"Tell me what is 'better'!" How medical students experience feedback, through the lens of self-regulatory learning.

INTRODUCTION: While feedback aims to support learning, students frequently struggle to use it. In studying feedback responses there is a gap in explaining them in relation to learning theory. This study explores how feedback experiences influence medical students' self-regulation of learning. METHODS: Final-year medical students across three campuses (Ireland, Bahrain and Malaysia) were invited to share experiences of feedback in individual semi-structured interviews. The data were thematically analysed and explored through the lens of self-regulatory learning theory (SRL). RESULTS: Feedback interacts with learners' knowledge and beliefs about themselves and about learning. They use feedback to change both their cognitive and behavioural learning strategies, but how they choose which feedback to implement is complex. They struggle to generate learning strategies and expect teachers to make sense of the "how" in addition to the "what"" in planning future learning. Even when not actioned, learners spend time with feedback and it influences future learning. CONCLUSION: By exploring our findings through the lens of self-regulation learning, we advance conceptual understanding of feedback responses. Learners' ability to generate "next steps" may be overestimated. When feedback causes negative emotions, energy is diverted from learning to processing distress. Perceived non-implementation of feedback should not be confused with ignoring it; feedback that is not actioned often impacts learning.

Enablement and empowerment among patients participating in a supported osteoarthritis self-management programme - a prospective observational study.

BACKGROUND: In Sweden, core treatment for osteoarthritis is offered through a Supported Osteoarthritis Self-Management Programme (SOASP), combining education and exercise to provide patients with coping strategies in self-managing the disease. The aim was to study enablement and empowerment among patients with osteoarthritis in the hip and/or knee participating in a SOASP. An additional aim was to study the relation between the Swedish version of the Patient Enablement Instrument (PEI) and the Swedish Rheumatic Disease Empowerment Scale (SWE-RES-23). METHODS: Patients with osteoarthritis participating in a SOASP in primary health care were recruited consecutively from 2016 to 2018. The PEI (score range 0-12) was used to measure enablement and the SWE-RES-23 (score range 1-5) to measure empowerment. The instruments were answered before (SWE-RES-23) and after the SOASP (PEI, SWE-RES-23). A patient partner was incorporated in the study. Descriptive statistics, the Wilcoxon's signed rank test, effect size (r), and the Spearman's rho (rs) were used in the analysis. RESULTS: In total, 143 patients were included in the study, 111 (78%) were women (mean age 66, SD 9.3 years). At baseline the reported median value for the SWE-RES-23 (n = 142) was 3.6 (IQR 3.3-4.0). After the educational part of the SOASP, the reported median value was 6 (IQR 3-6.5) for the PEI (n = 109) and 3.8 (IQR 3.6-4.1) for the SWE-RES-23 (n = 108). At three months follow-up (n = 116), the reported median value was 6 (IQR 4-7) for the PEI and 3.9 (IQR 3.6-4.2) for the SWE-RES-23. The SWE-RES-23 score increased between baseline and three months (p ≤ 0.000). The analysis showed a positive correlation between PEI and SWE-RES-23 after the educational part of the SOASP (rs = 0.493, p < 0.00, n = 108) and at follow-up at three months (rs = 0.507, p < 0.00, n = 116). CONCLUSIONS: Patients reported moderate to high enablement and empowerment and an increase in empowerment after participating in a SOASP, which might indicate that the SOASP is useful to enable and empower patients at least in the short term. Since our results showed that the PEI and the SWE-RES-23 are only partly related both instruments can be of use in evaluating interventions such as the SOASP. TRIAL REGISTRATION: ClinicalTrials.gov. NCT02974036 . First registration 28/11/2016, retrospectively registered.

Self-regulatory learning theory as a lens on how undergraduate and postgraduate learners respond to feedback: A BEME scoping review: BEME Guide No. 66.

