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.

Basic psychological needs satisfaction as a mediator between clinical learning climate, self-regulated learning and perceived learning in the nursing education context.

PURPOSE: Self-regulated learning (SRL) can enhance students' learning process. Students need support to effectively regulate their learning. However, the effect of learning climate on SRL behavior, its ultimate effect on learning and the underlying mechanisms have not yet been established. We explored these relationships using self-determination theory. MATERIALS AND METHODS: Nursing students (N = 244) filled in questionnaires about SRL behavior, perceived learning, perceived pedagogical atmosphere and Basic Psychological Needs (BPN) satisfaction after their clinical placement. Structural equation modelling was used to test a model in which perceived pedagogical atmosphere affects SRL behavior and subsequent perceived learning through BPN satisfaction. RESULTS: The tested model had an adequate fit (RMSEA = 0.080, SRMR = 0.051; CFI = 0.972; TLI = 0.950). A positively perceived pedagogical atmosphere contributed to SRL behavior, which was fully explained by BPN satisfaction. SRL partially mediated the contribution of pedagogical atmosphere/BPN to perceived learning. CONCLUSIONS: A learning climate that satisfies students' BPN contributes to their SRL behavior. SRL behavior plays a positive but modest role in the relationship between climate and perceived learning. Without a culture that is supportive of learning, implementation of tools to apply SRL behavior may not be effective. Study limitations include reliance on self-report scales and the inclusion of a single discipline.

The Effect of Assessments on Student Motivation for Learning and Its Outcomes in Health Professions Education: A Review and Realist Synthesis.

PURPOSE: In health professions education (HPE), the effect of assessments on student motivation for learning and its consequences have been largely neglected. This is problematic because assessments can hamper motivation and psychological well-being. The research questions guiding this review were: How do assessments affect student motivation for learning in HPE? What outcomes does this lead to in which contexts? METHOD: In October 2020, the authors searched PubMed, Embase, APA PsycInfo, ERIC, CINAHL, and Web of Science Core Collection for "assessments" AND "motivation" AND "health professions education/students." Empirical papers or literature reviews investigating the effect of assessments on student motivation for learning in HPE using quantitative, qualitative, or mixed methods from January 1, 2010, to October 29, 2020, were included. The authors chose the realist synthesis method for data analysis to study the intended and unintended consequences of this complex topic. Assessments were identified as stimulating autonomous or controlled motivation using sensitizing concepts from self-determination theory and data on context-mechanism-outcome were extracted. RESULTS: Twenty-four of 15,291 articles were ultimately included. Assessments stimulating controlled motivation seemed to have negative outcomes. An example of an assessment that stimulates controlled motivation is one that focuses on factual knowledge (context), which encourages studying only for the assessment (mechanism) and results in surface learning (outcome). Assessments stimulating autonomous motivation seemed to have positive outcomes. An example of an assessment that stimulates autonomous motivation is one that is fun (context), which through active learning (mechanism) leads to higher effort and better connection with the material (outcome). CONCLUSIONS: These findings indicate that students strategically learned what was expected to appear in assessments at the expense of what was needed in practice. Therefore, health professions educators should rethink their assessment philosophy and practices and introduce assessments that are relevant to professional practice and stimulate genuine interest in the content.

[Should we keep the graduation with distinction in medical school?] / Cum laude in de master geneeskunde.

Historically, medical students can graduate medical school with distinction if they have a high mark on average or excellent performance on a number of rubrics. Recently, one of the Dutch medical schools abolished marks during the clerkships, based on the decision to introduce programmatic assessment. This led to an internal debate about whether or not to keep the option of graduating with distinction. The authors believe firstly that it is difficult to derive a mark from narrative feedback. Secondly, more theoretically, without receiving marks or distinctions, we enable students to focus their attention to the process of learning, allowing mistakes, and uncertainties, instead of showing how good they are in meeting expectations.

Learning in and across communities of practice: health professions education students' learning from boundary crossing.

Learning to adapt to new contexts is crucial in health professions education (HPE). Boundaries between and within contexts challenge continuity in students' learning processes. Little is known about how HPE students can make these "boundary experiences" productive for learning. We investigated how and what nursing students learn from boundary experiences while they are simultaneously growing into a community of practice (CoP). Using a boundary-crossing lens, experiences of discontinuity were identified in pre-placement and post-placement interviews and diary fragments with 14 nursing students during their placement in an academic hospital. We found that students experience discontinuity as a result of different approaches to nursing care and to learning, both between (academic and clinical) settings and within a setting. When students feel safe enough, they can convert boundary experiences into meaningful learning situations, such as critical discussions with staff. Successfully overcoming boundary experiences improves students' understanding of healthcare and professional development and helps them to develop a personal approach to learning. Students critically address boundary experiences when they are motivated to learn and when they perceive a violation of ethical standards but not when they are concerned that it will affect their assessment. Objects designed to bridge theory and practice can generate additional barriers. This study adds to the HPE literature by demonstrating the learning potential of boundaries and to the broader literature by showing how responses to boundary experiences are intertwined with the process of growing into a CoP. The findings can be used to design future boundary objects.

