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PURPOSE: Prescribing is a common task, often performed by junior clinicians, with potential for significant harm. Despite this, it is common for medical students to qualify having only prescribed in simulated scenarios or assessments. We implemented an alternative: students were given pens with purple ink, which permitted them to write prescriptions for real patients. We set out to understand how this intervention, pre-prescribing, created a zone of proximal development (ZPD) for learners.METHODS: An anonymous, mixed methods, evaluation questionnaire was distributed to all final-year medical students at one university in the United Kingdom. Analysis was guided by Experience Based Learning theory.RESULTS: Two hundred and eighteen students made 386 free-text comments. Most participants reported that pre- helped them become capable doctors (Strongly Agree n = 96, 45%; Agree: n = 110, 50%). Pre-prescribing created a ZPD in which participants could use the tools of practice in authentic contexts under conditions that made it safe to fail.CONCLUSIONS: This research shows how a theoretically informed intervention can create conditions to enhance learning. It encourages educators to identify aspects of routine practice that could be delegated, or co-performed, by learners. With appropriate support, educators can create 'safe-fails' which allow learners to participate safely in authentic, risky, and indeterminate situations they will be expected to navigate as newly qualified clinicians.

Objective Simulated and standardized patients (SPs) are increasingly being used in communication skills training for healthcare professionals' education. Despite this broad use of SPs, there is no recent literature with an overview on SP working formats being used. We ran a study to fill this gap. Methods First, a survey on formats on the use of SPs in various curricula for education of healthcare professionals in Belgium and The Netherlands was run by members of the Dutch Association of Medical Education Special Interest Group on Simulated and Standardized patients (SIG-NL/B). Then the SIG-NL/B organized a national workshop where professionals working with or interested in SPs were invited to come forward with SP working formats they used. They were also asked to provide relevant details about the use. Finally, the outcomes of these two phases were combined. Results Fifteen SP working formats were found. Six of them were described before. The details of all formats are listed and discussed. Conclusion We categorised 15 SP working formats. The choice to use a particular format is mainly based on the learning objectives of the session involved and the expertise at hand.

Phenomenon: In South Africa, as with many other developing countries, a call has been made for institutions of higher learning to participate in more research and set the pace for societal transformation. At the Faculty of Health Sciences (FoHS), University of the Free State (UFS), numerous strategic efforts are focused on supporting and stimulating research. An essential prerequisite for the success of these vital efforts is to be aware of the research culture within the academic faculties. A peculiarity of medical colleges in South Africa is that medical faculties are in partnership with the government through the academic training hospitals; hence, staff appointment occurs through a joint structure with both the provincial Department of Health and the National Health Laboratory Services. So far, no known study has investigated research culture in this context (joint staff appointment). Approach: This study included elements of case study evaluation and improvement-oriented evaluation. We distributed to 242 educators a structured questionnaire to obtain perceptions of aspects of research, research processes, and existing research culture in the FoHS, UFS. Suggestions on how to improve the research culture also were obtained. The structured questionnaire was self-administered, consisted of closed and open-ended questions grouped into five main sections, and was distributed electronically and manually (hard copy) to participants. Findings: One-hundred-eleven questionnaires were returned (46% response rate). Motivation to do research varied by school and included career advancement (77%, School of Allied Health Professions); change the situation (80%, Academic support); develop individual skillset (67%, School of Nursing) and improve patient care (62%, School of Medicine). Perceived factors affecting research culture included limited funding and allocated time for research, minimal leadership support for research, and absence of research-related support structures as well as minimal teamwork/collaboration. Frustration was the most reported (negative) emotion (25%). Participants suggested that encouraging teamwork among staff, reducing workload to allow time for research, establishing a mentorship program, providing training on deficient skills, and more support from leadership would improve research culture. Insights: This present study reveals some of the factors that impact negatively on research, research culture, and productivity in a medical college in a resource-limited setting. While the benefits of joint staff appointment cannot be overemphasized, our findings highlight that the complex interplay between employers/stakeholders result in poorly executed joint appointment scheme/models (i.e., competitive approach) and creates numerous challenges that negatively impact research productivity and research culture. Recommendations suggested herein can be implemented by the FoHS and other medical colleges in similar contexts to improve research productivity and foster an enabling research culture.

