment of competence.

Five Domains of a Conceptual Framework of Continuing Professional Development.

ABSTRACT: Continuing professional development (CPD) for health professionals involves efforts at improving health of individuals and the population through educational activities of health professionals who previously attained a recognized level of acceptable proficiency (licensure). However, those educational activities have inconsistently improved health care outcomes of patients. We suggest a conceptual change of emphasis in designing CPD to better align it with the goals of improving health care value for patients through the dynamic incorporation of five distinct domains to be included in learning activities. We identify these domains as: (1) identifying, appraising, and learning new information [New Knowledge]; (2) ongoing practicing of newly or previously acquired skills to maintain expertise [New Skills and Maintenance]; (3) sharing and transfer of new learning for the health care team which changes their practice [Teams]; (4) analyzing data to identify problems and drive change resulting in improvements in the health care system and patient outcomes [Quality Improvement]; and (5) promoting population health and prevention of disease [Prevention]. We describe how these five domains can be integrated into a comprehensive conceptual framework of CPD, supported by appropriate learning theories that align with the goals of the health care delivery system. Drawing on these distinct but interrelated areas of CPD will help organizers and directors of learning events to develop their activities to meet the goals of learners and the health care system.

Identification of multicultural learning experiences following an international cross campus medical student exchange programme between the UK and Malaysia: a qualitative study.

OBJECTIVES: In an increasingly global society, there is a need to develop culturally competent doctors who can work effectively across diverse populations. International learning opportunities in undergraduate healthcare programmes show various benefits. In medical education, these occur predominantly towards the end of degree programmes as electives, with scant examples of programmes for preclinical students. This study set out to identify the multicultural learning experiences following an early year international medical student exchange programme between the UK and Malaysian campuses of one UK medical school. SETTING: Two cohorts of international exchange programme for second year medical students in the UK and Malaysia. DESIGN: Interpretivist qualitative design using semistructured interviews/focus groups with students and faculty. METHODS: Participants were asked about their learning experiences during and after the exchange. Data were recorded with consent and transcribed verbatim. Thematic analysis was used to analyse the data. RESULTS: Four themes were identified: (1) overall benefits of the exchange programme, (2) personal growth and development, (3) understanding and observing a different educational environment and (4) experiencing different healthcare systems. CONCLUSION: The international exchange programme highlighted differences in learning approaches, students from both campuses gained valuable learning experiences which increased their personal growth, confidence, cultural competence, giving them an appreciation of a better work-life balance and effective time management skills. It is often a challenge to prepare healthcare professionals for work in a global multicultural workplace and we would suggest that exchange programmes early on in a medical curriculum would go some way to addressing this challenge.

A pilot study evaluating the feasibility of assessing undergraduate pharmacy and medical students interprofessional collaboration during an online interprofessional education intervention about hospital discharge.

BACKGROUND: Interprofessional education (IPE) has been identified as a strategy towards improving competence at interprofessional working and collaboration within teams. Entrustable professional activities (EPAs) provide a framework for translating competencies into elements of clinical practice, some of which in healthcare are inherently interprofessional. However, it is challenging to reconcile that entrustment decisions about student competence in an interprofessional activity are made about an individual without considering the dynamics and tensions between interprofessional team members and the task itself. This can influence students' development and demonstration of competence at interprofessional collaboration. METHODS: In this study, undergraduate medical and pharmacy students worked in pairs online (Zoom) to undertake the hospital discharge process (a professional activity reliant on interprofessional collaboration) for a simulated patient, producing a hospital discharge letter and completing a consultation with the simulated patient. The online sessions were recorded and interprofessional behaviours were assessed using a validated scale completed by an interprofessional assessment team. Students undertook this IPE intervention three times after receiving feedback and a period of reflection each time. RESULTS: Eighteen students participated across the entire intervention and 27 one-hour online IPE sessions were completed and recorded. Students demonstrated statistically significant improvements in interprofessional behaviours across the three iterations (p < 0.05 for all the sessions). The discharge letter students produced also improved over the three sessions (p = 0.01). Students found the educational sessions useful and relevant. CONCLUSION: This online IPE intervention provided the students with an authentic opportunity to work collaboratively. At the end of each iteration, students received feedback about their work as a team and about the discharge letter, helping students to reflect and purposefully develop their performance. The IPE intervention with this assessment strategy is feasible and allows student development to be captured but has proved to be time and resource intensive.

