Debriefing to nurture clinical reasoning in nursing students: A design-based research study.

BACKGROUND: Students' clinical reasoning can be stimulated by guiding them to use their experiences with patients to develop own illness scripts. Debriefing during hospital shifts invites students to put patient experiences into words, link them to previously acquired knowledge and make connections. OBJECTIVES: To develop, implement and evaluate a debriefing procedure for nursing internships based on illness script theory and generate corresponding design principles. DESIGN: Qualitative design-based research. SETTING: Clinical education in dedicated educational hospital units. PARTICIPANTS: Nurse educators, nursing students. METHODS: From a collaboration between nurse educators and a researcher, a short, peer-debriefing procedure was designed, tested and enacted through four cycles of planning, action, evaluation and reflection. Students drew mind maps about patients. Nurse educators and students joined focus group discussions to evaluate outcomes and processes. Mind map and iterative thematic analysis were applied to these data. RESULTS: An adjusted design and more extensive design principles resulted. Differences in mind maps were evident over time. Three themes in the process evaluation were established: trigger to reason; energy giving and taking; and form follows function. CONCLUSIONS: This design-based investigation displays how nurse educators could design and implement a debriefing procedure to facilitate students' clinical reasoning skills and how students could learn from this. This method integrates research, innovation and collaboration. The design and enactment under real-life hospital conditions generated design principles for educators and researchers which may be useful for those seeking to improve teaching and learning clinical reasoning in practice. More clarification is needed about the path from design through enactment to real change in practice.

Promoting students' autonomous motivation for the ongoing curriculum using a 'Societal Impact Project' with basic psychological needs characteristics.

PURPOSE: Autonomous motivation is important for university students, but it remains a challenge to stimulate their autonomous motivation for their curricula. We developed an extracurricular intervention (Societal Impact Project) with basic psychological needs supportive characteristics such as learning with self-defined problems relevant to curriculum and society, collaborative group work, and coaching by a teacher. This study aims at evaluating the intervention in fostering students' autonomous motivation for their regular curricula. METHODS: We conducted a quasi-experimental study, using between-group pre- and post-test design. Participants from the intervention and control group completed a survey before and after the intervention, which measured the satisfaction of three basic psychological needs, autonomous motivation, controlled motivation, enjoyment, value, and well-being within their regular curricula. We compared the post-test differences between the two groups while controlling for pre-test scores. RESULTS: Students in the intervention group had greater enjoyment in their regular curricula and perceived their regular curricula to have more value compared to students in the control group. The other variables did not differ significantly between the two groups in the post-test. CONCLUSION: The intervention is effective for improving students' enjoyment and perceived value in their regular curricula. The variables with non-significant differences indicate the difficulty to alter students' basic psychological needs and motivation in their regular curricula, even after participating in a long-term intervention.

Going beyond the comparison: toward experimental instructional design research with impact.

To design effective instruction, educators need to know what design strategies are generally effective and why these strategies work, based on the mechanisms through which they operate. Experimental comparison studies, which compare one instructional design against another, can generate much needed evidence in support of effective design strategies. However, experimental comparison studies are often not equipped to generate evidence regarding the mechanisms through which strategies operate. Therefore, simply conducting experimental comparison studies may not provide educators with all the information they need to design more effective instruction. To generate evidence for the what and the why of design strategies, we advocate for researchers to conduct experimental comparison studies that include mediation or moderation analyses, which can illuminate the mechanisms through which design strategies operate. The purpose of this article is to provide a conceptual overview of mediation and moderation analyses for researchers who conduct experimental comparison studies in instructional design. While these statistical techniques add complexity to study design and analysis, they hold great promise for providing educators with more powerful information upon which to base their instructional design decisions. Using two real-world examples from our own work, we describe the structure of mediation and moderation analyses, emphasizing the need to control for confounding even in the context of experimental studies. We also discuss the importance of using learning theories to help identify mediating or moderating variables to test.

Bridging School and Practice? Barriers to the Integration of 'Boundary Objects' for Learning and Assessment in Clinical Nursing Education.