Students' learning environments often change during school career, due to school transitions and the introduction of educational innovations, causing discontinuity in teaching and learning. Success of students entering a new learning environment depends in part on their prior expectations of education, as these influence later perceptions. Heterogeneity between students, however, needs to be acknowledged. In seeking to determine expectation profiles and their potential linkage to divergent perceptions of education, we longitudinally surveyed secondary school students regarding their expectations before, and their perceptions one and two years after entering an innovative learning environment. We identified three expectation profiles that differed in terms of students' motivation, learning conceptions, and affective strategies: optimistic, moderately optimistic, and pessimistic. For each profile, perceptions developed differently over time, with the moderately optimistic and pessimistic students being at risk in different ways. Results imply that expectations deserve a more prominent place when designing innovative learning environments.

Leaders in academic medicine have observed that ‘the goal of faculty development is to provide faculty members with the skills relevant to their institutional setting and faculty position, and to s...

Introduction: Teachers’ conceptions of learning and teaching (COLT) affect their teaching behaviour. The 18 item COLT instrument has been developed in the Netherlands and comprises three scales, ‘teacher centredness’, ‘appreciation of active learning’ and ‘orientation to professional practice’. Previously we found five teacher profiles. The aim of this study was to find out if the COLT instrument can be used in an international setting. Methods: Data were collected with the web-based COLT. Cronbach’s alphas of the three COLT scales were calculated. Subsequently a cluster analysis was conducted to identify different teacher profiles, followed by a split half validation procedure. Results: Respondents (n = 708) worked in 28 countries. Cronbach’s alphas were 0.67, 0.54, and 0.66. A six-cluster solution fitted best, based on meaning and explained variance. The sixth teacher profile scored high on ‘teacher centredness’, average on ‘appreciation of active learning’ and low on ‘orientation to professional practice’. The split half validation resulted in a Cohen’s kappa of 0.744. Discussion: Cronbach’s alphas indicated acceptable reliablities for all three subscales. The new, sixth profile was labelled ‘neo-transmitter’. Conclusion: We found evidence supporting the validity of the use of COLT in an international context and identified a new, sixth teacher profile.

Background: Throughout their careers, doctors and other healthcare professionals experience numerous transitions. When supporting transitions, opportunities for development and learning should be maximized, while stressors having negative impacts on well-being should be minimized. Building on our international data, this study aimed to develop a conceptual model of the trainee-trained transition (i.e. the significant transitions experienced by doctors as they complete postgraduate training moving from trainee/resident status to medical specialist roles). Methods: Employing Multiple and Multidimensional Transitions (MMT) theory and current conceptualizations of clinical context, this study undertook secondary analysis of 55 interviews with doctors from three countries (Netherlands, Cananda and the UK) undergoing trainee-trained transitions. Results: Through this analysis, the Transition-To-Trained-Doctor (T3D) conceptual model has been developed. This model takes into consideration the multiple contexts and multiple domains in which transitions take place. Discussion: This model is significant in that it has several uses and is applicable across countries: to remind doctors, managers and medical educators of the complexity of transitions; to frame and facilitate supportive conversations; and as a basis to teach about transitions.

