Improving medical students' communication competencies to deal with intimate partner violence using clinical simulations in Mozambique.

BACKGROUND: During their medical training, medical students aim to master communication skills and professionalism competencies to foster the best possible patient-physician relationship. This is especially evident when dealing with sensitive topics. This study describes and analyses the outcomes of a simulation-based training module on clinical communication competency through interacting with simulated intimate partner violence (IPV) survivors. The training was set up as part of a broader IPV module within a Gynaecology and Obstetrics Bachelor of Medicine and Bachelor of Surgery of Medicine (MBBS). METHODS: In total, 34 (59%) of all fourth-year medical students from one medical school in Mozambique were involved. A mixed-method approach was adopted. First, a quasi-experimental pre-test/post-test design was adopted to study the impact of the intervention to tackle critical IPV knowledge, skills, and attitudes, underlying a patient communication script. Second, a qualitative analysis of student perceptions was carried out. RESULTS: The results of the paired sample t-tests point at a significant and positive change in post-test values when looking at the general IPV self-efficacy (IPV SE) score and the subscales mainly in attitudes. Participants expressed a desire for additional IPV communication competency and suggested enhancements to the module. CONCLUSION: We conclude that due to IPV being a sensitive issue, simulation activities are a good method to be used in a safe environment to develop clinical skills. The results of this study are a good complement of the analysis of the competencies learned by the medical students in Mozambique with the current curriculum.

Scaffolding reflective learning in clinical practice: a comparison of two types of reflective activities.

BACKGROUND: The development of reflective learning skills is a continuous process that needs scaffolding. It can be described as a continuum, with the focus of reflection differing in granularity from recent, concrete activities to global competency development. AIM: To explore learners' perceptions regarding the effects of two reflective writing activities designed to stimulate reflection at different degrees of granularity during clinical training. METHODS: Totally 142 respondents (students and recent graduates) completed a questionnaire. Quantitative and qualitative data were triangulated. RESULTS: Immediate reflection-on-action was perceived to be more valuable than delayed reflection-on-competency-development because it facilitated day-to-day improvement. Delayed reflection was perceived to facilitate overall self-assessment, self-confidence and continuous improvement, but this perception was mainly found among graduates. Detailed reflection immediately after a challenging learning experience and broad reflection on progress appeared to serve different learning goals and consequently require different arrangements regarding feedback and timing. CONCLUSIONS: Granularity of focus has consequences for scaffolding reflective learning, with immediate reflection on concrete events and reflection on long-term progress requiring different approaches. Learners appeared to prefer immediate reflection-on-action.

Evaluation of the impact of the exposure route on the human kinetic adjustment factor.

The objective of this study was to assess the impact of the exposure route on the human kinetic adjustment factor (HKAF), for which a default value of 3.16 is used in non-cancer risk assessment. A multi-route PBPK model was modified from the literature and used for computing the internal dose metrics in adults, neonates, children, elderly and pregnant women following three route-specific scenarios to chloroform, bromoform, tri- or per-chloroethylene (TCE or PERC). These include 24-h inhalation exposure, body-weight adjusted oral exposure and 30 min dermal exposure to contaminated drinking water. Distributions for body weight (BW), height (BH) and hepatic cytochrome P450 2E1 (CYP2E1) content were obtained from the literature, whereas model parameters (flows, volumes) were calculated from BW and BH. Monte Carlo simulations were performed and the HKAF was calculated as the ratio of the 95th percentile value of internal dose metrics in subpopulation to the 50th percentile value in adults. On the basis of the area under the parent compound's arterial blood concentration vs time curve (AUC(pc)), highest HKAFs were obtained in neonates for every scenario considered, and were the highest for bromoform (range: 3.6-7.4). Exceedance of the default value based on AUC(PC) was also observed for an oral exposure to chloroform in neonates (4.9). In all other cases, HKAFs remained below the default value. Overall, this study has pointed out the dependency of the HKAF on the exposure route, dose metrics and subpopulation considered, as well as characteristics of the chemicals investigated.

Impact of the transition from a conventional to an integrated contextual medical curriculum on students' learning patterns: a longitudinal study.

BACKGROUND: Until now, most research studying the impact of curriculum innovations on student learning patterns was restricted to short term or cross-sectional research. AIM: Studying longitudinal changes in student learning patterns parallel to the implementation of a curriculum innovation from a discipline based to an integrated contextual medical curriculum (ICMC). METHODS: A post hoc study applying General Linear Model ANOVA one-way repeated-measures. The inventory of learning styles(126-item version) is used to determine changes in student learning patterns. RESULTS: Though not all hypotheses could be accepted, the results suggest a significant impact of the ICMC on learning processing strategies; regulation strategies; and on learning orientations. The clear build-up of the curriculum and vertical and horizontal integration of subject knowledge seem to have significantly reduced lack of regulation and promoted at an earlier stage structuring, relating, critical processing and vocational-orientation. The effect on use of sources of knowledge, self-regulation of learning content and certificate-orientation was less important than expected. It was yet not possible to confirm the hypothesis that ICMC students become better in translating study topics into their own phrasing or expressions; and neither the expected impact on vocation-orientation could be confirmed. CONCLUSIONS: There is little doubt that the present results are important to curriculum (re)designers and those interested in the evaluation of curriculum reforms.