Introduction: In clinical health professions education, portfolios, assignments and assessment standards are used to enhance learning. When these tools fulfill a bridging function between school and practice, they can be considered 'boundary objects'. In the clinical setting, these tools may be experienced as time-consuming and lacking value. This study aimed to investigate the barriers to the integration of boundary objects for learning and assessment from a Cultural-Historical Activity Theory (CHAT) perspective in clinical nursing education. Methods: Nineteen interviews and five observations were conducted with team leads, clinical educators, supervisors, students, and teachers to obtain insight into intentions and use of boundary objects for learning and assessment. Boundary objects (assessment standards, assignments, feedback/reflection/patient care/development plan templates) were collected. The data collection and thematic analysis were guided by CHAT. Results: Barriers to the integration of boundary objects included: a) conflicting requirements in clinical competency monitoring and assessment, b) different application of analytical skills, and c) incomplete integration of boundary objects for self-regulated learning into supervision practice. These barriers were amplified by the simultaneous use of boundary objects for learning and assessment. Underlying contradictions included different objectives between school and practice, and tensions between the distribution of labor in the clinical setting and school's rules. Discussion: School and practice have both convergent and divergent priorities around students' clinical learning. Boundary objects can promote continuity in learning and increase students' understanding of clinical practice. However, effective integration requires for flexible rules that allow for collaborative learning around patient care.

When I say inclusion.

There is no unified understanding of the concept of inclusion in the literature. Since inclusion is a hot topic in the current debates on equity diversity and inclusion, it is important to move towards creating a common understanding of this term. In this article I explore the concept of inclusion based on the current literature. When I say inclusion, it is not just a sense of belonging, but also the opportunity to participate and contribute meaningfully.

Medical Teacher's equity diversity inclusion policy.

Medical Teacher is a leading international journal in health professions education. The Journal recognizes its responsibility to publish papers that reflect the breadth of topics that meet the needs of its readers around the globe including contributions from countries underrepresented in the health professions education arena. This paper sets out the Journal's policy with regard to Equity Diversity Inclusion (EDI) and the steps to be taken to implement the policy in practice.

Learning from the Experts: Stimulating Student Engagement in Small-group Active Learning.

Introduction: Engaging students in small-group active learning methods is essential for their development. Yet, medical teachers frequently face difficulties in stimulating this engagement, resulting in students remaining passive or detached from the learning process. The aim of this study was to uncover ways in which expert medical teachers, proficient at cultivating high levels of student engagement, stimulate such engagement. This knowledge might inform faculty development initiatives, so that medical teachers can be better equipped to teach in a way that engages students. Methods: We conducted an interview study using a constructivist grounded theory approach, integrating elements from appreciative inquiry. The eleven participants were qualified medical teachers who repeatedly received high scores on student engagement. Each interview was transcribed, coded, and analyzed using constant comparison until theoretical saturation was achieved. Results: We constructed a grounded theory of expert teaching practice, describing student engagement as an integrated process consisting of three components: 1) aiming for a supportive learning environment; 2) employing a personal educational approach; and 3) facilitating the active learning process. Discussion: This study uncovered that there are multiple ways to stimulate high levels of student engagement. Although there was consensus on the importance of a supportive learning environment and the ability to facilitate the active learning process, participants recognized the contextual nature of student engagement and took on a reflective mindset to adapt strategies to their specific situations. These findings highlight the need for faculty development initiatives to adopt a comprehensive, context-sensitive approach that considers the complexity of student engagement.

Interprofessional collaboration skills and motivation one year after an interprofessional educational intervention for undergraduate medical and nursing students.

BACKGROUND: The increasingly complex patient care in the twenty-first century is delivered by interprofessional health care teams. Interprofessional collaboration can be taught during interprofessional education. However, whether a long-term change in collaborative competencies can be achieved by interprofessional education has not been studied sufficiently. Our research questions were: How does motivation for interprofessional collaboration and interprofessional collaborative skills change up to one year after an interprofessional educational intervention? How are they related to each other? METHODS: During a one-year period, undergraduate medical and nursing students attended four interprofessional (intervention) or uniprofessional (control group) education sessions. Self-determination Theory was used as the theoretical framework. Autonomous and controlled motivation scores for interprofessional collaboration were calculated using the Academic Self-Regulation Questionnaire, before (T1), directly after (T2) and one year post-intervention (T3). At T3, the students also filled out the Interprofessional Collaborative Competencies Attainment Survey (ICCAS), which measured the perceived attainment of collaborative competencies by a retrospective pre-test/post-test design. We used linear mixed effects models to analyse the motivation scores and linear regression for the relation between motivation and competence. RESULTS: In the interprofessional group, autonomous motivation scores of the participants were significantly lower at T2 vs. T1. Controlled motivation scores were significantly higher at T3 vs. T1. Controlled motivation scores for T2 were significantly higher in the uniprofessional group than in the interprofessional group. Perceived competence was related to higher autonomous motivation scores. At T3 the interprofessional collaborative competencies seemed to have grown more among students in the interprofessional group. CONCLUSIONS: The perceived growth in interprofessional collaboration competence lasted at least up to one year after the intervention, and was measurable with the ICCAS. The growth was significantly more in the IPE students than in the UPE students. The few differences found in motivation scores for interprofessional collaboration were probably caused by an imbalance of nursing versus medical students over the different time points. This finding indicates that classroom based IPE can contribute to interprofessional collaboration skills of nursing and medical students at least up to one year after an intervention.