Validity evidence for summative performance evaluations in postgraduate community pharmacy education.

INTRODUCTION: Workplace-based assessment of competencies is complex. In this study, the validity of summative performance evaluations (SPEs) made by supervisors in a two-year longitudinal supervisor-trainee relationship was investigated in a postgraduate community pharmacy specialization program in the Netherlands. The construct of competence was based on an adapted version of the 2005 Canadian Medical Education Directive for Specialists (CanMEDS) framework. METHODS: The study had a case study design. Both quantitative and qualitative data were collected. The year 1 and year 2 SPE scores of 342 trainees were analyzed using confirmatory factor analysis and generalizability theory. Semi-structured interviews were held with 15 supervisors and the program director to analyze the inferences they made and the impact of SPE scores on the decision-making process. RESULTS: A good model fit was found for the adapted CanMEDS based seven-factor construct. The reliability/precision of the SPE measurements could not be completely isolated, as every trainee was trained in one pharmacy and evaluated by one supervisor. Qualitative analysis revealed that supervisors varied in their standards for scoring competencies. Some supervisors were reluctant to fail trainees. The competency scores had little impact on the high-stakes decision made by the program director. CONCLUSIONS: The adapted CanMEDS competency framework provided a valid structure to measure competence. The reliability/precision of SPE measurements could not be established and the SPE measurements provided limited input for the decision-making process. Indications of a shadow assessment system in the pharmacies need further investigation.

An inter-professional student-run medication review programme. Reducing adverse drug reactions in a memory outpatient clinic: a controlled clinical trial.

BACKGROUND: We investigated if the addition of an inter-professional student-led medication review team (ISP-team) to standard care can increase the number of detected ADRs and reduce the number of ADRs 3 months after an outpatient visit. RESEARCH DESIGN AND METHODS: In this controlled clinical trial, patients were allocated to standard care (control group) or standard care plus the ISP team (intervention group). The ISP team consisted of medical and pharmacy students and student nurse practitioners. The team performed a structured medication review and adjusted medication to reduce the number of ADRs. Three months after the outpatient visit, a clinical pharmacologist who was blinded for allocation performed a follow-up telephone interview to determine whether patients experienced ADRs. RESULTS: During the outpatient clinic visit, significantly more (p < 0.001) ADRs were detected in the intervention group (n = 48) than in the control group (n = 10). In both groups, 60-63% of all detected ADRs were managed. Three months after the outpatient visit, significantly fewer (predominantly mild and moderately severe) ADRs related to benzodiazepine derivatives and antihypertensive causing dizziness were detected in the patients of the intervention group. CONCLUSIONS: An ISP team in addition to standard care increases the detection and management of ADRs in elderly patients resulting in fewer mild and moderately severe ADRs.

An Interprofessional Student-Run Medication Review Program: The Clinical STOPP/START-Based Outcomes of a Controlled Clinical Trial in a Geriatric Outpatient Clinic.

As the population ages, more people will have comorbid disorders and polypharmacy. Medication should be reviewed regularly in order to avoid adverse drug reactions and medication-related hospital visits, but this is often not done. As part of our student-run clinic project, we investigated whether an interprofessional student-run medication review program (ISP) added to standard care at a geriatric outpatient clinic leads to better prescribing. In this controlled clinical trial, patients visiting a memory outpatient clinic were allocated to standard care (control group) or standard care plus the ISP team (intervention group). The medications of all patients were reviewed by a review panel ("gold standard"), resident, and in the intervention arm also by an ISP team consisting of a group of students from the medicine and pharmacy faculties and students from the higher education school of nursing for advanced nursing practice. For both groups, the number of STOPP/START-based medication changes mentioned in general practitioner (GP) correspondence and the implementation of these changes about 6 weeks after the outpatient visit were investigated. The data of 216 patients were analyzed (control group = 100, intervention group = 116). More recommendations for STOPP/START-based medication changes were made in the GP correspondence in the intervention group than in the control group (43% vs. 24%, P = < 0.001). After 6 weeks, a significantly higher proportion of these changes were implemented in the intervention group (19% vs. 9%, P = 0.001). The ISP team, in addition to standard care, is an effective intervention for optimizing pharmacotherapy and medication safety in a geriatric outpatient clinic.