Construct: The globalization of healthcare has been accentuated by the export of health professional curricula overseas. Yet intact translation of pedagogies and practices devised in one cultural setting may not be possible or necessarily appropriate for alternate environments. Purposeful examination of workplace learning is necessary to understand how the source or “home” program may need adapting in the distributed or “host” setting. Background: Strategies to optimize cross-border medical education partnerships have been largely focused on elements of campus-based learning. Determining how host clinical supervisors approach assessment in experiential settings within a different culture and uphold the standards of home programs is relevant given the influence of context on trainees’ demonstrated competencies. In this mixed-methods study, we sought to explore assessor judgments of student workplace-based performance made by preceptors sharing a pharmacy curriculum in Canada and Qatar. Approach: Using modified Delphi consensus technique, we asked clinical supervisors in Canada (n = 18) and in Qatar (n = 14) to categorize trainee performance as described in 16 student vignettes. The proportion of ratings for three levels of expectation (exceeds, meets, or below) was calculated and within-country group consensus achieved if the level of agreement reached 80%. Between-country group comparisons were measured using a chi-square statistic. We then conducted follow-up semi-structured interviews to gain further perspectives and clarify assessor rationale. Transcripts were analyzed using thematic content analysis. Results: The threshold for between-country group differences in assessor impressions was met for only two of the 16 student vignettes. Compared to Canadian clinical supervisors, relatively more preceptors in Qatar judged one described student as meets rather than exceeds expectations and one as meets rather than falls below expectations. Analysis of follow-up interviews exploring how culture may inform variations in assessor judgments identified themes associated with the profession, organization, learner, and supervisor performance theories but not their particular geographic context. Clinical supervisors in both countries were largely aligned in expectations of student knowledge, skills, and behaviors demonstrated in patient care and multidisciplinary team interactions. Conclusions: Our study demonstrated that variation in student assessment was more frequent among clinical supervisors within the same national context than any differences identified between the two countries. In these program settings, national sociocultural norms did not predict global assessor impressions or competency-specific judgments; instead, professional and organizational cultures were more likely to inform student characterizations of performance in workplace-based settings. Further study situated within the specific experiential learning contexts of cross-border health professional curricula is assuredly warranted.

Introduction: Clinical reasoning is considered to be at the core of health practice. Here, we report on the diversity and inferred meanings of the terms used to refer to clinical reasoning and consider implications for teaching and assessment. Methods: In the context of a Best Evidence Medical Education (BEME) review of 625 papers drawn from 18 health professions, we identified 110 terms for clinical reasoning. We focus on iterative categorization of these terms across three phases of coding and considerations for how terminology influences educational practices. Results: Following iterative coding with 5 team members, consensus was possible for 74, majority coding was possible for 16, and full team disagreement existed for 20 terms. Categories of terms included: purpose/goal of reasoning, outcome of reasoning, reasoning performance, reasoning processes, reasoning skills, and context of reasoning. Discussion: Findings suggest that terms used in reference to clinical reasoning are non-synonymous, not uniformly understood, and the level of agreement differed across terms. If the language we use to describe, to teach, or to assess clinical reasoning is not similarly understood across clinical teachers, program directors, and learners, this could lead to confusion regarding what the educational or assessment targets are for "clinical reasoning."

Introduction: Developments in outcome-based medical education led to the introduction of time-variable medical training (TVMT). Although this idea of training may be a consequence of competency-based training that calls for individualized learning, its implementation has posed significant challenges. As a new paradigm it is likely to have repercussions on the organization of teaching hospitals. The purpose of this study is therefore to explore how hospital administrators cope with this implementation process. Methods: We conducted an exploratory qualitative study for which we interviewed administrators of hospitals who were actively implementing TVMT in their postgraduate programs. Results: Several problems of implementation were identified: existing governance structures proved unfit to cope with the financial and organizational implications of TVMT. Administrators responded to these problems by delegating responsibilities to departments, reallocating tasks, learning from other hospitals and scaling up their teaching facilities. Conclusions: Hospital administrators perceived the implementation of TVMT as challenging. TVMT affects the existing equilibrium between education and clinical service. Administrators’ initial attempts to regain control, using steering strategies that were based on known concepts and general outcomes, including cutting departmental budgets did not work, nor did their subsequent wait-and-see approach of leaving the implementation to the individual departments.