INTRODUCTION: Little is known of processes by which feedback affects learners to influence achievement. This review maps what is known of how learners interact with feedback, to better understand how feedback affects learning strategies, and to explore enhancing and inhibiting factors. METHODS: Pilot searching indicated a wide range of interpretations of feedback and study designs, prompting the use of scoping methodology. Inclusion criteria comprised: (i) learners (undergraduate, postgraduate, continuing education) who regularly receive feedback, and (ii) studies that associated feedback with subsequent learner reaction. The screening was performed independently in duplicate. Data extraction and synthesis occurred via an iterative consensus approach. Self-regulatory learning theory (SRL) was used as the conceptual framework. RESULTS: Of 4253 abstracts reviewed, 232 were included in the final synthesis. Understandings of feedback are diverse; a minority adopt recognised definitions. Distinct learner responses to feedback can be categorized as cognitive, behavioural, affective, and contextual with complex, overlapping interactions. Importantly emotional responses are commonplace; factors mediating them are pivotal in learner recipience. CONCLUSION: Feedback benefits learners most when focussed on learner needs, via engagement in bi-directional dialogue. Learner emotions must be supported, with the construction of positive learner-teacher relationships. A developmental agenda is key to learner's acceptance of feedback and enhancing future learning.

Remote learning developments in postgraduate medical education in response to the COVID-19 pandemic - A BEME systematic review: BEME Guide No. 71.

BACKGROUND: Prior reviews investigated medical education developments in response to COVID-19, identifying the pivot to remote learning as a key area for future investigation. This review synthesized online learning developments aimed at replacing previously face-to-face 'classroom' activities for postgraduate learners. METHODS: Four online databases (CINAHL, Embase, PsychINFO, and PubMed) and MedEdPublish were searched through 21 December 2020. Two authors independently screened titles, abstracts and full texts, performed data extraction, and assessed risk of bias. The PICRAT technology integration framework was applied to examine how teachers integrated and learners engaged with technology. A descriptive synthesis and outcomes were reported. A thematic analysis explored limitations and lessons learned. RESULTS: Fifty-one publications were included. Fifteen collaborations were featured, including international partnerships and national networks of program directors. Thirty-nine developments described pivots of existing educational offerings online and twelve described new developments. Most interventions included synchronous activities (n Fif5). Virtual engagement was promoted through chat, virtual whiteboards, polling, and breakouts. Teacher's use of technology largely replaced traditional practice. Student engagement was largely interactive. Underpinning theories were uncommon. Quality assessments revealed moderate to high risk of bias in study reporting and methodology. Forty-five developments assessed reaction; twenty-five attitudes, knowledge or skills; and two behavior. Outcomes were markedly positive. Eighteen publications reported social media or other outcomes, including reach, engagement, and participation. Limitations included loss of social interactions, lack of hands-on experiences, challenges with technology and issues with study design. Lessons learned highlighted the flexibility of online learning, as well as practical advice to optimize the online environment. CONCLUSIONS: This review offers guidance to educators attempting to optimize learning in a post-pandemic world. Future developments would benefit from leveraging collaborations, considering technology integration frameworks, underpinning developments with theory, exploring additional outcomes, and designing and reporting developments in a manner that supports replication.

Virtual interviewing for graduate medical education recruitment and selection: A BEME systematic review: BEME Guide No. 80.

BACKGROUND: The COVID-19 pandemic caused graduate medical education (GME) programs to pivot to virtual interviews (VIs) for recruitment and selection. This systematic review synthesizes the rapidly expanding evidence base on VIs, providing insights into preferred formats, strengths, and weaknesses. METHODS: PubMed/MEDLINE, Scopus, ERIC, PsycINFO, MedEdPublish, and Google Scholar were searched from 1 January 2012 to 21 February 2022. Two authors independently screened titles, abstracts, full texts, performed data extraction, and assessed risk of bias using the Medical Education Research Quality Instrument. Findings were reported according to Best Evidence in Medical Education guidance. RESULTS: One hundred ten studies were included. The majority (97%) were from North America. Fourteen were conducted before COVID-19 and 96 during the pandemic. Studies involved both medical students applying to residencies (61%) and residents applying to fellowships (39%). Surgical specialties were more represented than other specialties. Applicants preferred VI days that lasted 4-6 h, with three to five individual interviews (15-20 min each), with virtual tours and opportunities to connect with current faculty and trainees. Satisfaction with VIs was high, though both applicants and programs found VIs inferior to in-person interviews for assessing 'fit.' Confidence in ranking applicants and programs was decreased. Stakeholders universally noted significant cost and time savings with VIs, as well as equity gains and reduced carbon footprint due to eliminating travel. CONCLUSIONS: The use of VIs for GME recruitment and selection has accelerated rapidly. The findings of this review offer early insights that can guide future practice, policy, and research.

