Exploring residents' perceptions of PA and NP roles and barriers to collaboration.

OBJECTIVE: Developing competencies for interprofessional collaboration, including understanding other professionals' roles on interprofessional teams, is an essential component of medical education. This study explored resident physicians' perceptions of the clinical roles and responsibilities of physician assistants (PAs) and NPs in the clinical learning environment. METHODS: Using a constructivist grounded theory approach, semistructured interviews were conducted with 15 residents in one academic setting. Transcripts were analyzed using an iterative approach to inductive coding. RESULTS: Participants typically perceived PAs' and NPs' roles as being "like a resident," less commonly as independent clinicians, and rarely as collaborators. Barriers to understanding PA and NP roles and perceiving them as collaborators included the lack of preparatory instruction about PAs and NPs, the hierarchical structure of medical education, and inadequate role modeling of interprofessional collaboration. CONCLUSIONS: This study suggests that barriers in the clinical learning environment and the structure of medical education itself may impede residents' learning about PAs and NPs and how to collaborate with them.

Advancing quality culture in health professions education: experiences and perspectives of educational leaders.

The concept of quality culture has gained increased attention in health professions education, drawing on insights that quality management processes and positive work-related attitudes of staff in synergy lead to continuous improvement. However, the directions that guide institutions from quality culture theory to educational practice have been missing so far. A prospective qualitative case study of three health professions education programmes was conducted to explore how a quality culture can be enhanced according to the experiences and perspectives of educational leaders. The data collection was structured by an appreciative inquiry approach, supported with vignette-based interviews. A total of 25 participants (a selection of course coordinators, bachelor coordinators and directors of education) reflected on quality culture themes to learn about the best of what is (Discover), envision positive future developments (Dream), identify actions to reach the desired future (Design), and determine how to support and sustain improvement actions (Destiny) within their own educational setting. The results are presented as themes subsumed under these four phases. The experiences and perspectives of educational leaders reveal that peer learning in teams and communities, attention to professional development, and embedding support- and innovation networks, are at the heart of quality culture enhancement. An emphasis on human resources, (inter)relations and contextual awareness of leaders stood out as quality culture catalysts. Educational leaders are therefore encouraged to especially fuel their networking, communication, coalition building, and reflection competencies.

Student participation in the design of learning and teaching: Disentangling the terminology and approaches.

Background: Students are ever more involved in the design of educational practices, which is reflected in the growing body of literature about approaches to student participation. Similarities and differences between these approaches often remain vague since the terms are used interchangeably. This confusing and fragmented body of literature hampers our understanding the process and outcomes of student participation and choosing the most suitable approach for it. Method: We identified the three most frequently used terms related to the design of learning and teaching - design-based research (DBR), participatory design (PD), and co-creation - and disentangled the terminology by focusing on relevant definitions, aims, involvement of students, outcomes, and related terminology. Results: Differences between the approaches to student participation can be found in the degree to which students are the central actors and the degree to which the design is informed by educational theory. Conclusion: It is important to align the level of student participation with the purpose of the approach.

Exploring the validity and reliability of a questionnaire for evaluating veterinary clinical teachers' supervisory skills during clinical rotations.

BACKGROUND: Feedback to aid teachers in improving their teaching requires validated evaluation instruments. When implementing an evaluation instrument in a different context, it is important to collect validity evidence from multiple sources. AIM: We examined the validity and reliability of the Maastricht Clinical Teaching Questionnaire (MCTQ) as an instrument to evaluate individual clinical teachers during short clinical rotations in veterinary education. METHODS: We examined four sources of validity evidence: (1) Content was examined based on theory of effective learning. (2) Response process was explored in a pilot study. (3) Internal structure was assessed by confirmatory factor analysis using 1086 student evaluations and reliability was examined utilizing generalizability analysis. (4) Relations with other relevant variables were examined by comparing factor scores with other outcomes. RESULTS: Content validity was supported by theory underlying the cognitive apprenticeship model on which the instrument is based. The pilot study resulted in an additional question about supervision time. A five-factor model showed a good fit with the data. Acceptable reliability was achievable with 10-12 questionnaires per teacher. Correlations between the factors and overall teacher judgement were strong. CONCLUSIONS: The MCTQ appears to be a valid and reliable instrument to evaluate clinical teachers' performance during short rotations.

