Unravelling residents' and supervisors' workplace interactions: an intersubjectivity study.

CONTEXT: Successful engagement between residents and supervisors lies at the core of workplace learning, a process that is not exempt from challenge. Clinical encounters have unique learning potential as they offer opportunities to achieve a shared understanding between the resident and supervisor of how to accomplish a common goal. How residents and supervisors develop such a mutual understanding is an issue that has received limited attention in the literature. We used the 'intersubjectivity' concept as a novel conceptual framework to analyse this issue. METHODS: We conducted a constructivist grounded theory study in an anaesthesiology department in Bogota, Colombia, using focus groups and field observations. Eleven residents of different training levels and 18 supervisors with varying years of teaching experience participated in the study. Through iterative data analysis, collection and constant comparison, we constructed the final results. RESULTS: We found that residents and supervisors achieved a shared understanding by adapting to one another in the process of providing patient care. Continuous changes in the composition of resident-supervisor dyads exposed them to many procedural variations, to which they responded by engaging in various adaptation patterns that included compliance by residents with supervisors' directions, negotiation by residents of supervisors' preferences, and the sharing of decision making. In the process, the resident played an increasingly key role as a member of the supervisory dyad. Additionally, experiencing these adaptation patterns repeatedly resulted in the creation of a working repertoire: an attuned working code used by the members of each supervisory dyad to work together as a team. CONCLUSIONS: The development of shared understanding between residents and supervisors entailed experiencing diverse adaptation patterns which resulted in the creation of working repertoires. Seeing supervisory interactions as adaptation processes has essential theoretical and practical implications regarding workplace learning in postgraduate settings. Our findings call for further exploration to understand learning in postgraduate education as a social process.

Reaching consensus on GP interprofessional competencies: a nominal group study.

BACKGROUND: As the requirements for collaboration in primary care increase, effective interprofessional teamwork between GPs and other primary care professionals is crucial. The need for more training in interprofessional collaborative competencies is widely recognised. However, existing competency frameworks do not sufficiently specify interprofessional collaboration to guide interprofessional competency development. AIM: To reach consensus among GPs and other primary care professionals on interprofessional competencies that GP and GP trainees should learn. DESIGN & SETTING: A qualitative consensus study among Dutch GPs and other primary care professionals, all with expertise in primary care interprofessional collaborative practice. METHOD: Three nominal group sessions were held, each resulting in its own group consensus on GP interprofessional collaborative competencies. The researchers conducted a content analysis to merge and thematise the prioritised competencies into one list. Participants prioritised this list of competencies. A pre-set cut-off point was applied to determine the overall consensus on core GP interprofessional competencies. RESULTS: Eighteen professionals from nine different disciplines participated. The content analysis resulted in 31 unique competencies, of which 14 competencies were prioritised in the final ranking into the following three main themes: (1) professional identity development and role definition by the GP (three competencies); (2) developing and executing shared care plans for individual patients (six competencies); and (3) initiating and maintaining interprofessional collaborative partnerships (five competencies). CONCLUSION: An interprofessional group of experts reached consensus on 14 competencies within three themes. This framework provides a stepping stone for GPs to focus on their development regarding interprofessional collaboration.

Factors adversely affecting student learning in the clinical learning environment: a student perspective.

PURPOSE: To investigate, from the students' perspective, factors that may adversely affect student learning in the clinical environment. METHOD: Medical students evaluated the perceived effectiveness of the clinical learning environment at the end of various clerkship rotations, such as surgery, gynaecology, paediatrics, ophthalmology. After each clerkship students answered a standard questionnaire containing closed-ended questions about supervision, patient contacts, organisation, learning effectiveness and the learning climate, as well as one open-ended question about the clerkship-site's perceived weaknesses. Because supervision is crucial to the quality of clerkships but often lacking, we compared clerkship-sites with relatively low and high ratings on supervision and analysed students' comments on the weaknesses of their clerkship-sites. RESULTS: Factors that students perceived were inhibiting learning were too few opportunities for students to examine patients independently and lack of time for supervision. In addition, lack of observation, insufficient feedback, negative attitudes of the staff towards students and teaching, the presence of too many students at one time, too few educational sessions, and poor organisation were mentioned as perceived weaknesses in open-ended comments. CONCLUSIONS: Based on these students' perceptions, effective clerkships should present students with patients with a variety of health problems who can be examined both independently and with supervision. Continuity of supervision is important and can be addressed by assigning a teacher or mentor to each student.

Assessing Students in Community Settings: The Role of Peer Evaluation.

