Feedback practices in undergraduate clinical teaching in Sri Lanka - a qualitative study.

BACKGROUND: Feedback is integral to medical education, enabling students to improve their knowledge, skills, and attitudes. Feedback practices may vary according to prevalent cultural and contextual factors. This study aimed to explore how feedback is conceptualized and practised in the clinical education of medical students in Sri Lanka. METHODS: The study was conducted in three medical schools and affiliated hospitals that represent the cultural diversity of Sri Lanka. Purposive sampling was utilized to recruit clinical teachers and students who would provide rich information for the study. The study had three components: an observation study, interviews with clinical teachers and focus group discussions with clinical students. During the observation study, video recording was used as a data collection tool to observe feedback in real-life clinical teaching/learning settings. A constructivist grounded theory approach was adapted for analysis to explore current practices and perceptions inductively. RESULTS: Feedback was conceptualised as spontaneous unidirectional provision of information for the improvement of students. It was often provided in public settings and in student groups. Error correction was the primary focus of feedback, but both teachers and students desired a balanced approach with reinforcement and reflection. Although the direct approach to corrective feedback was found beneficial for student learning, participants agreed that harsh feedback was to be avoided. The hierarchical culture and lack of programmed feedback in the curricula influenced feedback practices, suggesting the need for modification. CONCLUSIONS: This study highlighted feedback practices in the local context, emphasizing the need to address the hierarchical gap in clinical settings, balance reinforcement and correction, and promote dialogue and reflection in the feedback processes. The findings will help clinical teachers from both the global south as well as the global north to recognize cultural and contextual differences in providing feedback.

Advancing careers in medical education: 'Practice architectures' for success in a resource-constrained setting.

INTRODUCTION: Advancement of careers in medical education remains a challenge around the world and is under-researched in resource-constrained contexts. Using the Theory of Practice Architectures (TPA) as a conceptual lens, we investigated the emergence and subsequent development of medical education careers in a resource-constrained country. METHODS: Qualitative semi-structured interviews were conducted with a purposive sample of 14 early-career and leading medical educators from all 9 medical schools and the 1 postgraduate institute in Sri Lanka. Thematic analysis was performed, informed by the three conceptual lenses of TPA: discursive-cultural, material-economic, and socio-political. RESULTS: Three themes were identified: faculty development as a career-building discourse (discursive-cultural); leadership focused on creating a workforce with expertise in medical education, equal to clinical medicine specialties (material-economic); and collaborative professional networks in health professions education originating from faculty development activities (socio-political). CONCLUSION: Using TPA, our findings highlight that faculty development can foster a powerful discourse for promoting academic careers in medical education. Medical education leaders can also play a critical role by establishing formal training programmes in medical education, and collaborative professional networks can improve visibility of careers in medical education, particularly when participants share expertise and resources between institutions and health professions, across the continuum of undergraduate to postgraduate training. TPA can also be used to better understand how cultural, material-economic and socio-political factors can enhance or hinder career development in different contexts, whether resource-limited or well-resourced.

Barriers to healthy dietary choice amongst students in Sri Lanka as perceived by school principals and staff.

Summary: Sri Lanka has experienced a massive demographic, environmental, economic and social transition in recent decades. Over this period of time the country has undergone rapid urbanization leading to accompanying shifts in lifestyle and it suffers a double burden of under- and over-nutrition. Current programmes in the country focus on improving the dietary behaviour of secondary school students. The purpose of this study was to investigate principal's perceptions on barriers to healthy dietary choice among pupils within a socio-ecological framework. Focus groups (n = 11) were carried out with school principals and staff (n = 55) in two rural districts of Sri Lanka. Principals identified a number of barriers to healthy dietary choice by students, which could be found at a number of levels of influence of a socio-ecological framework: (i) structural level barriers included educational and agricultural policies, (ii) living and working level barriers included employment opportunities and local food production, (iii) social and community level barriers included traditions and social/cultural beliefs and (iv) individual level barriers included knowledge and preference. Findings from this study suggest that the barriers to healthy dietary choice amongst secondary school students in Sri Lanka occur at many levels supporting the use of multifactorial programmes to promote healthy eating. Only from understanding these barriers and finding ways to counter them can we hope to reduce the double burden of under- and over-nutrition the country is currently suffering.

Educational impact of an assessment of medical students' collaboration in health care teams.