Conceptions of clinical learning among stakeholders involved in undergraduate nursing education: a phenomenographic study.

BACKGROUND: To prepare nursing students to become critical, autonomous members of the workforce, an agreement among stakeholders on how this can be achieved in the clinical setting is needed. However, a critical discussion of the clinical learning process in relation to actual and desirable outcomes is lacking in the nursing education literature. This study aimed to map conceptions of the desired process and outcomes of clinical learning among stakeholders involved in undergraduate clinical nursing education. METHODS: Twenty-five semi-structured interviews about their understanding of clinical learning were conducted with nursing students, supervisors, clinical educators and higher education institute professionals involved in clinical nursing education in a Dutch academic medical center. Data were analyzed using a phenomenographic approach. RESULTS: Four conceptions were identified: clinical learning as a process to 1) meet curricular demands, 2) learn to deliberately deliver patient care, 3) learn to deliver patient care within the larger (healthcare) context, and 4) become a continuously developing professional. Conceptions 3 and 4 represented a broader, more inclusive perspective on clinical learning than conception 1 and 2. Conceptions were distinguished by five dimensions: role of guidelines from the school; learning opportunities, focus of supervisor; focus of reflection; desirable outcomes of clinical learning. CONCLUSIONS: Those directly involved in clinical learning in nursing may have qualitatively different understandings of its desired nature and outcomes. Two patterns across conceptions could be discerned: a) a shift in focus from learning as following standards, to following an individualized learning trajectory and b) a shift in focus from increasing patient load, to understanding oneself and the patient within the healthcare context. To prepare nursing students for the future workforce, a flexible, social form of self-regulated learning is warranted, as well as an understanding of one's own role within the healthcare system and a critical attitude towards healthcare. Schools and hospitals should collaborate to integrate these values in the curriculum. The current study adds different ways of applying self-regulated learning as a relevant dimension in understanding clinical learning to the literature. Through the phenomenographic approach we identified conceptions that can be a basis for training and policy development.

Collaborative testing in physical examination skills training and the autonomous motivation of students: a qualitative study.

BACKGROUND: Teaching methods that stimulate the active learning of students make a positive impact on several aspects of learning in higher education. Collaborative testing blended with teaching is one such method. At our medical school, a training session was designed using a collaborative testing format to engage medical students actively in the theoretical phase of a physical examination training, and this session was evaluated positively by our students. Therefore, we extended the use of the format and converted more of the training into collaborative testing sessions. The literature on collaborative testing and the theoretical framework underlying its motivational mechanisms is scarce; however, students have reported greater motivation. The aim of the current study was to investigate student perceptions of a collaborative testing format versus a traditional teaching format and their effects on student motivation. METHODS: Year four medical students attended seven physical examination training sessions, of which three followed a collaborative testing format and four a traditional format. The students were asked to evaluate both formats through questionnaires comprised of two items that were answered on a five-point Likert scale and five open-ended essay questions. Content analysis was conducted on the qualitative data. The themes from this analysis were finalized through the consensus of the full research team. RESULTS: The quantitative data showed that 59 students (55%) preferred collaborative testing (agreed or strongly agreed), 40 students (37%) were neutral, and 8 students (8%) did not prefer collaborative testing (disagreed or strongly disagreed). The themes found for the collaborative testing format were: 'interaction', 'thinking for themselves', and 'active participation'. 'Interaction' and 'thinking for themselves' were mainly evaluated positively by the students. The most frequently mentioned theme for the traditional format was: 'the teacher explaining'. Students evaluated this theme both positively and negatively. CONCLUSIONS: The most frequently mentioned themes for the collaborative testing format, namely 'interaction', 'thinking for themselves', and 'active participation', fit within the framework of self-determination theory (SDT). Therefore, the collaborative testing format may support the fulfilment of the three basic psychological needs indicated in SDT: autonomy, competence, and relatedness. Thus, our findings provide initial support for the idea that the use of collaborative testing in medical education can foster the autonomous motivation of students.

The clinical and educational outcomes of an inter-professional student-led medication review team, a pilot study.