Introduction: A new form of internationalization has been trending upward in the medical education realm: crossborder medical curriculum partnerships established to deliver the same, or adapted, curriculum to groups of geographically separated students. This study aims to investigate crossborder medical curriculum partnerships by exploring the experiences of teachers at the recipient institution who have a key role in delivering the program. Methods: From four pioneering recipient medical schools, 24 teachers participated in a Q-sort study. Each participant rank-ordered 42 statements about teaching in a crossborder medical curriculum on a scale from -5 (indicating strong disagreement) to +5 (indicating strong agreement). The authors conducted a "by-person" factor analysis to uncover distinct patterns in the ranking of statements, using the statistical results and participants' comments about their Q sorts to interpret these patterns and translate them into distinct viewpoints. Results: Three viewpoints emerged, reflecting: (1) a feeling of connectedness with the partner institution, trust in the quality of the curriculum, and appreciation of interinstitutional relationships; (2) the partnership's attractiveness because of the career opportunities it offers; and (3) concerns over the quality of graduates because of doubts about the appropriateness of the didactic model and insufficient attention to local healthcare needs, and over the practical feasibility of such partnerships. Conclusions: The three viewpoints identified revealed a pallet of views on how host teachers might experience their work. It shows the heterogeneous features of this group and seems to counterbalance reports that they are feeling "deprived" from their role as teacher. Two viewpoints featured an appreciation of interinstitutional relationships and of the partnership, especially when perceiving a degree of autonomy. Partners can capitalize on all different viewpoints by deploying procedure and policies to raise the quality of education delivery.

Students' educational engagement is both an important predictor of study success and a key preventive factor for dropout. Vocational tracks in secondary education show high dropout rates. There is strong evidence that the solution to educational disengagement lies in student-centred, powerful learning environments (PLEs). This study investigates characteristics of PLEs from the perspective of students in vocational secondary education. Students' perspectives on a learning environment are crucial for their satisfaction and learning engagement. Therefore, we investigated whether the perceived learning environment meets the requirements of PLEs, and to what extent it meets students' preferences. Additionally, it was investigated whether students who perceive their learning environment as more powerful, are also more engaged for school. Survey data of 532 students showed that student perceptions of their current learning environment were largely discrepant from the characteristics of PLEs. Students strongly asked for more challenging learning pathways, in combination with adaptive learning support. Students who perceived the characteristics of PLEs as being present, reported higher satisfaction and stronger engagement than students who perceived their education to be a less powerful environment. There is a need to redesign curricula in vocational education in such a way that these more intensely implement characteristics of PLEs.

Phenomenon: Interdisciplinary coteaching has become a popular pedagogic model in medical education, yet there is insufficient research to guide effective practices in this context. Coteaching relationships are not always effective, which has the potential to affect the student experience. The purpose of this study was to explore interdisciplinary coteaching relationships between a physician (MD) and social behavioral scientist (SBS) in an undergraduate clinical skills course. We aimed to gain an in-depth understanding of what teachers perceive as influencing the quality of relationships to begin to construct a framework for collaborative teaching in medical education. Approach: A qualitative study was conducted consisting of 12 semistructured interviews (6 MD and 6 SBS) and 2 monodisciplinary focus groups. Sampling was purposive and aimed at maximal variation from among 64 possible faculty. The data were analyzed using the constant comparative method to develop a grounded theory. Findings: Five major themes resulted from the analysis that outline a framework for interdisciplinary coteaching: respect, shared goals, shared knowledge and understanding, communication, and complementary pairings. Insights: The first 4 themes align with elements of relational coordination theory, an organizational theory of collaborative practice that describes how work roles interact. The complementary pairings extend this theory from work roles to individuals, with unique identities and personal beliefs and values about teaching. Prior studies on coteaching have not provided a clear linkage to theory. The conceptual framework helps suggest future directions for coteaching research and has practical implications for administrative practices and faculty development. These findings contribute to the sparse research in medical education on interdisciplinary coteaching relationships.

Item does not contain fulltext BACKGROUND: It remains unclear which item format would best suit the assessment of clinical reasoning: context-rich single best answer questions (crSBAs) or key-feature problems (KFPs). This study compared KFPs and crSBAs with respect to students' acceptance, their educational impact, and psychometric characteristics when used in a summative end-of-clinical-clerkship pediatric exam. METHODS: Fifth-year medical students (n = 377) took a computer-based exam that included 6-9 KFPs and 9-20 crSBAs which assessed their clinical reasoning skills, in addition to an objective structured clinical exam (OSCE) that assessed their clinical skills. Each KFP consisted of a case vignette and three key features using a "long-menu" question format. We explored students' perceptions of the KFPs and crSBAs in eight focus groups and analyzed statistical data of 11 exams. RESULTS: Compared to crSBAs, KFPs were perceived as more realistic and difficult, providing a greater stimulus for the intense study of clinical reasoning, and were generally well accepted. The statistical analysis revealed no difference in difficulty, but KFPs resulted more reliable and efficient than crSBAs. The correlation between the two formats was high, while KFPs correlated more closely with the OSCE score. CONCLUSIONS: KFPs with long-menu exams seem to bring about a positive educational effect without psychometric drawbacks.