CONTEXT: This paper explores how structured feedback and other features of workplace-based assessment (WBA) impact on medical students' learning in the context of an evaluation of a workplace-based performance assessment: the teamwork mini-clinical evaluation exercise (T-MEX). The T-MEX enables observation-based measurement of and feedback on the behaviours required to collaborate effectively as a junior doctor within the health care team. The instrument is based on the mini-clinical evaluation exercise (mini-CEX) format and focuses on clinical encounters such as consultations with medical and allied health professionals, discharge plan preparation, handovers and team meetings. METHODS: The assessment was implemented during a 6-week period in 2010 with 25 medical students during their final clinical rotation. Content analysis was conducted on the written feedback provided by 23 assessors and the written reflections and action plans proposed by the 25 student participants (in 88 T-MEX forms). Semi-structured interviews with seven assessors and three focus groups with 14 student participants were conducted and the educational impact was explored through thematic analysis. RESULTS: The study enabled the identification of features of WBA that promote the development of collaborative competencies. The focus of the assessment on clinical encounters and behaviours important for collaboration provided opportunities for students to engage with the health care team and highlighted the role of teamwork in these encounters. The focus on specific behaviours and a stage-appropriate response scale helped students identify learning goals and facilitated the provision of focused feedback. Incorporating these features within an established format helped students and supervisors to engage with the instrument. Extending the format to include structured reflection enabled students to self-evaluate and develop plans for improvement. CONCLUSIONS: The findings illuminate the mechanisms by which WBA facilitates learning. The educational features highlighted include effectively structured feedback processes, support for situated learning, a positive backwash (facilitation of learning through preparation for the assessment), and facilitation of informed self-assessment.

A student-led process to enhance the learning and teaching of teamwork skills in medicine.

CONTEXT: The development of teamwork skills is a critical aspect of modern medical education. This paper reports on a project that aimed to identify student perceptions of teamwork-focused learning activities and generate student recommendations for the development of effective educational strategies. METHODS: The project utilized a unique method, which drew on the skills of student research assistants (RAs) to explore the views of their peers. Using structured interview guides, the RAs interviewed their colleagues to clarify their perceptions of the effectiveness of current methods of teamwork teaching and to explore ideas for more effective methods. The RAs shared their deidentified findings with each other, identified preliminary themes, and developed a number of recommendations which were finalized through consultation with faculty. RESULTS: The key themes that emerged focused on the need to clarify the relevance of teamwork skills to clinical practice, reward individual contributions to group process, facilitate feedback and reflection on teamwork skills, and systematically utilize clinical experiences to support experiential learning of teamwork. Based on these findings, a number of recommendations for stage appropriate teamwork learning and assessment activities were developed. Key among these were recommendations to set up a peer-mentoring system for students, suggestions for more authentic teamwork assessment methods, and strategies to utilize the clinical learning environment in developing teamwork skills. DISCUSSION: The student-led research process enabled identification of issues that may not have been otherwise revealed by students, facilitated a better understanding of teamwork teaching and developed ownership of the curriculum among students. The project enabled the development of recommendations for designing learning, teaching, and assessment methods that were likely to be more effective from a student perspective.

Transferability of faculty development resources.

BACKGROUND: Adapting existing training resources for clinical teachers is more efficient than creating resources de novo. There is limited evidence on how to effectively use and ensure the relevance of training materials originally developed for different contexts and audiences. We tested in Sri Lanka and Malaysia the transferability of scenario-based training videos and session plans developed for Australian medical schools, to identify those aspects which need adaptation, and make recommendations to enhance transferability. METHODS: Staff involved in student support from three medical schools were invited to participate in five workshops facilitated by an Australian educator. Video discussion triggers of students presenting with concerns were used in workshop activities, including written exercises, group discussions and reflection. The quantitative and qualitative data collected included categorical and free-text participant responses to questionnaires and structured field notes from local faculty developers using peer observation. FINDINGS: Academic and clinician-teacher participants predominated in the workshops. Of 66 participant questionnaires (92% response rate), over 90% agreed that the workshop was relevant, and over 95% agreed that the videos facilitated discussion and the sharing of experiences. Field notes confirmed that participants were engaged by the videos, but identified that one student scenario and the approaches for seeking support in others were not immediately transferable to local contexts. The adaptation of facilitation techniques used in Australian workshops was needed to address audience responses. DISCUSSION: Our findings confirm faculty development principles of content relevancy and incorporation of reflection. To enhance transferability, we recommend co-facilitation with local faculty members, the explicit signposting of topics and re-contextualising key concepts through reflective discussion.

Innovative Assessment That Combines Collaborative and Self-Directed Learning With Integration and Application of Knowledge: Teamwork Group Projects.

INTRODUCTION: There is a worldwide focus on the early development of collaborative skills in medical students as reflected in the design of the medicine program at the University of New South Wales, Australia. Integral to the success of student-centered curricula, is early development of students' self-directed and collaborative learning skills. The purpose of this innovative assessment is to develop and assess students' skills in self-directed and collaborative learning while they concurrently engage with stage-appropriate content knowledge. METHODS: The educational design of the group projects allows junior medical students to work collaboratively to develop a deep understanding of the concepts and principles of a clinical scenario. Students are required to integrate and apply knowledge from different disciplines and share their learning with a wider peer group through appropriate peer teaching strategies. Two variants of these group projects are described in this resource, and generic versions of student and assessor instructions are included as Appendices A and B. RESULTS: Feedback on the projects collected over the last 7 years has been positive. Students begin to see the relevance and benefits of learning together and appreciate the impact this has on the quality of their learning. They also begin to appreciate the relevance of collaborative skills to their future practice as doctors. DISCUSSION: The group projects are based on well-established educational principles, and the templates provided in the appendices can be adapted by other medical educators.