Exploring Medical Students' Learning Around Uncertainty Management Using a Digital Educational Escape Room: A Design-based Research Approach.

Introduction: Medical professionals meet many transitions during their careers, and must learn to adjust rapidly to unfamiliar workplaces and teams. This study investigated the use of a digital educational escape room (DEER) in facilitating medical students' learning around managing uncertainty in transitioning from classroom to clinical placement. Methods: We used design-based research to explore the design, build, and test of a DEER, as well as gain insight into how these novel learning environments work, using Community of Inquiry (CoI) as a guiding conceptual framework. This study represented a mixed methods pilot test of a prototype DEER. Twenty-two medical students agreed to participate, and data were collected through qualitative (i.e., focus groups, game-play observations) and quantitative (i.e., questionnaires) methods. Results: Eighty-two per cent of participants agreed or strongly agreed that the DEER supported their learning around uncertainty. Participants offered diverse examples of how the game had facilitated new insights on, and approaches to, uncertainty. With respect to the learning environment, multiple indicators and examples of the three domains of CoI - cognitive, teaching and social presence - were observed. Discussion: Our findings suggested that DEERs offer a valuable online learning environment for students to engage with complex and emotion-provoking challenges, such as those experienced at transitions. The study also suggested that CoI can be applied to the design, implementation, and evaluation of DEER learning environments, and we have proposed a set of design principles that may offer guidance here.

Are We Ever Going Back? Exploring the Views of Health Professionals on Postpandemic Continuing Professional Development Modalities.

INTRODUCTION: The COVID-19 pandemic has profoundly altered the ways in which health care professionals engage with continuing professional development (CPD), but the extent to which these changes are permanent remains unknown at present. This mixed-methods research aims to capture the perspectives of health professionals on their preferences for CPD formats, including the conditions that inform preferences for in-person and online CPD events and the optimum length and type of online and in-person events. METHODS: A survey was used to gain a high-level perspective on health professionals' engagement with CPD, areas of interest, and capabilities and preferences in relation to online formats. A total of 340 health care professionals across 21 countries responded to the survey. Follow-up semistructured interviews were conducted with 16 respondents to gain deeper insights into their perspectives. RESULTS: Key themes include CPD activity before and during COVID, social and networking aspects, access versus engagement, cost, and time and timing. DISCUSSION: Recommendations regarding the design of both in-person and online events are included. Beyond merely moving in-person events online, innovative design approaches should be adopted to capitalize on the affordances of digital technologies and enhance engagement.

Patient outcomes in a Longitudinal Integrated Clerkship: A systematic literature review.

CONTEXT: Patient-student relationships are at the heart of Longitudinal Integrated Clerkships (LICs). Outcomes for students and preceptors are beneficial, but patient outcomes remain unclear. This systematic literature review explored the current evidence base of patient outcomes in an LIC. Patient outcomes were defined as issues related to patient safety, clinical effectiveness or patient experience. METHODS: Seven bibliographic databases were searched. A wider search strategy included a hand search of three medical education journals' previous issues and backward/forward citation searching of included studies and of a relevant systematic review. Included studies were quality appraised and assessed for their strength and level of evidence. A qualitative data synthesis was performed. RESULTS: Databases searches identified 7237 titles. Following the removal of duplicates, titles and abstracts were reviewed against the inclusion criteria. Forty-eight studies had a full-text review. Nineteen met the inclusion criteria. Seven studies were included from the wider search strategy. From the 26 included studies, two major themes were identified. (1) 'A trusting patient-student relationship' contains the sub-themes: 'care and compassion', 'patient education and empowerment' and 'the loss of the student as 'my' doctor'. (2) 'The student acts as an agent of change for the patient' contains the sub-themes: 'patient advocacy', 'supporting the patient to navigate the healthcare system', 'communication between patient and healthcare professional' and 'enhancement of preceptors' care, healthcare services and communities'. CONCLUSIONS: LICs provide educational continuity allowing the creation of a trusting patient-student relationship. This relationship leads to students becoming agents of change for patients by enhancing patient outcomes. This review provides further evidence on the benefits of having an LIC as part of the medical education curricula and implications for its successful delivery. Further research is needed to explore educationally induced benefits for patients and look at objective assessments of patient health outcomes.

Enablers and barriers to effective clinical supervision in the workplace: a rapid evidence review.