A scoping review: virtual patients for communication skills in medical undergraduates.

BACKGROUND: Communication is an essential competence for medical students. Virtual patients (VP), computerized educational tools where users take the role of doctor, are increasingly used. Despite the wide range of VP utilization, evidence-based practical guidance on supporting development of communication skills for medical students remains unclear. We focused this scoping review on VP affordance for student learning especially important in the current environment of constrained patient access. METHODS: This scoping review followed Arksey & O'Malley's methodology. We tested and used a search strategy involving six databases, resulting in 5,262 citations. Two reviewers independently screened titles, full texts (n= 158) and finally performed data extraction on fifty-five included articles. To support consideration of educational affordance the authors employed a pragmatic framework (derived from activity theory) to map included studies on VP structure, curricular alignment, mediation of VP activity, and socio-cultural context. RESULTS: Findings suggest that not only the VP itself, but also its contextualization and associated curricular activities influence outcomes. The VP was trialled in the highest proportion of papers as a one-off intervention (19 studies), for an average duration of 44.9 minutes (range 10-120min), mainly in senior medical students (n=23), notably the largest group of studies did not have VP activities with explicit curricular integration (47%). There was relatively little repeated practice, low levels of feedback, self-reflection, and assessment. Students viewed VPs overall, citing authenticity and ease of use as important features. Resource implications are often omitted, and costings would facilitate a more complete understanding of implications of VP use. CONCLUSION: Students should be provided with maximal opportunity to draw out the VPs' full potential through repeated practice, without time-constraint and with curricular alignment. Feedback delivery enabling reflection and mastery is also key. The authors recommend educators to explicitly balance computerized authenticity with instructional design integrated within the curriculum.

"It's okay to not know " a qualitative exploration of faculty approaches to working with uncertainty.

BACKGROUND: Whilst it is recognised that a capacity to manage uncertainty is an essential aspect of working as a healthcare professional, there is little clear guidance on how to facilitate student learning in this domain. A lack of faculty development opportunities also suggests that health professions' educators may feel ill-equipped to assist students in developing effective approaches to uncertainty. The purpose of this study was to explore a faculty development intervention designed to help educators unpack students' experiences of uncertainty, and identify attributes which may help students to manage uncertain situations. METHODS: This qualitative study was informed by a constructivist methodological approach, where participants were encouraged to share meaning around the nature of uncertainty in health professions' education. Two 90-min faculty development sessions were held. These sessions invited participants to apply Han et al.'s taxonomy of uncertainty to role-played scenarios of student uncertainty within a focus group setting. Focus group data were collected, and examined using a two-stage, hybrid approach of deductive and inductive thematic analysis. RESULTS: Han et al.'s taxonomy helped participants to identify multiple sources and issues of uncertainty in the role played scenarios, thus unveiling the extent of uncertainties encountered by health professions' learners. Data analysis revealed four themes overall: "Sources of uncertainty", "Issues of uncertainty", "Uncertainty attributes", and "Learning environment." Participants also contributed to a list of attributes which they considered helpful to undergraduate health professions' students in managing uncertain situations. These included an awareness of the nature of uncertainty within healthcare practice, an ability to recognise uncertainty, and adopting attitudes of adaptability, positivity, and resilience. CONCLUSIONS: This study highlights the successful use of Han et al.'s taxonomy of uncertainty within a faculty development setting. Our findings suggest that the taxonomy is a practical and versatile tool that health professions' educators can use in shared reflections and conversations around uncertainty with students or colleagues.