How do ageism, death anxiety and ageing anxiety among medical students and residents affect their attitude towards medical care for older patients: a systematic review.

BACKGROUND: Although the number of older patients requiring medical care is increasing, caring for older patients is often seen as unattractive by medical trainees (i.e., medical students, residents, interns, and fellows). Terror Management Theory states that people have a negative attitude towards older people, because they remind people of their own mortality. We hypothesize that ageism, death anxiety, and ageing anxiety among medical trainees negatively affect their attitude towards medical care for older patients. This review aimed to examine and generate an overview of available literature on the relationship between ageism, death anxiety, and ageing anxiety among medical trainees and their attitude towards medical care for older patients. METHODS: A systematic review was performed with a review protocol based on the PRISMA Statement. PubMed, Ebsco/PsycInfo, Ebsco/ERIC and Embase were searched from inception to August 2022, using the following search terms, including their synonyms and closely related words: "medical trainees" AND "ageism" OR "death anxiety" OR "ageing anxiety" AND "(attitude AND older patient)". RESULTS: The search yielded 4072 different studies; 12 eligible studies (10 quantitative and 2 qualitative) were identified and synthesized using narrative synthesis. Findings suggest that a positive attitude towards older people was related to a positive attitude towards medical care for older patients among medical students. The available literature on the relationship between death anxiety and/or ageing anxiety and attitude towards medical care for older patients among medical trainees was limited and had a heterogeneity in focus, which hindered comparison of results. CONCLUSION: Our findings suggest that a positive attitude towards older people in general is related to a positive attitude towards medical care for older patients among medical students. Future research should focus on further exploring underlying mechanisms affecting the attitude towards medical care for older patients among medical trainees.

Inclusive leadership in the health professions and health professions education.

WHAT IS INCLUSION AND INCLUSIVE LEADERSHIP?: In this article, based on the literature and my own experiences, I try to shed light on the concepts of inclusion and inclusive leadership, as well as what leaders need to do in order to be inclusive. Inclusion means the act of including or being included in a group, which creates a sense of belonging as well as empowers individuals to contribute in an authentic and meaningful manner. Inclusive leadership is important in the health professions and health professions education so that health professionals and faculty in health professions education are able to contribute to their work in ways that they find meaningful. WHAT DO LEADERS NEED TO DO TO BE INCLUSIVE?: To be inclusive leaders need to to do the following: truly believe in inclusion, define the boundaries of acceptable behaviours, make difficult diversity conversations possible, build authentic diverse relationships, develop shared leadership, drive and role model inclusive practices in the organisation, and find the right balance between individual and institutional EDI initiatives. Driving inclusion in a health professions (education) organisation demands changes in the concept of leadership, as well as the organisational policy and culture.

Twelve tips for designing, implementing and sustaining interprofessional training units on hospital wards.

Dedicated Interprofessional Training Units (ITUs) in hospital wards are one way to prepare healthcare students for Interprofessional patient-centered care. Based on theoretical foundations, research, and our lived experiences of successes as well as failures, we propose 12 tips on how to prepare, implement, and sustain a dedicated ITU, combining the Grol & Wensing model for planning change with the Self-determination Theory of motivation. Start with a steering group, with a dedicated project leader, to translate awareness of the need for an ITU into wider awareness and motivation among stakeholders, with the ITU being a solution to authentic problems. Create shared ownership by jointly formulating feasible educational goals and starting with a pilot to provide opportunities for change. Motivate all stakeholders by stimulating their autonomy, interprofessional competence as well as relatedness to each other, in line with the Self-determination Theory. Confirm the value of the ITU at all stages and embed the ITU in the organizational strategy.