OBJECTIVES: We aimed to review the international literature to understand the enablers of and barriers to effective clinical supervision in the workplace and identify the benefits of effective clinical supervision. DESIGN: A rapid evidence review. DATA SOURCES: Five databases (CINAHL, OVID Embase, OVID Medline, OVID PsycInfo and ProQuest) were searched to ensure inclusion and breadth of healthcare professionals. ELIGIBILITY CRITERIA: Studies identifying enablers and barriers to effective clinical supervision across healthcare professionals in a Western context between 1 January 2009 and 12 March 2019. DATA EXTRACTION AND SYNTHESIS: An extraction framework with a detailed inclusion/exclusion criteria to ensure rigour was used to extract data. Data were analysed using a thematic qualitative synthesis. These themes were used to answer the research objectives. RESULTS: The search identified 15 922 papers, reduced to 809 papers following the removal of duplicates and papers outside the inclusion criteria, with 135 papers being included in the full review. Enablers identified included regular supervision, occurs within protected time, in a private space and delivered flexibly. Additional enablers included supervisees being offered a choice of supervisor; supervision based on mutual trust and a positive relationship; a cultural understanding between supervisor and supervisee; a shared understanding of the purpose of supervision, based on individual needs, focused on enhancing knowledge and skills; training and feedback being provided for supervisors; and use of a mixed supervisor model, delivered by several supervisors, or by those trained to manage the overlapping (and potentially conflicting) needs of the individual and the service. Barriers included a lack of time, space and trust. A lack of shared understanding to the purpose of the supervision, and a lack of ongoing support and engagement from leadership and organisations were also found to be barriers to effective clinical supervision. CONCLUSIONS: This review identified several enablers of and barriers to effective clinical supervision and the subsequent benefits of effective clinical supervision in a healthcare setting.

Breaking bad news: tackling cultural dilemmas.

Requesting that serious diagnoses be concealed from patients, a widespread phenomenon in many cultures, presents a professional dilemma. Practical and sensitive communication strategies are needed. METHODOLOGY: In this paper, we use analysis of the existing literature to develop a communication tool for practitioners facing requests for diagnostic non-disclosure. Our approach builds on existing strategies, in providing a mnemonic communication tool, permitting more than one outcome, and focusing on the need for mutual understanding and cooperation. RESULTS: Existing work on this dilemma highlights the need to appreciate the family's standpoint, affirm their benevolent intentions and correct misperceptions. To this end, we have developed a mnemonic tool, 'ARCHES', to be used in situations where the family has requested diagnostic non-disclosure. The model has six stages: acknowledge the request for non-disclosure, build the relationship, find common ground, honour the patient's preferences and outline the harm of non-disclosure, provide emotional support and devise a supportive solution. CONCLUSION: Facing requests for diagnostic non-disclosure is a challenge of communication. The dilemma is particularly marked when practising across cultures. Our model gives a structure for building rapport with the family and realigning their misperceptions while upholding the patient's right to knowledge.

Assessment tools in pre-licensure interprofessional education: A systematic review, quality appraisal and narrative synthesis.

OBJECTIVES: Interprofessional education (IPE) aims to provide students with the opportunity to develop and demonstrate the team working behaviours and skills that will lead to positive patient outcomes. This systematic review aims to identify and critically appraise the assessment tools used after a pre-licensure IPE intervention and provide guidance on which tool to use according to the focus of the intervention. METHODS: In July 2019, the following electronic databases were searched: MEDLINE, ERIC, CINHAL, EMBASE and NEXUS website. All studies involving pre-licensure health care students exposed to an IPE intervention and undertook an assessment measuring student knowledge, skills, behaviour, or change in organisational practice or a benefit to patients were included. Studies that used tools relying on self-assessment only were excluded. Constructive alignment of the IPE intervention with the assessment was evaluated and quality assessment of the studies and critical appraisal of the validity evidence for the tools was undertaken. RESULTS: From 9502 returned studies, 39 studies met the inclusion criteria and were analysed. These were rated as good in terms of methodological quality. Acquisition of knowledge was the most commonly assessed outcome, mainly with pre/post knowledge tests, followed by behaviour change, which was measured by a range of validated tools. Patient benefit was defined as change in clinical effectiveness, patient safety or patient satisfaction. Constructive alignment of the IPE aim with the assessment was limited due to issues with study reporting. Tools measuring behaviour change demonstrate mixed adherence to quality standards around reliability, validity and scales and scoring. CONCLUSIONS: Various methods have been used to identify change following IPE; however, choosing the most appropriate tool to support and align with the aim of the IPE intervention is crucial. We have critically appraised the available tools and offered an indication of their quality. This has informed the production of a decision aid to support the selection of the appropriate IPE assessment tool depending on the purpose of the intervention. More studies using these tools in rigorous study designs are required to substantiate the evidence base.