The assessment of students in community settings faces unique difficulties. Since students are usually posted in small groups in different community settings and since the learning (largely) takes place outside the classroom, assessing student performance becomes an intrinsically complex endeavor. In this article, the proposition is made and tested that peers may be used to accurately assess particular aspects of performance, in particular those which need extensive and close observation. Examples are: Effort displayed while working in a community, quality of the interaction with that community, display of leadership, and subject-matter contributions.The Faculty of Medicine of the University of Gezira, a community-based medical school, uses peer evaluation to assess these attributes of its students. Thirty four students divided into three groups participated in the present study. Goals of the study were to appraise the reliability, validity and acceptability of an instrument designed to measure these characteristics. Reliability was estimated using generalizability theory. A high generalizability coefficient (G) was found when all items were taken into account. In this case, G equaled 0.97. Its sub-scales each had also fairly high G-coefficients: Effort: 0.89, Subject-matter Contribution: 0.91, Community Interaction: 0.89, and Leadership: 0,88 respectively. The validity of the instrument was studied using confirmatory factor analysis. The results suggested that the proposed model of peer evaluation is reasonably valid. Finally, the instrument turned out to be quite acceptable to students.

Student perceptions about the occurrence of critical incidents in tutorial groups.

The study reported here examines student perceptions about the occurrence of critical incidents in tutorial groups across years of medical training. The study investigates the following research questions. (1) Which factors underlie the occurrence of critical incidents in the tutorial group? (2) How do students rate the incidents with respect to whether they occur in the tutorial groups? (3) Are there differences in scores on the factors identified across years of medical training? The subjects consisted of a stratified random sample of 200 students at the Medical School of the University of Maastricht. In general, the results of the confirmatory factor analyses indicate that a six-factor model showed a good fit. The results show that students frequently perceive lack of elaboration, lack of interaction and unequal participation in tutorial groups. For most of the factors (lack of elaboration, difficult personalities, lack of cohesion, and lack of motivation) the average scores differ significantly (p<0.01) across the years.

Quality of student-generated learning issues in a problem-based curriculum.

In a problem-based curriculum students generate learning issues that are the guidelines for their individual study. In an earlier study it was found that a useful learning issue contains a keyword that demarcates the content of a certain topic to be studied and is formulated concisely and unambiguously for all members of the tutorial group. This study investigates two questions. First, how many learning issues can be classified as being of good or bad quality as evaluated against three criteria? Second, what are examples of well and badly formulated learning issues? Learning issues were collected for two problems in the first year during two tutorial meetings of the Maastricht Medical School in the academic year 1998-99. In the next academic year, 12 first year-students were asked to judge the learning issues for each problem against three criteria. The results showed that 21% of the learning issues for one problem and 32% for the other problem were classified as scoring high on all three characteristics. A very small percentage of learning issues (5% and 2%) were classified as scoring low on all three characteristics. Most learning issues scored differently on each of the characteristics. Although most learning issues contain a keyword, many of them were formulated ambiguously and not concisely. It is concluded that first-year students are not yet able to formulate clear learning issues.

The relationship between professional behaviour grades and tutor performance ratings in problem-based learning.

PURPOSE: We investigated the influence of harsh grading by tutors on tutor performance rating by students. METHODS: A total of 187 tutors assessed students' professional behaviour in tutorial groups. Students rated tutor performance after receiving their grades for professional behaviour. In addition, students were asked to indicate whether they perceived their professional behaviour grades as too positive, adequate or too negative. This was considered to reflect tutors' harshness of grading. Students also rated the quality of the feedback they received from tutors with respect to their grades. RESULTS: Professional behaviour grades that students perceived as too negative, adequate or too positive were associated with tutor performance ratings of 7.4 (SD = 0.9, scale 1-10, n = 33), 7.7 (SD = 0.9, scale 1-10, n = 95) and 7.5 (SD = 0.8, scale 1-10, n = 59), respectively. Harshness of grading did not influence tutor performance ratings significantly. Tutor ratings were predicted more effectively by the quality of the feedback tutors provided on grades than by the harshness of grading. CONCLUSIONS: Tutor performance ratings were not related significantly to harshness of grading. Two explanations can be given: (1) tutor performance ratings were based on rating by groups of students and (2) the percentage of tutors who rated students' professional behaviour as unsatisfactory was low. The strong relationship between tutor performance ratings and the adequacy of the feedback given by tutors suggests that the tutor performance ratings collected in this study are a valid measure of the quality of their teaching, although, for a full picture of teaching quality, more measures will be needed.