Mentorship in health professions education - an AMEE guide for mentors and mentees: AMEE Guide No. 167.

This AMEE guide discusses theoretical principles and practical strategies for health professions educators to promote impactful mentoring relationships. Traditional definitions are challenged, distinctions are made between roles such as mentor, advisor, coach and sponsor. As educational environments change and options for professional development expand, we argue that the traditional dyadic format of mentoring alone will not help mentees to maximise their professional growth. Newer formats of mentoring are discussed in detail and their advantages and disadvantages compared. We use a variety of theoretical concepts to anchor the practice of mentorship: self-focussed and other-focussed motives; psychological safety; personal interpretive framework; Daloz model for balancing support and challenge; zone of proximal development; communities of practice; and development along multiple layers of competence. Recommended strategies for effective mentoring are based on extensive review of literature, as well as combined professional mentoring experiences of the authors. We use key principles from the theories described and phases of mentoring relationships as foundations for the suggested best practices of mentorship. Finally, we emphasise the role of mentees in their own professional development and provide tips for them on seeking mentors, expanding their mentoring network and taking the lead in setting the agenda during mentoring meetings and formulating action plans for their own advancement.

Adaptation and validation of the encoding of observations using CONSUL-MCC: A self-determination theory-based tool to observe consultations in maternity care.

Objective: During autonomy-supportive consultations, professionals use a need-supportive interaction style to facilitate patients' self-regulated behaviour. To improve maternity care professionals' need-supportive interactions, it is important to provide insights into their interaction style. No tool is currently available for measuring need-supportive interactions in maternity care. Therefore, the aim of this study was to adapt the COUNSEL-CCE to evaluate need-supportive interactions in maternity care and to validate their measurements. Methods: A five-step adaptation and validation process was performed based on the guideline of Sousa and Rojjanasrirat: 1) adaptation of COUNSEL-CCE by two authors independently; 2) development of a consensus-based tool: CONSUL-MCC; 3) qualitative assessment of CONSUL-MCC; 4) pilot testing of CONSUL-MCC in the target population (N = 10) and 5) psychometric testing in the target population (N = 453). Results: All indicators of the original tool remained relevant. Four items were rephrased, one indicator was added, and all examples were adapted to maternity care. The results of psychometric testing indicated good construct validity. However, the data characteristics made it impossible to prove the presumed factor structure and perform an accurate intraclass correlation. Conclusions and innovation: COUNSEL-CCE proved to be a new instrument to gain insights into professionals' interactions and be applied to maternity care.

Effectiveness of Life Goal Framing to Motivate Medical Students During Online Learning: A Randomized Controlled Trial.

Introduction: Educators need design strategies to support medical students' motivation in online environments. Prompting students to frame a learning activity as preparing them to attain their life goals (e.g., helping others) via their clinical practice, a strategy called 'life goal framing', may enhance their autonomous motivation, learning strategy use, and knowledge retention. However, for students with low perceived competence for learning (PCL), life goal framing may have an adverse effect. A randomized controlled trial was conducted to test the effectiveness of life goal framing and the moderating effect of students' PCL. Methods: First- and second-year medical students across four Canadian universities (n = 128) were randomized to receive a version of an online module with an embedded prompt for life goal framing, or one without. Students' motivation, learning strategy use, and knowledge retention were assessed. Differences between conditions on each outcome were estimated using Bayesian regression. Results: Students' PCL was a moderator for autonomous motivation but no other outcomes. The prompt did not have a statistically significant effect on any outcome, even for learners with high PCL, except for a small effect on link-clicking behaviour. Discussion: The results of this study suggest that learners' autonomous motivation is influenced by how they make meaning of instruction in terms of their future life goals and their present confidence. We cannot recommend life goal framing as an effective design strategy at this point, but we point to future work to increase the benefit of life goal framing for learners with high confidence.

Inequality of opportunity in selection procedures limits diversity in higher education: An intersectional study of Dutch selective higher education programs.