Synchronized Video-Review as a Tool to Enhance Reflection and Feedback: A Design-Based Feasibility Study.

INTRODUCTION: UK surgical training currently faces the challenge of expanding surgical skills in a context of reduced training opportunities. Video-review in theatre offers the potential to gain more from each learning opportunity and to enhance feedback. AIM: This was a designed-based study to test the feasibility of using synchronized video-review as a reflective tool to enhance surgical training and to gain a deeper understanding of intraoperative feedback. METHOD: Ten supervised laparoscopic cholecystectomy operations were video-recorded using a synchronized split screen, to show trainees' actions, instrument manipulation, and interactions with other theatre staff. This was followed up by joint review of the operation-recording by both the trainee and supervisor. Video-review sessions were audio-recorded along with the consultant and Specialist Registrar interviews after the review session. Audio recordings were thematically analyzed. Supervisors completed the Procedure-Based Assessment forms, twice: post operation and post video-review to check potential trainers' enhanced insight. Forms were analyzed to note any changes and to triangulate the findings. RESULTS: Overall trainee and supervisor feedback was positive. Trainees and supervisors reported the video-review added value in terms of reflection-on-action. It removed the stress of conducting/supervising the operation in real time and focused the attention on feedback. Satisfaction was reported across trainee levels with both scrubbed and unscrubbed supervisors. Audio-visual review allowed trainees to understand the feedback better and to identify new targets beyond those gained from the verbal feedback during the procedure. It also facilitated appraisal of the trainer's teaching. DISCUSSION: This study established the feasibility of using synchronized video-review as a reflection-on-action tool to potentially enhance surgical training by improving feedback. It identified trainees' difficulty in processing intraoperative feedback due to mental overload from the operation. It showed the limitations of current verbal feedback practice, using Procedure-Based Assessment forms, with regard to enhancing technical and nontechnical skills due to denial and memory fading.

Critical Realism and Realist Inquiry in Medical Education.

Understanding complex interventions, such as in medical education, requires a philosophy of science that can explain how and why things work, or fail to work, in different contexts. Critical realism and its operationalization in the form of realist inquiry provides this explanatory power. Ontologically, critical realism posits that the social world is real, that it exists independent of our knowledge of it, and that it is driven by causal mechanisms. However, unlike postpositivism, a realist epistemological position is that our understanding of the mechanisms that underlay social reality is limited and subjective. Critical realism is focused on understanding the mechanisms that drive social reality even when they are not directly observable. One of the most commonly used methodologies in the critical realist paradigm is realist inquiry, which focuses on the relationships between context, mechanisms, and outcomes. At its core, realist inquiry is concerned with "What works for whom, under what circumstances, how, and why?" To that end, realist inquiry explores the mechanisms that drive social systems and the ways in which these mechanisms work to develop explanatory theories of the phenomena under consideration. Although, compared with other approaches, realist inquiry is relatively new in medical education, the value of realist inquiry is in its ability to model how complex interventions function differently across multiple contexts, explaining what works, how it works, for whom, and in what contexts.

The Development of an Online Standalone Cognitive Hazard Training for Laparoscopic Cholecystectomy: A Feasibility Study.