Improving student midwives' workplace learning by moving from self- to co-regulated learning!

BACKGROUND: Contemporary perspectives on regulated learning are moving beyond models, emphasising individual learning (self-regulated learning) to models that position social transactions at the core of learning (co-regulated learning). In discussing this paradigm shift, it is important to study self- and co-regulated learning in situational context but research in the context of midwifery education is scarce. OBJECTIVE: This study aimed to improve our understanding of regulating midwifery students' learning by exploring factors that promote or inhibit the capacity to independently self-regulate learning during internships. DESIGN: We conducted a qualitative study involving semi-structured group discussions with final year undergraduate midwifery students (Belgium). Focus groups were audio-taped, transcribed verbatim and analysed in a thematic way. FINDINGS: The majority of respondents did not experience an education intended to stimulate continuous self-regulated learning. They identified many social transactions (with mentors, teachers, teams of midwives, students, peer students, personal environments, personal coaches and curriculum managers) that were instrumental in promoting or inhibiting the ability to independently self-regulate. Flexibility and resilience to cope with the differences in practices, guidance, beliefs and behaviours of individual midwives within and between workplaces, was seen as paramount. CONCLUSION: Broadening the perspective of the individual learner to the complex interplay between all the stakeholders involved with workplace learning is an essential step to move forward in the effort to improve student midwives' learning in the workplace.

The potential of the inventory of learning styles to study students' learning patterns in three types of medical curricula.

BACKGROUND: Introducing innovative curricular designs can be evaluating by scrutinizing the learning patterns students use. AIM: Studying the potential of Vermunt's Inventory of Learning Styles (ILS) in detecting differences in student learning patterns in different medical curricula. METHODS: Cross-sectional between-subjects comparison of ILS-scores in third-year medical students in a conventional, an integrated contextual and a PBL-curriculum using one-way post hoc ANOVA. RESULTS: Response rate was 85%: 197 conventional, 130 integrated contextual and 301 PBL students. The results show a differential impact from the three curricula. In relation to processing strategies, the students in the problem-based curriculum showed less rote learning and rehearsing, greater variety in sources of knowledge used and less ability to express study content in a personal manner than did the students in the conventional curriculum. The students of the integrated contextual curriculum showed more structuring of subject matter by integrating different aspects into a whole. In relation to regulation strategies, the students in the problem-based curriculum showed significantly more self-regulation of learning content and the students in the integrated contextual curriculum showed lower levels of regulation. As to learning orientations, the students in the problem-based curriculum showed less ambivalence and the students of the conventional curriculum were less vocationally oriented. CONCLUSION: The study provides empirical support for expected effects of traditional and innovative curricula which thus far were not well supported by empirical studies.

Continuing midwifery education beyond graduation: Student midwives' awareness of continuous professional development.

Midwifery education plays an important role in educating graduates about engaging in continuous professional development (CPD) but there is a lack of empirical research analysing student midwives' awareness of CPD beyond graduation. We aimed to explore student midwives' awareness of the need to become lifelong learners and to map their knowledge of CPD activities available after graduation. Therefore, forty-seven reflective documents, written in the last week of student midwives' training programme, were analysed in a thematic way. Content analysis confirmed student midwives' awareness of the importance of CPD before graduation. They mentioned different reasons for future involvement in CPD and described both, formal and informal CPD-activities. Respondents were especially aware of the importance of knowledge, to a lesser degree of skills-training and still less of the potential value of the Internet for individual and collective learning. Respondents perceived a need for a mandatory preceptorship. Supporting learning guides were highly valued and the importance of reflection on CPD was well-established. This could have resulted from an integrated reflective learning strategy during education. CONCLUSION: Undergraduate midwives are aware of the importance of CPD and the interplay of formal and informal learning activities. Virtual learning requires special attention to overcome CPD challenges.

A Delphi study to validate competency-based criteria to assess undergraduate midwifery students' competencies in the maternity ward.