The ubiquity of uncertainty: a scoping review on how undergraduate health professions' students engage with uncertainty.

Although the evidence base around uncertainty and education has expanded in recent years, a lack of clarity around conceptual terms and a heterogeneity of study designs means that this landscape remains indistinct. This scoping review explores how undergraduate health professions' students learn to engage with uncertainty related to their academic practice. To our knowledge, this is the first scoping review which examines teaching and learning related to uncertainty across multiple health professions. The scoping review is underpinned by the five-stage framework of (Arksey and O'Malley in Scoping studies: Towards a methodological framework International Journal of Social Research Methodology 8(1) 19-32, 2005). We searched MEDLINE, Embase, PsychINFO, ISI Web of Science, and CINAHL and hand-searched selected health professions' education journals. The search strategy yielded a total of 5,017 articles, of which 97 were included in the final review. Four major themes were identified: "Learners' interactions with uncertainty"; "Factors that influence learner experiences"; "Educational outcomes"; and, "Teaching and learning approaches". Our findings highlight that uncertainty is a ubiquitous concern in health professions' education, with students experiencing different forms of uncertainty at many stages of their training. These experiences are influenced by both individual and system-related factors. Formal teaching strategies that directly support learning around uncertainty were infrequent, and included arts-based teaching, and clinical case presentations. Students also met with uncertainty indirectly through problem-based learning, clinical teaching, humanities teaching, simulation, team-based learning, small group learning, tactical games, online discussion of anatomy topics, and virtual patients. Reflection and reflective practice are also mentioned as strategies within the literature.

An update on developments in medical education in response to the COVID-19 pandemic: A BEME scoping review: BEME Guide No. 64.

BACKGROUND: COVID-19 has fundamentally altered how education is delivered. Gordon et al. previously conducted a review of medical education developments in response to COVID-19; however, the field has rapidly evolved in the ensuing months. This scoping review aims to map the extent, range and nature of subsequent developments, summarizing the expanding evidence base and identifying areas for future research. METHODS: The authors followed the five stages of a scoping review outlined by Arskey and O'Malley. Four online databases and MedEdPublish were searched. Two authors independently screened titles, abstracts and full texts. Included articles described developments in medical education deployed in response to COVID-19 and reported outcomes. Data extraction was completed by two authors and synthesized into a variety of maps and charts. RESULTS: One hundred twenty-seven articles were included: 104 were from North America, Asia and Europe; 51 were undergraduate, 41 graduate, 22 continuing medical education, and 13 mixed; 35 were implemented by universities, 75 by academic hospitals, and 17 by organizations or collaborations. The focus of developments included pivoting to online learning (n = 58), simulation (n = 24), assessment (n = 11), well-being (n = 8), telehealth (n = 5), clinical service reconfigurations (n = 4), interviews (n = 4), service provision (n = 2), faculty development (n = 2) and other (n = 9). The most common Kirkpatrick outcome reported was Level 1, however, a number of studies reported 2a or 2b. A few described Levels 3, 4a, 4b or other outcomes (e.g. quality improvement). CONCLUSIONS: This scoping review mapped the available literature on developments in medical education in response to COVID-19, summarizing developments and outcomes to serve as a guide for future work. The review highlighted areas of relative strength, as well as several gaps. Numerous articles have been written about remote learning and simulation and these areas are ripe for full systematic reviews. Telehealth, interviews and faculty development were lacking and need urgent attention.

A realist evaluation exploring simulated patient role-play in pharmacist undergraduate communication training.