Does a faculty development programme improve teachers' perceived competence in different teacher roles?

BACKGROUND: Changing concepts of education have led many medical schools to adopt student-centred approaches to teaching, requiring different teaching competencies than more traditional approaches. AIMS: The aim of this study was to investigate whether participation in a faculty development (FD) programme had a positive effect on veterinary medical teachers' perceptions of their competence in seven different teaching roles. METHOD: All teaching staff of a veterinary medical school (251) were invited to complete a questionnaire asking about their perceived competence in seven teaching roles. A stepwise multiple linear regression analysis examined the effect of the completion of a FD programme on perceived teaching competence. RESULTS: There was a significant positive effect of the FD programme on teachers' perceived competence in majority of the teaching roles at issue. CONCLUSIONS: FD appeared to have a positive effect on the perceived competence of veterinary medical teachers. Further research should investigate whether FD actually results in improved teaching performance.

Educational approaches aimed at preparing students for professional veterinary practice.

Changes in society and dissatisfaction with current educational practices have led to changes in undergraduate veterinary curricula. New approaches that are thought to better prepare students for future professional veterinary practice are being introduced. One such change is a transition from conventional teacher-centred curricula to student-centred curricula. In student-centred curricula, students are actively involved in learning and teachers not only transmit knowledge but help students to obtain a deep understanding. Furthermore, learning within these curricula takes place in a multi-disciplinary context which is more relevant for the future of the profession. Another change is that more emphasis is put on training in academic skills, for instance, by establishing research internships. Finally, a new emphasis is being placed on training in more generic competencies, such as communication and business skills. These changes are assumed to better suit the profile of veterinary students today and in the future and to better prepare them for future veterinary practice.

Perceptions of problem-based learning (PBL) group effectiveness in a socially-culturally diverse medical student population.

INTRODUCTION: A key aspect of the success of a PBL curriculum is the effective implementation of its small group tutorials. Diversity among students participating in tutorials may affect the effectiveness of the tutorials and may require different implementation strategies. AIMS: To determine how students from diverse backgrounds perceive the effectiveness of the processes and content of the PBL tutorials. This study also aims to explore the relationship between students' perceptions of their PBL tutorials and their gender, age, language, prior educational training, and secondary schooling. MATERIALS/METHODS: Data were survey results from 244 first-year student-respondents at the Nelson Mandela School of Medicine at the University of KwaZulu-Natal in South Africa. Exploratory factor analysis was conducted to verify scale constructs in the questionnaire. Relationships between independent and dependent variables were investigated in an analysis of variance. RESULTS: The average scores for the items measured varied between 3.3 and 3.8 (scale value 1 indicated negative regard and 5 indicated positive regard). Among process measures, approximately two-thirds of students felt that learning in a group was neither frustrating nor stressful and that they enjoyed learning how to work with students from different social and cultural backgrounds. Among content measures, 80% of the students felt that they learned to work successfully with students from different social and cultural groups and 77% felt that they benefited from the input of other group members. Mean ratings on these measures did not vary with students' gender, age, first language, prior educational training, and the types of schools they had previously attended. DISCUSSION AND CONCLUSION: Medical students of the University of KwaZulu-Natal, regardless of their backgrounds, generally have positive perceptions of small group learning. These findings support previous studies in highlighting the role that small group tutorials can play in overcoming cultural barriers and promoting unity and collaborative learning within diverse student groups.

Can students differentiate between PBL tutors with different tutoring deficiencies?