AIMS: The involvement of an inter-professional healthcare student team in the review of medications used by geriatric patients could not only provide patients with optimized therapy but also provide students with a valuable inter-professional learning experience. We describe and evaluate the clinical and learning outcomes of an inter-professional student-run mediation review program (ISP). SUBJECT AND METHOD: A variable team consisting of students in medicine, pharmacy, master advanced nursing practice, and master physician assistant reviewed the medication lists of patients attending a specialized geriatric outpatient clinic. RESULTS: During 32 outpatient visits, 188 medications were reviewed. The students identified 14 medication-related problems, of which 4 were not recognized by healthcare professionals. The ISP team advised 95 medication changes, of which 68 (71.6%) were directly implemented. Students evaluated this pilot program positively and considered it educational (median score 4 out of 5) and thought it would contribute to their future inter-professional relationships. CONCLUSION: An inter-professional team of healthcare students is an innovative healthcare improvement for (academic) hospitals to increase medication safety. Most formulated advices were directly incorporated in daily practice and could prevent future medication-related harm. The ISP also offers students a first opportunity to work in an inter-professional manner and get insight into the perspectives and qualities of their future colleagues.

How do undergraduate nursing students learn in the hospital setting? A scoping review of conceptualisations, operationalisations and learning activities.

OBJECTIVES: Although clinical learning is pivotal for nursing education, the learning process itself and the terminology to address this topic remain underexposed in the literature. This study aimed to examine how concepts equivalent to 'learning in practice' are used and operationalised and which learning activities are reported in the nursing education literature. The final aim was to propose terminology for future studies. DESIGN: The scoping framework proposed by Arksey and O'Malley was used to answer the research questions and address gaps in the literature. Two systematic searches were conducted in PubMed, EBSCO/ERIC and EBSCO/CINAHL between May and September 2018: first, to identify concepts equivalent to 'learning in practice' and, second, to find studies operationalising these concepts. Eligible articles were studies that examined the regular learning of undergraduate nursing students in the hospital setting. Conceptualisations, theoretical frameworks and operationalisations were mapped descriptively. Results relating to how students learn were synthesised using thematic analysis. Quality assessment was performed using the Critical Appraisal Skills Programme checklist. RESULTS: From 9360 abstracts, 17 articles were included. Five studies adopted a general, yet not explained, synonym for learning in practice, and the other approaches focused on the social, unplanned or active nature of learning. All studies used a qualitative approach. The small number of studies and medium study quality hampered a thorough comparison of concepts. The synthesis of results revealed five types of learning activities, acknowledged by an expert panel, in which autonomy, interactions and cognitive processing were central themes. CONCLUSIONS: Both theoretical approaches and learning activities of the current body of research fit into experiential learning theories, which can be used to guide and improve future studies. Gaps in the literature include formal and informal components of learning, the relation between learning and learning outcomes and the interplay between behaviour and cognitive processing.

Protocol for a scoping review on the conceptualisation of learning in undergraduate clinical nursing practice.

INTRODUCTION: Learning in the clinical setting is a major form of learning in undergraduate nursing education. In spite of this, how nursing students learn in clinical practice is still largely unknown. Moreover, there is no conceptual clarity on learning in practice in the current literature. This paper aims to set up a protocol for a scoping review of the literature in order to map different conceptualisations of learning in practice in undergraduate clinical nursing education in the hospital setting. The operationalisations of different concepts will be compared and the findings of the studies will be synthesised. METHODS AND ANALYSIS: This scoping review will be guided by the methodological framework proposed by Arksey and O'Malley and refined by Levac et al. and the Joanna Briggs Institute. The search strategy will be developed together with a medical information specialist and the search will be performed in electronic databases (PubMed, EBSCO/ERIC and EBSCO/CINAHL). In a first search, we will identify concepts that are used as an equivalent to learning in practice. Next, we will search for studies operationalising these concepts in undergraduate nursing education. Finally, we will check reference lists for additional publications. Abstracts and full-text studies will independently be screened by two researchers. All studies that have 'learning in undergraduate clinical nursing practice' as their main topic and that include a definition and operationalisation of an equivalent to learning in clinical practice, will be considered for inclusion. We will chart different conceptualisations and their theoretical underpinnings, as well as reported learning opportunities, informal and formal aspects of learning, social aspects of learning and gaps in the literature. ETHICS AND DISSEMINATION: This review will help design future studies on learning in clinical nursing practice using well-defined and agreed on terminology. The results will be disseminated through journal publications and conference presentations.

Exploring the timing of medical student research internships: before or after clerkships?