Selection for higher education (HE) programs may hinder equal opportunities for applicants and thereby reduce student diversity and representativeness. However, variables which could play a role in inequality of opportunity are often studied separately from each other. Therefore, this retrospective cohort study conducts an innovative intersectional analysis of the inequality of opportunity in admissions to selective HE programs. Using a combination of multivariable logistic regression analyses and descriptive statistics, we aimed to investigate 1) the representativeness of student populations of selective HE programs, as compared to both the applicant pool and the demographics of the age cohort; 2) the demographic background variables which are associated with an applicant's odds of admission; and 3) the intersectional acceptance rates of applicants with all, some or none of the background characteristics positively associated with odds of admission. The study focused on all selective HE programs (n = 96) in The Netherlands in 2019 and 2020, using Studielink applicant data (N = 85,839) and Statistics Netherlands microdata of ten background characteristics. The results show that student diversity in selective HE programs is limited, partly due to the widespread inequality of opportunity in the selection procedures, and partly due to self-selection. Out of all ten variables, migration background was most often (negatively) associated with the odds of receiving an offer of admission. The intersectional analyses provide detailed insight into how (dis)advantage has different effects for different groups. We therefore recommend the implementation of equitable admissions procedures which take intersectionality into account.

Diversity in the pathway from medical student to specialist in the Netherlands: a retrospective cohort study.

Background: Medical specialist workforces are not representative of the society they serve, partially due to loss of diversity in the path from student to specialist. We investigated which demographic characteristics of bachelor students of medicine (BSM) are associated with becoming a physician and (particular type of) medical specialist; and whether this suggests 'cloning' (reproduction of sameness) of the existing workforce. Methods: We used a retrospective cohort design, based on Statistics Netherlands data of all first-year BSM in 2002-2004 in The Netherlands (N = 4503). We used logistic regression to analyze the impact of sex, migration background, urbanity of residence, parental income and assets categories, and having healthcare professional parents, on being registered as physician or medical specialist in 2021. We compared our results to the national pool of physicians (N = 76,845) and medical specialists (N = 49,956) to identify cloning patterns based on Essed's cultural cloning theory. Findings: Female students had higher odds of becoming a physician (OR 1.87 [1.53-2.28], p < 0.001). Physicians with a migration background other than Turkish, Moroccan, Surinamese, Dutch Caribbean or Indonesian (TMSDI) had lower odds of becoming a specialist (OR 0.55 [0.43-0.71], p < 0.001). This was not significant for TMSDI physicians (OR 0.74 [0.54-1.03], p = 0.073). We found a cloning pattern with regard to sex and migration background. Nationwide, physicians with a Turkish or Moroccan migration background, and female physicians with other migration backgrounds, are least likely to be a medical specialist. Interpretation: In light of equity in healthcare systems, we recommend that every recruitment body increases the representativeness of their particular specialist workforce. Funding: ODISSEI.

How should we do equity, diversity and inclusion work in health professions education?

This is an editorial for the special collection on equity, diversity and inclusion (EDI) for MedEdPublish. In this article, the guest advisors of this collection first reflect on the paradoxes in EDI in health professions education (HPE), then on the importance of recognising the existence of multiple authenticities on the basis of different contexts and settings, and finally encourage authors and readers to reflect on their position on the continuum of EDI work. They conclude the editorial by outlining the direction they wish to set for articles in the collection.

Quality of the educational environment in postgraduate community pharmacy education and the relationship with trainees’ basic psychological needs

Background: Quality of the educational environment affects trainee performance and well-being in postgraduate healthcare education. In pharmacy practice the quality of the educational environment has not been extensively studied. Self-determination Theory can assist in understanding the underlying mechanisms. Objectives: In this study, the quality of the educational environment and its relationship with satisfaction and frustration of trainees’ basic psychological needs and motivation were investigated in a Dutch community pharmacy postgraduate education programme. Methods: In a cross-sectional study, pharmacists specializing to become community pharmacists completed the Scan of Postgraduate Educational Environment Domains (SPEED), the Basic Psychological Need Satisfaction and Frustration Scale for the Work Domain, and the Academic Motivation Scale. Confirmatory factor analysis followed by path analysis was used to analyse the relationships between the variables. Results: Out of 232 trainees, 205 responded (88%). Most trainees (82%) were positive about the quality of the educational environment. The resulting path model displayed a moderate to good fit. The perceived quality of the educational environment had a moderate positive association with basic psychological needs satisfaction (Factor loading = 0.40) and a similar negative association with basic psychological needs frustration (Factor loading = -0.47). Basic psychological needs frustration had a moderate association with an increased sense of internal and external pressures also known as controlled motivation (Factor loading = 0.31). Intrinsic motivation was not affected by the perceived quality of the educational environment. (AU)