INTRODUCTION: In the UK, surgical training is under pressure due to reductions in training time and training opportunities, which pose patient safety risks. Cognitive, nontechnical, training has been suggested as a possible solution inspired by the identified benefits in aviation industry. A recent review article highlighted the need for such training despite its high cost and the need for expert trainers. AIM: This study aimed to design and test the feasibility of an online standalone module to address the current gap in cognitive surgical training. METHOD: An online standalone, Cognitive Hazard Training module for laparoscopic cholecystectomy was created. It combined multiple choice questions, extended matching items, and single-line free text questions. It contained relevant sketch images and real life hazards video clips, highlighting potential mistakes to enhance: Safety knowledge, reduce bias, and improve self-limitation awareness. Two experts were invited to validate the prototype before testing its feasibility in one English Deanery training environment. RESULTS: In total 93 candidates signed up to review the training. However only 47 (50%) later participated and 33 completed the Module. Those included 3 juniors, 20 higher trainees, and 10 consultants. Candidates' answers were quantitatively analysed. Qualitative feedback was also collected from 27 candidates, via semi-structured interviews. The overall feedback from the feasibility study was positive. Results supported this online resource value in enhancing knowledge and awareness. Interview data also suggested the module's potential to change trainees' practice by being more cautious and adhering to the safety steps of dissection. DISCUSSION: This new training module overcomes some of the previously reported problems in surgical cognitive training. It is a stand-alone online resource with low running cost and does not require expert trainers. The feasibility study supported the aim to enhance hazard awareness and create an attitude shift towards adherence to safety steps during the procedure.

Gender Division of Labor, Burnout, and Intention to Leave Work Among Young Female Nurses in Japan: A Cross-Sectional Study.

Women in Japan face difficulties balancing work and personal life due to the gender division of labor, and medical professions are no exception. The purpose of this study was to investigate if the gender division of labor affects the intention to leave the workplace among the nursing profession. Among 328 female nurses working for three university-affiliated hospitals in Tokyo, Japan, above 70% were in their 20s and 30s and single, and agreed with the gender division of labor that men should be the breadwinner and women should assume family responsibilities. Adjusting for three types of Copenhagen burnout inventory, stepwise multivariable logistic regression models identified that being younger (all p-values < 0.05), each domain of burnout score (each p < 0.001 for work-, personal-, and client-related burnout) increased a risk of intention to leave, and high support decreased the risk (all p < 0.001). Women who agreed with the gender division of labor were more likely to have intentions to leave (p = 0.003 but this association disappeared when adjusted. The findings of study demonstrate that perceptions toward gender division of labor are not a determinant of intention to leave the workplace but the young nurses and those who scored high on burnout were the most vulnerable population.

INTERNATIONAL: Overseas doctors of the NHS: migration, transition, challenges and towards resolution.

Overseas doctors are playing an important role in the successful running of the NHS. They represent one-third of the total number of UK doctors and include doctors from the European Economic Area and international medical graduates. The main aim of this review is to explore the challenges that overseas doctors might face when they take up their first job in the UK. We conducted literature search using MEDLINE and EMBASE databases. The inclusion and exclusion criteria were designed to include published literature concerning overseas doctors in the UK and the NHS. Lack of information about the UK health system; language and communication challenges; clinical, educational and work-culture challenges; and discrimination challenges are some of the difficulties that overseas doctors might experience. Understanding these challenges and providing support are important steps in helping overseas doctors to make a smooth transition.

How can positive and negative trainer feedback in the operating theatre impact a surgical trainee's confidence and well-being: a qualitative study in the north of England.

OBJECTIVE: To identify the perception of positive feedback (PF) and negative feedback (NF) provided by trainers in the operating theatre on surgical trainees' confidence and well-being. DESIGN: Narrative interview study. SETTING: Twelve hospitals that form part of one deanery within the UK. PARTICIPANTS: Maximum variation sampling of 15 higher general surgical trainees provided insight into how PF and NF from trainers in the operating theatre affect confidence and well-being. METHODS: Narrative telephone interviews were conducted with general surgical trainees between April and June 2016. All interviews were recorded, transcribed and anonymised. Transcriptions were analysed using the five-step framework analysis by two independent researchers. RESULTS: Fifteen trainees (age 28-38 years) were interviewed (median interview time: 29 min). Thematic framework analysis identified nine themes within the data. PF, which included corrective feedback, helped the trainees to relax and seemed to enhance their operative performance. All trainees reported significant and unjustified NF, some of which would be defined as undermining and bullying. Many believed this to have a negative impact on their training with minimal educational benefit. Many trainees felt NF adversely affected their performance in the operating theatre with some expressing a wish to leave the profession as a consequence. CONCLUSION: Both PF and NF exist in the operating theatre. Both have an important influence on the trainee, their performance and career. PF, if specific, helped aid progression of learning, increased motivation and performance of surgical trainees. In contrast, NF was perceived to have detrimental effects on trainees' performance and their well-being and, in some, introduced a desire to pursue an alternative career.