Nursing intensive care skills training: a nurse led, short, structured, and practical training program, developed and tested in a resource-limited setting.

PURPOSE: To assess the impact of a nurse-led, short, structured training program for intensive care unit (ICU) nurses in a resource-limited setting. METHODS: A training program using a structured approach to patient assessment and management for ICU nurses was designed and delivered by local nurse tutors in partnership with overseas nurse trainers. The impact of the course was assessed using the following: pre-course and post-course self-assessment, a pre-course and post-course Multiple Choice Questionnaire (MCQ), a post-course Objective Structured Clinical Assessment station, 2 post-course Short Oral Exam (SOE) stations, and post-course feedback questionnaires. RESULTS: In total, 117 ICU nurses were trained. Post-MCQ scores were significantly higher when compared with pre-MCQ (P < .0001). More than 95% passed the post-course Objective Structured Clinical Assessment (patient assessment) and SOE 1 (arterial blood gas analysis), whereas 76.9% passed SOE 2 (3-lead electrocardiogram analysis). The course was highly rated by participants, with 98% believing that this was a useful experience. CONCLUSIONS: Nursing Intensive Care Skills Training was highly rated by participants and was effective in improving the knowledge of the participants. This sustainable short course model may be adaptable to other resource-limited settings.

The Teamwork Mini-Clinical Evaluation Exercise (T-MEX): a workplace-based assessment focusing on collaborative competencies in health care.

PURPOSE: Teamwork is an important and challenging area of learning during the transition from medical graduate to intern. This preliminary investigation examined the psychometric and logistic properties of the Teamwork Mini-Clinical Evaluation Exercise (T-MEX) for the workplace-based assessment of key competencies in working with health care teams. METHOD: The authors designed the T-MEX for direct observation and assessment of six collaborative behaviors in seven clinical situations important for teamwork, feedback, and reflection. In 2010, they tested it on University of New South Wales senior medical students during their last six-week clinical term to investigate its overall utility, including validity and reliability. Assessors rated students in different situations on the extent to which they met expectations for interns for each collaborative behavior. Both assessors and students rated the tool's usefulness and feasibility. RESULTS: Assessment forms for 88 observed encounters were submitted by 25 students. The T-MEX was suited to a broad range of collaborative clinical practice situations, as evidenced by the encounter types and the behaviors assessed by health care team members. The internal structure of the behavior ratings indicated construct validity. A generalizability study found that eight encounters were adequate for high-stakes measurement purposes. The mean times for observation and feedback and the participants' perceptions suggested usefulness for feedback and feasibility in busy clinical settings. CONCLUSIONS: Findings suggest that the T-MEX has good utility for assessing trainee competence in working with health care teams. It fills a gap within the suite of existing tools for workplace-based assessment of professional attributes.

The students' voice: Strengths and weaknesses of an undergraduate medical curriculum in a developing country, a qualitative study.

BACKGROUND: In medical education, feedback from students' is essential in course evaluation and development. Students at Faculty of Medicine, University of Colombo, Sri Lanka complete a five year medical curriculum comprising of five different streams. We aimed to evaluate the five year medical curriculum at the Faculty of Medicine, University of Colombo, Sri Lanka. METHODS: A qualitative research was conducted among recent graduates of the faculty. Students' opinions on strengths and weaknesses of the curriculum were collected via questionnaires, which were analysed and classified into common themes. A focus group discussion (FGD) based on these themes was conducted among two student groups, each comprising of a facilitator, two observers and nine students selected as a representative sample from questionnaire respondents. FGDs were conducted using a semi-structured set of open-ended questions to guide participants and maintain consistency between groups. The FGD evaluated the reasons behind students' perceptions, attitudes, emotions and perceived solution. Verbal and non-verbal responses were transcribed and analysed. RESULTS: Questionnaire response rate was 82% (153/186). Students highlighted 68 and 135 different responses on strengths and weaknesses respectively. After analysis of both questionnaire and FGD results the following themes emerged: a well organized module system, increased frequency of assessments, a good variety in clinical appointments, lack of specific objectives and assessments at clinical appointments, community and behavioural sciences streams beneficial but too much time allocation, lengthy duration of course, inadequate knowledge provided on pharmacology and pathology. CONCLUSION: We demonstrate how a brief qualitative method could be efficiently used to evaluate a curriculum spanning a considerable length of time. This method provided an insight into the students' attitudes and perceptions of the present faculty curriculum. Qualitative feedback from students highlighted certain key areas that need attention and also possible solutions as perceived by the students'.