BACKGROUND: Effective communication between pharmacists and patients is essential and improves health outcomes. Simulated patients (SPs) are trained to reproduce real-life situations and can help pharmacy students to develop and adapt their communication skills in a safe, learner-centred environment. The aim of this research was to explore how SP and pharmacy student role-play supports communication training. METHODS: A mixed methods realist evaluation approach was adopted to test an initial theory relating to SP role-play for pharmacy students. The intervention tested involved complex communication cases in a men's and women's health module in year three of a new MPharm programme. This SP session was the first such session, of the programme which exclusively focused on complex communication skills for the students. Data collected comprised video-recordings of both training and mock OSCE sessions, and from student focus groups. Communication videos were scored using the Explanation and Planning Scale (EPSCALE) tool. Scores from SP and mock OSCE sessions were compared using the Wilcoxon-signed rank test. Focus groups were conducted with students about their experience of the training and analysed thematically, through a realist lens. Data was analysed for Context-Mechanism-Outcome configurations to produce modified programme theories. RESULTS: Forty-six students (n = 46/59, 78 %) consented to their video-recorded interactions to be used. Students identified contextual factors relating to the timing within the course and the setting of the intervention, the debrief and student individual contexts. Mechanisms included authenticity, feedback, reflection, self-awareness and confidence. Negative responses included embarrassment and nervousness. They distinguished outcomes including increased awareness of communication style, more structured communication and increased comfort. However quantitative data showed a decrease (p < 0.001) in communication scores in the mock OSCE compared with scores from training sessions. Modified programme theories relating to SP training for pharmacy students were generated. CONCLUSIONS: SP role-play is a valuable communication skills training approach. Emphasis should be placed on multiple stakeholder feedback and promotion of reflection. Time limits need to be considered in this context and adjusted to meet student needs, especially for students with lower levels of communication comfort and those communicating in languages different to their first language.

Developments in medical education in response to the COVID-19 pandemic: A rapid BEME systematic review: BEME Guide No. 63.

BACKGROUND: The novel coronavirus disease (COVID-19) was declared a pandemic in March 2020. This rapid systematic review synthesised published reports of medical educational developments in response to the pandemic, considering descriptions of interventions, evaluation data and lessons learned. METHODS: The authors systematically searched four online databases and hand searched MedEdPublish up to 24 May 2020. Two authors independently screened titles, abstracts and full texts, performed data extraction and assessed risk of bias for included articles. Discrepancies were resolved by a third author. A descriptive synthesis and outcomes were reported. RESULTS: Forty-nine articles were included. The majority were from North America, Asia and Europe. Sixteen studies described Kirkpatrick's outcomes, with one study describing levels 1-3. A few papers were of exceptional quality, though the risk of bias framework generally revealed capricious reporting of underpinning theory, resources, setting, educational methods, and content. Key developments were pivoting educational delivery from classroom-based learning to virtual spaces, replacing clinical placement based learning with alternate approaches, and supporting direct patient contact with mitigated risk. Training for treating patients with COVID-19, service reconfiguration, assessment, well-being, faculty development, and admissions were all addressed, with the latter categories receiving the least attention. CONCLUSIONS: This review highlights several areas of educational response in the immediate aftermath of the COVID-19 pandemic and identifies a few articles of exceptional quality that can serve as models for future developments and educational reporting. There was often a lack of practical detail to support the educational community in enactment of novel interventions, as well as limited evaluation data. However, the range of options deployed offers much guidance for the medical education community moving forward and there was an indication that outcome data and greater detail will be reported in the future.

Patient involvement in assessing consultation quality: validation of patient enablement instrument (PEI) in Lithuanian general practice.

BACKGROUND: The Patient Enablement Instrument (PEI) was designed to encapsulate consultation outcome from the perspective that increasing their understanding and coping ability would underpin a positive consultation outcome for patients. The objective of the study was the validation of the PEI in Lithuanian general practice and comparison of Lithuanian patients' enablement with previous studies in Europe to see if factors associated with patient enablement in Lithuania were reflective of those in the previous studies. METHODS: The Patient Enablement Instrument was translated into Lithuanian and included in the questionnaire along with the questions about a person's health, reasons for visiting the doctor and feeling about the consultation. Practices from 4 different municipalities that are situated in different geographical regions which have both town and rural areas were sampled randomly. Patients scheduled consecutively aged 18 years or more were the subjects of the study. The data analyses focused on internal reliability and concept validity. RESULTS: The overall mean patient enablement score was 6.43. Enablement scores declined with increasing patient age, and female patients were more enabled. Patients with biomedical problems had the highest enablement results, while patients with complex problems had the lower results. Enablement was positively related to receiving a prescription and knowing a doctor, and negatively related to wish having consultation with another doctor. CONCLUSIONS: This study substantiates the rationality of using PEI in assessing primary care consultations in Lithuania. The correlations of enablement largely reflect the situation in Western and Central Europe: longer consultation and access to the same physician increases patient enablement.