Item does not contain fulltext BACKGROUND: A variety of tools have been developed to assess performance which typically use a single clinical encounter as a source for making competency inferences. This strategy may miss consistent behaviors. We therefore explored experienced clinical supervisors' perceptions of behavioral patterns that potentially exist in postgraduate general practice trainees expressed as narrative profiles to aid the grading of clinical performance. METHODS: We conducted semistructured interviews with clinical supervisors who had frequently observed clinical performance in trainees. Supervisors were asked to describe which behavioral patterns they had discerned in excellent and underperforming trainees, during different stages of training, in their careers as clinical supervisor. We analyzed the interviews using a grounded theory approach. RESULTS: The analysis resulted in a conceptual framework that distinguishes between desirable and undesirable narrative profiles. The framework consists of two dimensions: doctor-patient interaction and medical expertise. Personal values appear to be a moderating factor. CONCLUSIONS: According to experienced clinical supervisors, consistent behaviors do exist in GP trainees when observing clinical performance over time. The conceptual framework has to be validated by further observational studies to assess its potential for making robust and fair assessments of clinical performance and monitor the development of consultation performance over time.

Aim: Many instruments for evaluating clinical teaching have been developed, albeit most in Western countries. This study aims to develop a validated cultural and local context sensitive instrument for clinical teachers in an East Asian setting (Japan), Japanese Clinical Teacher Evaluation Sheet (JaCTES).Methods: A multicenter, cross-sectional evaluation study was conducted. We collected a total of 1368 questionnaires on 304 clinical teachers, completed by residents in 16 teaching hospitals. The construct validity was examined by conducting a factor analysis and using structural equation modeling (SEM). We also assessed the reliability using generalizability analysis and decision study.Results: Exploratory factor analysis resulted in three-factor (role model, teaching activities, and accessibility) model including 18 items. Confirmatory factor analysis was performed, using SEM. The comparative fit index was 0.931 and the root mean square error of approximation was 0.087, meaning an acceptable goodness of fit for this model. To obtain a reliable dependability-coefficient of at least 0.70 or higher, 5-8 resident responses are necessary.Discussion and conclusion: JaCTES is the first reported instrument with validity evidence of content and internal structure and high feasibility in Japan, an East Asian setting. Medical educators should be aware of the local context and cultural aspects in evaluating clinical teachers.

Background: Portfolios are used as tools to coach and assess students in the workplace. This study sought to evaluate the content validity of portfolios as reflected in their capacity to adequately assess achieved competences of medical students during clerkships. Methods: We reviewed 120 workplace portfolios at three medical universities (Belgium and the Netherlands). To validate their content, we developed a Validity Inventory for Portfolio Assessment (VIPA) based on the CanMEDS roles. Two raters evaluated each portfolio and indicated for each VIPA item whether the portfolio provided sufficient information to enable satisfactory assessment of the item. We ran a descriptive analysis on the validation data and computed Cohens Kappa to investigate interrater agreement. Results: The portfolios adequately covered the items pertaining to the communicator (90%) and professional (87%) roles. Coverage of the medical expert, collaborator, scholar and manager roles ranged between 75% and 85%. The health advocate role, covering 59%, was clearly less well represented. This role also exhibited little interrater agreement (Kappa

Every year, thousands of students go abroad for part of their study programme. Supervision from the home institution is then crucial for good study progress. Providing supervision and feedback at a distance is challenging. This project aims to identify bottlenecks for supervision and hypothesises that online supervisory group meetings with videoconferencing contribute to good supervision. Study 1 showed that students who were abroad perceived lower-quality supervision and feedback on all measured aspects, compared with students staying at the home institution. Within a quasi-experimental design, Study 2 showed that students participating in online meetings experienced better supervision than those who were abroad without online meetings, and they were equally positive about supervision as students who stayed at the home institution. These findings stress the need for extra support for students during their stay abroad and the large potential of videoconferencing in optimising supervision at a distance.