BACKGROUND: workplace learning plays a crucial role in midwifery education. Twelve midwifery schools in Flanders (Belgium) aimed to implement a standardised and evidence-based method to learn and assess competencies in practice. This study focuses on the validation of competency-based criteria to guide and assess undergraduate midwifery students' postnatal care competencies in the maternity ward. METHOD: an online Delphi study was carried out. During three consecutive sessions, experts from workplaces and schools were invited to score the assessment criteria as to their relevance and feasibility, and to comment on the content and their formulation. A descriptive quantitative analysis, and a qualitative thematic content analysis of the comments were carried out. A Mann-Whitney U-test was used to investigate differences between expert groups. FINDINGS: eleven competencies and fifty-six assessment criteria were found appropriate to assess midwifery students' competencies in the maternity ward. Overall median scores were high and consensus was obtained for all criteria, except for one during the first round. Although all initial assessment criteria (N=89) were scored as relevant, some of them appeared not feasible in practice. Little difference was found between the expert groups. Comments mainly included remarks about concreteness and measurability. CONCLUSION: this study resulted in validated criteria to assess postnatal care competencies in the maternity ward.

Workplace learning in midwifery education in Flanders (Belgium).

Workplace learning plays a crucial role in midwifery education. Twelve midwifery schools in Flanders (Belgium) implemented a new competency framework and aimed at implementing a more standardized and evidence-based method to learn and assess competencies, as well as to guide continuous competency development in practice. This paper describes the introduction of 'Embo's continuous workplace learning model', a holistic and competency-based method that integrates all workplace learning components. Available research evidence helps concluding the learning model is a feasible approach to organize workplace learning in such a way that continuous professional competency development is achieved.

Integrating learning assessment and supervision in a competency framework for clinical workplace education.

Although competency-based education is well established in health care education, research shows that the competencies do not always match the reality of clinical workplaces. Therefore, there is a need to design feasible and evidence-based competency frameworks that fit the workplace reality. This theoretical paper outlines a competency-based framework, designed to facilitate learning, assessment and supervision in clinical workplace education. Integration is the cornerstone of this holistic competency framework.

Relationship between reflection ability and clinical performance: a cross-sectional and retrospective-longitudinal correlational cohort study in midwifery.

BACKGROUND: increasingly, reflection is highlighted as integral to core practice competencies but empirical research into the relationship between reflection and performance in the clinical workplace is scarce. AIM: this study investigated the relationship between reflection ability and clinical performance. METHODS: we designed a cross-sectional and a retrospective-longitudinal cohort study. Data from first, second and third year midwifery students were collected to study the variables 'clinical performance' and 'reflection ability'. Data were analysed with SPSS for Windows, Release 20.0. Descriptive statistics, Pearson׳s Product Moment Correlation Coefficients (r) and r² values were computed to investigate associations between the research variables. FINDINGS: the results showed a moderate observed correlation between reflection ability and clinical performance scores. When adopting a cross-sectional perspective, all correlation values were significant (p<0.01) and above 0.4, with the exception of the third year correlations. Assuming perfect reliability in the measurement, the adjusted correlations, for year 2 and year 3 indicated a high association between reflection ability and clinical performance (>0.6). The results based on the retrospective-longitudinal data set explained a moderate proportion of the variance after correction for attenuation. Finally, the results indicate that 'reflection ability' scores of earlier years are significant related with 'clinical performance' scores of subsequent years. These results suggest that (1) reflection ability is linked to clinical performance; (2) that written reflections are an important, but not the sole way to assess professional competence and that (3) reflection is a contributor to clinical performance improvement. CONCLUSIONS: the data showed a moderate but significant relationship between 'reflection ability' and 'clinical performance' scores in clinical practice of midwifery students. Reflection therefore seems an important component of professional competence.

A framework to facilitate self-directed learning, assessment and supervision in midwifery practice: a qualitative study of supervisors' perceptions.

BACKGROUND: Self-directed learning is an educational concept that has received increasing attention. The recent workplace literature, however, reports problems with the facilitation of self-directed learning in clinical practice. We developed the Midwifery Assessment and Feedback Instrument (MAFI) as a framework to facilitate self-directed learning. In the present study, we sought clinical supervisors' perceptions of the usefulness of MAFI. METHODS: Interviews with fifteen clinical supervisors were audio taped, transcribed verbatim and analysed thematically using Atlas-Ti software for qualitative data analysis. RESULTS: Four themes emerged from the analysis. (1) The competency-based educational structure promotes the setting of realistic learning outcomes and a focus on competency development, (2) instructing students to write reflections facilitates student-centred supervision, (3) creating a feedback culture is necessary to achieve continuity in supervision and (4) integrating feedback and assessment might facilitate competency development under the condition that evidence is discussed during assessment meetings. Supervisors stressed the need for direct observation, and instruction how to facilitate a self-directed learning process. CONCLUSION: The MAFI appears to be a useful framework to promote self-directed learning in clinical practice. The effect can be advanced by creating a feedback and assessment culture where learners and supervisors share the responsibility for developing self-directed learning.