A Best Evidence in Medical Education systematic review to determine the most effective teaching methods that develop reflection in medical students: BEME Guide No. 51.

INTRODUCTION: Reflection is thought to be an essential skill for physicians. Although much has been written about it, there is little concurrence about how to best teach reflection in medical education. The aim of this review was to determine: (i) which educational interventions are being used to develop reflection, (ii) how is reflection being assessed, and (iii) what are the most effective interventions. METHODS: Inclusion criteria comprised: (i) undergraduate medical students, (ii) a teaching intervention to develop reflection, and (iii) assessment of the intervention. A review protocol was developed and nine databases were searched. Screening, data extraction, and analysis procedures were performed in duplicate. Due to the heterogeneity of studies, a narrative synthesis approach was performed for the study analysis. RESULTS: Twenty-eight studies met the inclusion criteria. The interventions in these studies had at least of two of the following components related to reflection: (i) introduction, (ii) trigger, (iii) writing, (iv) guidelines, (v) small group discussion, (vi) tutor and (vii) feedback. Three validated rubrics were used to assess reflective writing in these studies. CONCLUSIONS: The strongest evidence from studies in this review indicates that guidelines for, and feedback on, reflective writing improve student reflection.

Peer assessment to improve medical student's contributions to team-based projects: randomised controlled trial and qualitative follow-up.

BACKGROUND: Medical schools increasingly incorporate teamwork in their curricula but medical students often have a negative perception of team projects, in particular when there is unequal participation. The purpose of this study is to evaluate whether a novel peer evaluation system improves teamwork contributions and reduces the risk of students "free loading". METHODS: A cluster randomised controlled trial (RCT) with qualitative follow up enrolled 37 teams (n = 223 students). Participating teams were randomised to intervention group (19 teams) or control group (18 teams). The validated Comprehensive Assessment Team Member Effectiveness (CATME) tool was used as the outcome measure, and was completed at baseline (week 2) and at the end of the project (week 10). The team contribution subscale was the primary outcome, with other subscales as secondary outcomes. Six focus group discussions were held with students to capture the team's experiences and perceptions of peer assessment and its effects on team work. RESULTS: The results of the RCT showed that there was no difference in team contribution, and other forms of team effectiveness, between intervention and control teams. The focus group discussions highlighted students' negative attitudes, and lack of implementation of this transparent, points-based peer assessment system, out of fear of future consequences for relationships with peers. The need to assess peers in a transparent way to stimulate open discussion was perceived as threatening by participants. Teams suggested that other peer assessment systems could work such as rewarding additional or floating marks to high performing team members. CONCLUSIONS: Other models of peer assessment need to be developed and tested that are non-threatening and that facilitate early acceptance of this mode of assessment.

The 'connectaholic' behind the curtain: medical student use of computer devices in the clinical setting and the influence of patients.

BACKGROUND: The use of mobile devices such as tablets and laptops by students to support their learning is now ubiquitous. The clinical setting is an environment, which lends itself to the use of mobile devices as students are exposed to novel clinical scenarios that may require rapid location of information to address knowledge gaps. It is unknown what preferences students have for these devices and how they are used in the clinical environment. METHODS: In this study we explored medical students' choices and their use of different devices in their first year of clinical attachments. We sought to evaluate learners' experiences with these devices using a mixed methods approach. All students newly entered into the clinical years were given the option of a MacBook Air or iPad. We surveyed these students using an online survey tool followed by individual semi-structured interviews to explore survey findings in more depth. RESULTS: Students owned a multitude of devices however their preferences were for the 11 in. MacBook Air Laptop over the iPad mini. Students made constant use of online information to support their clinical learning, however three major themes emerged from the interview data: connection and devices (diverse personal ownership of technology by students and how this is applied to source educational materials), influence and interaction with patients (use of any device in a clinical setting) and influence and interaction with staff. In general students preferred to use their device in the absence of patients however context had a significant influence. CONCLUSIONS: These mobile devices were useful in the clinical setting by allowing access to online educational material. However, the presence of patients, and the behaviour of senior teaching staff significantly influenced their utilisation by students. Understanding the preferences of students for devices and how they use their preferred devices can help inform educational policy and maximise the learning from online educational content.