BACKGROUND: The objective of this study was to determine the optimal positioning of the research internship, either before clinical clerkships, at the beginning of the medical Master's programme, or at the end. METHODS: A mixed methods study was carried out. We compared characteristics such as duration, location and grades for internships performed and students' motives for choosing to perform their research internship before or after clinical clerkships. We analysed students' answers to open-ended questions about the reasons for their choices, using the Self-Determination Theory of motivation. RESULTS: Students performing their research internship before clinical clerkships (n = 338) opted more often for an extended internship (OR = 3.16, 95% CI = 2.32-4.31) and an international location (OR = 2.22, 95% CI = 1.46-3.36) compared to those performing their research internships after clinical clerkships (n = 459). Neither the internship grades nor the number of international publications differed significantly between the two groups. Most of the students' motives (102 participants) were classified as extrinsic motivation for research. Students performing research before clinical clerkships more often showed intrinsic motivation for research, students performing research after clinical clerkships were mainly motivated by their career choice. CONCLUSION: To accommodate both groups of students, offering research internships before and after clinical clerkships, is recommended.

Symposia in undergraduate medical education: tailoring training in competencies to students' needs.

INTRODUCTION: In mastering competencies, it is a challenge to create training sessions which acknowledge individual students' needs and are logistically feasible in the medical master's program. METHODS: Symposia were implemented in the medical master's program to provide knowledge and training of skills in a number of topics, providing a positive contribution to students' competencies and personal development. Each symposium contained a morning and afternoon program, structured around medical and societal themes addressing various competencies and covering current national and international events. Alternating interactive teaching methods were used. Students were asked to rate each daypart program on a 5-point Likert scale in terms of both teaching methods and content, and to comment on the best aspects of the symposium as well as areas for improvement. Scores higher than 3.5 were interpreted as a predominantly favourable outcome. RESULTS: In 2016, 10 symposia were organized with an average of 108 attendees and a response rate of 63% (1,366 completed questionnaires). Mean overall scores on 'teaching methods' and 'usefulness for professional development' were 3.8 and 3.7, respectively. The overall results corresponded with a high level of student appreciation. CONCLUSION: Symposia offer a podium for training students in subject matter and competencies that is greatly appreciated. Using alternating interactive teaching methods, symposia are structured around medical and societal themes and adjusted to the latest developments and current events in healthcare. By allowing students to select the symposia they would like to participate in, a tailor-made medical master's program in competencies is created.

What difficulties do faculty members face when conducting workplace-based assessments in undergraduate clerkships?

OBJECTIVE: Workplace-based assessments are based on the principle of providing feedback to medical students on clinical performance in authentic settings. In practice, however, the assessment often overshadows the feedback. The aim of this study was to determine what problems faculty perceived when performing workplace-based assessments and what solutions they suggested to overcome these difficulties. METHODS: Discussion meetings were conducted with education coordinators and faculty (n=55) from 11 peripheral hospitals concerning the difficulties encountered when conducting workplace-based assessments. We analysed the reports from these discussion meetings using an integrated approach guided by our research questions to code the data. Two researchers analysed the data independently and resolved differences of opinion through consensus. RESULTS: The problems perceived by faculty in workplace-based assessments (difficulties) and suggestions for improvement formed the overarching themes. Problems included the short duration of clerkships, students choosing the assessment moments, the use of grades for the mini-Clinical Evaluation Exercise, the difficulty in combining teacher and assessor roles and the difficulty in giving fail judgements. Suggestions for improvement included longer clerkship duration, faculty choosing the assessment moments, using a pass/fail system for the mini-Clinical Evaluation Exercise and forward feeding of performance from earlier clerkships following a fail judgement. CONCLUSIONS: Our study indicates that faculty perceive difficulties when conducting workplace-based assessments. These assessments need periodical review to understand the difficulties faculty experience using them; they also require periodical feedback to ensure their proper and effective use.

[A woman with a linear skin eruption]. / Een vrouw met streepvormige huidafwijkingen.

A 31-year-old woman consulted the dermatologist with itchy linear skin lesions on the trunk and right upper leg. The lesions occurred 3 days after taking 3 tablets of immune-boosting supplements, which contained shiitake mushrooms. Based on the striking clinical presentation and the medical history, she was diagnosed with shiitake dermatitis.

Reliability of clinical oral examinations re-examined.

Many medical schools still use oral examinations for the evaluation of clinical competence of students in their clerkship, although it has been proven that orals have poor reliability. This study investigates the feasibility and reliability of multiple oral examinations. Students in the last week of their Internal Medicine clerkship in an outpatient clinic were given several patient-based oral examinations. The student's performance was rated on a list of items reflecting clinical competence. A global judgement of the student's performance was also given. The results indicate that it is possible to increase the number of orals and the number of examiners in the day-to-day practice of an outpatient clinic moderately. The reliability when using a number of orals is better than the reliability of the common single oral examination. The reliability using global judgements appeared to be better than the reliability of averaged item scores.