Item does not contain fulltext CONTEXT: Narrative feedback documented in performance evaluations by the teacher, i.e. the clinical supervisor, is generally accepted to be essential for workplace learning. Many studies have examined factors of influence on the usage of mini-clinical evaluation exercise (mini-CEX) instruments and provision of feedback, but little is known about how these factors influence teachers' feedback-giving behaviour. In this study, we investigated teachers' use of mini-CEX in performance evaluations to provide narrative feedback in undergraduate clinical training. METHODS: We designed an exploratory qualitative study using an interpretive approach. Focusing on the usage of mini-CEX instruments in clinical training, we conducted semi-structured interviews to explore teachers' perceptions. Between February and June 2013, we conducted interviews with 14 clinicians participated as teachers during undergraduate clinical clerkships. Informed by concepts from the literature, we coded interview transcripts and iteratively reduced and displayed data using template analysis. RESULTS: We identified three main themes of interrelated factors that influenced teachers' practice with regard to mini-CEX instruments: teacher-related factors; teacher-student interaction-related factors, and teacher-context interaction-related factors. Four issues (direct observation, relationship between teacher and student, verbal versus written feedback, formative versus summative purposes) that are pertinent to workplace-based performance evaluations were presented to clarify how different factors interact with each other and influence teachers' feedback-giving behaviour. Embedding performance observation in clinical practice and establishing trustworthy teacher-student relationships in more longitudinal clinical clerkships were considered important in creating a learning environment that supports and facilitates the feedback exchange. CONCLUSION: Teachers' feedback-giving behaviour within the clinical context results from the interaction between personal, interpersonal and contextual factors. Increasing insight into how teachers use mini-CEX instruments in daily practice may offer strategies for creating a professional learning culture in which feedback giving and seeking would be enhanced.

Although communication failures between professionals in acute care delivery occur, explanations for these failures remain unclear. We aim to gain a deeper understanding of interprofessional communication failures by assessing two different explanations for them. A multiple case study containing six cases (i.e. acute care chains) was carried out in which semi-structured interviews, physical artifacts and archival records were used for data collection. Data were entered into matrices and the pattern-matching technique was used to examine the two complementary propositions. Based on the level of standardization and integration present in the acute care chains, the six acute care chains could be divided into two categories of care processes, with the care chains equally distributed among the categories. Failures in communication occurred in both groups. Communication routines were embedded within organizations and descriptions of communication routines in the entire acute care chain could not be found. Based on the results, failures in communication could not exclusively be explained by literature on process typology. Literature on organizational routines was useful to explain the occurrence of communication failures in the acute care chains. Organizational routines can be seen as repetitive action patterns and play an important role in organizations, as most processes are carried out by means of routines. The results of this study imply that it is useful to further explore the role of organizational routines on interprofessional communication in acute care chains to develop a solution for failures in handover practices.

Item does not contain fulltext Abstract 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.

International journal for research in vocational education and training 1 (2014) 2, S. 107-124, If teachers and teacher educators are willing to support the learning of students, it is important for them to learn what motivates students to engage in learning. Students have their own preferences on design characteristics of powerful learning environments in vocational education. We developed an instrument – the Inventory Powerful Learning Environments in Vocational Education - to measure students’ preferences on characteristics of powerful learning environments in vocational education. We investigated whether student preferences on the design of their learning environments are in line with what is described in the literature as beneficial for learning. Data of 544 students show that the preferences of students support most characteristics of PLEs in vocational education. Looking through the eyes of students, teachers have to challenge their students and encourage them to take their learning in their own hands. Adaptive learning support is needed. Remarkable, students do not prefer having reflective dialogues with teachers or peers. (DIPF/orig.)

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