Can e-learning improve the performance of undergraduate medical students in Clinical Microbiology examinations?

BACKGROUND: Clinical Microbiology is a core subject in medical undergraduate curricula. However, students struggle to cover the content and clinically contextualise basic microbiology. Our aim was to evaluate student engagement with new e-learning material and to investigate the impact it had on examination performance in a Clinical Microbiology module. METHODS: An online resource was designed to support didactic teaching in a Fundamentals of Clinical Microbiology module. One cohort of students had access to the online material (2017/2018 class) and the other did not (2016/2017 class). Each cohort sat the same multiple-choice question (MCQ) and short-note question (SNQ) examination papers and the impact of engagement with the online resource and examination performance was analysed. RESULTS: Both groups were of the same academic standard prior to beginning the module. In the 2017/2018 cohort, 227/309 (73.5%) students had ≥80% engagement with the content. Students engaged most with the index of pathogens and pathogen focused clinical cases related to diverse genera and families of clinically important microorganisms. A statistically higher difference in the mean percentage grade in both the MCQ and SNQ examinations was seen for 2017/2018 compared to 2016/2017 cohort. For the MCQ examination, the 2017/2018 cohort were on average 5.57% (95% confidence interval (CI): 3.92 to 7.24%; P < 0.001) higher, and for the SNQ examination the 2017/2018 cohort were on average 2.08% (95% CI: 0.74 to 3.41%; P = 0.02) higher. When the results were adjusted for previous examination performance, for every percentage increase in online engagement the grade in the SNQ examination only increased by 0.05% (95% CI: 0.02 to 0.08) on average. CONCLUSIONS: These findings suggest students engage with e-learning when studying and that such activities may help students perform better in assessments.

'Playing the game': How do surgical trainees seek feedback using workplace-based assessment?

OBJECTIVES: Although trainees and trainers find feedback interactions beneficial, difficulties in giving and receiving feedback are reported. Few studies have explored what drives trainees to seek feedback. This study explores how workplace-based assessments (WBAs) influence the ways surgical trainees seek feedback and feedback interactions. METHODS: Utilising a template analysis approach, we conducted 10 focus groups with 42 surgical trainees from four regions across the UK. Data were independently coded by three researchers, incorporating three a priori themes identified from a previous quantitative study. Further themes emerged from exploration of these data. The final template, agreed by the three researchers, was applied to all focus group transcripts. The themes were linked in a diagrammatical form to allow critical exploration of the data. RESULTS: Trainees' perceptions of the purpose of WBA for learning or an assessment of learning, and their relationship with their trainer impacted upon how trainees chose to use WBA. Perceiving WBA as a test led trainees to 'play the game': seek positive and avoid negative feedback through WBA. Perceiving WBA as a chance to learn led trainees to seek negative feedback. Some trainees sought negative feedback outside WBA. Negative feedback was more important for changing practice compared with positive feedback, which enabled trainees to 'look good' but had less of an effect on changing clinical practice. The timing of feedback relative to WBA was also important, with immediate feedback being more beneficial for learning; however, delayed feedback was still sought using WBA. DISCUSSION: Trainees' perceptions of the purpose of WBA and their relationship with their trainer informed when they chose to seek feedback. Trainees who perceived WBA as a test were led to 'play the game' by seeking positive and avoiding negative feedback. Outside of WBA, trainees sought negative feedback, which was most important for change in practice.

A comparative study: do "clickers" increase student engagement in multidisciplinary clinical microbiology teaching?