Modeling the Human Kinetic Adjustment Factor for Inhaled Volatile Organic Chemicals: Whole Population Approach versus Distinct Subpopulation Approach.

The objective of this study was to evaluate the impact of whole- and sub-population-related variabilities on the determination of the human kinetic adjustment factor (HKAF) used in risk assessment of inhaled volatile organic chemicals (VOCs). Monte Carlo simulations were applied to a steady-state algorithm to generate population distributions for blood concentrations (CAss) and rates of metabolism (RAMs) for inhalation exposures to benzene (BZ) and 1,4-dioxane (1,4-D). The simulated population consisted of various proportions of adults, elderly, children, neonates and pregnant women as per the Canadian demography. Subgroup-specific input parameters were obtained from the literature and P3M software. Under the "whole population" approach, the HKAF was computed as the ratio of the entire population's upper percentile value (99th, 95th) of dose metrics to the median value in either the entire population or the adult population. Under the "distinct subpopulation" approach, the upper percentile values in each subpopulation were considered, and the greatest resulting HKAF was retained. CAss-based HKAFs that considered the Canadian demography varied between 1.2 (BZ) and 2.8 (1,4-D). The "distinct subpopulation" CAss-based HKAF varied between 1.6 (BZ) and 8.5 (1,4-D). RAM-based HKAFs always remained below 1.6. Overall, this study evaluated for the first time the impact of underlying assumptions with respect to the interindividual variability considered (whole population or each subpopulation taken separately) when determining the HKAF.

An assessment of the impact of physico-chemical and biochemical characteristics on the human kinetic adjustment factor for systemic toxicants.

The objective of this study was to evaluate the magnitude of the human kinetic adjustment factor (HKAF) as a function of physico- and bio-chemical characteristics impacting the systemic clearance of chemicals. This factor is intended to replace the default value of 3.16 in non-cancer risk assessments and aims at accounting for interindividual variability in toxicokinetics. A steady-state algorithm was used to compute the internal dose metrics (blood concentration (C(blood)) and rate of metabolite produced/L liver (RAM)) of hypothetical chemicals in neonates, adults, elderly, and pregnant women. After evaluating the algorithm with chemical-specific experimental data, C(blood) and RAM were calculated for hypothetical chemicals exhibiting blood:air partition coefficients (Pb) between 1 and 10,000 and hepatic extraction ratios in the average adult (E) between 0.01 and 0.99. Based on Monte Carlo simulation results, HKAF values were computed as the ratio of the 95th percentile value for each subpopulation to the 50th percentile value in adults. The highest HKAF among those obtained for each subpopulation was reported in route-, pathway-, and dose metric-specific HKAF matrices as a function of Pb and E. These matrices allowed the recognition of cases where the default HKAF could be exceeded, and these occurred in neonates based on C(blood) in two situations. First, when the average adult-to-neonate ratio of body weight-adjusted systemic clearance was at least equal to 2.2 for a given systemic exposure (i.e., for CYP1A2 substrates only). Second, when E=0.01-0.2 and Pb ≥ 300 or when E=0.3-0.7 and Pb ≥ 100 for inhalation exposures to CYP2E1 substrates, with comparable values for the other substrates (higher for CYP1A2). Overall, this study showed the dependency of the HKAF on the dose metrics, chemical characteristics, metabolic pathways, and subpopulations considered.

Training to deeper compression depth reduces shallow compressions after six months in a manikin model.

INTRODUCTION: Studies show that students, trained to perform compressions between 40 and 50mm deep, often do not achieve sufficient depth at retention testing. We hypothesized that training to achieve depths >50mm would decrease the proportion of students with depth <40mm after 6 months, compared to students trained to a depth interval of 40-50mm. METHODS: A basic life support (BLS) self-learning station was attended by 190 third year medicine students. They were first offered the possibility to refresh their skills, following the instructions of a 15min abbreviated Mini Anne™ video (Laerdal, Norway) using a full size torso and a face shield. This was followed by further training using Resusci Anne Skills Station™ software (Laerdal, Norway). Voice feedback was provided according to randomisation to a standard group (SG) 40-50mm and a deeper group (DG) >50mm. Quality of compressions was tested after 6 months. RESULTS: The SG and DG groups consisted of 90 (67% female) and 100 (58% female) participants respectively. At the end of training, all students reached the target depth without overlap between groups. After 6 months, the proportion of students achieving a depth <40mm was 26/89 (29%) in the SG vs. 12/89 (14%) in the DG (P=0.01). The proportion of students with a depth >50mm was 5/89 (6%) for the SG and 44/89 (49%) in the DG (P<0.001). CONCLUSIONS: The educational strategy to train students to a deeper depth, reduced shallow compressions 6 months after training.