BACKGROUND: Audience response devices, or "clickers", have been used in the education of future healthcare professionals for several years with varying success. They have been reported to improve the learning experience by promoting engagement and knowledge retention. In 2014, our department evaluated the use of "clickers" in a newly introduced multidisciplinary approach to teaching large groups of third year medical students clinical cases developed around a microbiology theme. METHODS: Six multidisciplinary teaching sessions covering community-acquired pneumonia, tuberculosis, infective endocarditis, peritonitis, bloodstream infection with pyelonephritis and bacterial meningitis were included in the study. Three involved the use of the "clickers" and three did not. Consenting undergraduate students attended the designated classes and afterwards answered a short online quiz relating to the session. Students also answered a short questionnaire about the "clickers" to gauge their attitudes on the use of these devices. RESULTS: Of 310 students, 294 (94.8%) agreed to participate in the study. Interestingly, the grades of online quizzes after a session where a "clicker" was used were slightly lower. Looking only at the grades of students who engaged completely with the process (n = 19), there was no statistical difference to suggest that the devices had a positive or negative impact on knowledge retention. However, student attitudes to using the devices were positive overall. Fifty-five percent strongly agreed and 27% agreed that teaching sessions where the "clickers" were used were more engaging. Thirty-four percent strongly agreed and 36% agreed that the "clickers" made important concepts more memorable and 54% felt the device enhanced their understanding of the topic being covered. CONCLUSIONS: Overall, it appears that "clickers" help in improving student engagement in large classroom environments, enhance the learning experience, and are received positively by medical students but their impact on knowledge retention is variable.

Choice and perception of the nursing profession from the perspective of Polish nursing students: a focus group study.

BACKGROUND: Although previous quantitative studies provide important information on the factors which influence the choice of nursing as a career, qualitative analysis makes it possible to study the subject more thoroughly. The purpose of this study was to conduct an in-depth analysis of the reasons why Polish students choose nursing as a profession and their later perception of the job based on experiences acquired during the nursing course. METHODS: A qualitative descriptive study was designed. We organized 8 focus group discussions with third-year nursing students. A total of 76 students participated in the study. RESULTS: Several reasons why students had chosen the nursing profession were identified: desire to help others, family tradition, desire to work abroad, failure to get into another course, pure chance, and low admission requirements (relative to medical studies). The participants' views of the nursing profession were based on their own personal experiences or observations of nurses at work. Often these observations were superficial, concerning only selected fragments of nursing work. The participants also identified reasons for there being low regard for the nursing profession. CONCLUSION: The decision about choosing nursing is mainly determined by practical aspects, e.g., the opportunity for employment. Although young people are aware of the low prestige of the nursing profession in Poland, they believe it is possible to improve its image and enhance its prestige.

Family physicians' professional identity formation: a study protocol to explore impression management processes in institutional academic contexts.

BACKGROUND: Despite significant differences in terms of medical training and health care context, the phenomenon of medical students' declining interest in family medicine has been well documented in North America and in many other developed countries as well. As part of a research program on family physicians' professional identity formation initiated in 2007, the purpose of the present investigation is to examine in-depth how family physicians construct their professional image in academic contexts; in other words, this study will allow us to identify and understand the processes whereby family physicians with an academic appointment seek to control the ideas others form about them as a professional group, i.e. impression management. METHODS/DESIGN: The methodology consists of a multiple case study embedded in the perspective of institutional theory. Four international cases from Canada, France, Ireland and Spain will be conducted; the "case" is the medical school. Four levels of analysis will be considered: individual family physicians, interpersonal relationships, family physician professional group, and organization (medical school). Individual interviews and focus groups with academic family physicians will constitute the main technique for data generation, which will be complemented with a variety of documentary sources. Discourse techniques, more particularly rhetorical analysis, will be used to analyze the data gathered. Within- and cross-case analysis will then be performed. DISCUSSION: This empirical study is strongly grounded in theory and will contribute to the scant body of literature on family physicians' professional identity formation processes in medical schools. Findings will potentially have important implications for the practice of family medicine, medical education and health and educational policies.