Many medical schools evaluate the performance of their tutors by using questionnaires. One of the aims of these evaluations is to provide tutors with diagnostic feedback on strong and weak aspects of their performance. Although everyone will agree that students are able to distinguish between poor and excellent tutors, one can question whether students are also able to differentiate between tutors with different tutoring deficiencies--tutors who perform badly on a specific key aspect of their performance. The aim of this study was to investigate to what degree students are able to differentiate between tutors with different tutoring deficiencies, how effective tutors are with different deficiencies and what kind of tips students give for improvement of a tutor's behaviour. Based on students' ratings on a tutor evaluation questionnaire, tutors were ranked in groups with different deficiencies and the average overall tutor performance score was computed for each group with a particular deficiency. In addition, students' tips for improvement given in the open-ended question at the end of the questionnaire were analysed. The results demonstrated that on average one out of five tutors showed a deficiency on only one key aspect. Tutors who did not stimulate students towards active learning were perceived as least effective. Furthermore, students' tips for improvement could be categorized into four groups: tutors who do not evaluate adequately, tutors who are too directive, tutors who are too passive and tutors who lack content knowledge. The results of this study demonstrate that students are not only able to distinguish between poor and excellent tutors, but are also able to diagnose tutors with different tutoring deficiencies and are able to provide tutors with specific feedback to improve their performance.

Providing physicians with feedback on how they supervise students during patient contacts.

In this descriptive study an instrument is presented that has been developed to provide physicians with feedback about their strengths and weaknesses in facilitating student learning during patient contacts. The instrument is strongly theory based, i.e. it is based on current general theories of context-bound learning environments, and forms of facilitation promoting transfer of knowledge to actual professional practice. In addition, it has been developed in cooperation with physicians supervising students during patient contacts. The authors have shown how physicians can be provided with individualized feedback on their performance in supervising students during patient contacts.

From quality assurance to total quality management: how can quality assurance result in continuous improvement in health professions education?

CONTEXT: Quality assurance is a hot topic in many institutes for higher education. Quality assurance is a cyclic process, consisting of three steps: measuring, judging and improving. Many institutes in higher education collect data about the quality of their educational programme on a regular basis and with proper frequency, but these evaluative data are not always used to improve the quality of the programme. PURPOSE: The aim of this article is to demonstrate which conditions need to be fulfilled to ensure that quality assurance is a cyclic process resulting in continuous improvement. CONCLUSIONS: Quality assurance can only be successful, i.e. result in continuous improvement, if three conditions are met: the evaluation activities are carried out in (1). a systematic and (2). structural fashion and (3). are integrated in the organization's regular work patterns. Parts of the system for quality assurance at the Maastricht Medical School are presented to demonstrate how the three conditions can be realized in practice.

Students' perceptions of relationships between some educational variables in the out-patient setting.

BACKGROUND: Medical education uses the cognitive apprenticeship model of student learning extensively. Students rotate among different hospitals and out- patient clinics where they are exposed to a range of professionally relevant contexts. Here they learn to think and act in different domains under the supervision of experts. Previous research has shown that these learning situations involve little teaching. Students see a narrow range of patient problems and feedback is limited. The aim of this study is to investigate relationships among some educational variables in the out-patient clinic. METHOD: This paper provides a theoretical model that specifies the factors influencing the effectiveness of student rotations at out-patient clinics. The model makes distinctions between input variables, such as organizational quality, number of students contemporaneously involved and available space, and process variables, such as patient mix and supervision, and the output variable of the effectiveness of rotations in out-patient clinics. RESULTS: The model was tested against empirical data from evaluative surveys and showed a reasonable fit. The model offers suggestions for improving the learning environment of clinical rotations. DISCUSSION: The strength of this study lies in its process evaluation perspective which investigates interactions between intervening variables rather than the influence of particular variables in isolation from other variables.

Solving problems with group work in problem-based learning: hold on to the philosophy.

INTRODUCTION: Problem-based learning (PBL) has gained a foothold within many schools in higher education as a response to the problems faced within traditional education. DISCUSSION: Working with PBL tutorial groups is assumed to have positive effects on student learning. Several studies provide empirical evidence that PBL stimulates cognitive effects and leads to restructuring of knowledge and enhanced intrinsic interest in the subject matter. However, staff members do not always experience the positive effects of group work which they had hoped for. When confronted with problems in group work, such as students who only maintain an appearance of being actively involved and students who let others do the work, teachers all too often implement solutions which can be characterized as teacher- directed rather than student-directed. Teachers tend to choose solutions which are familiar from their own experience during professional training, i.e. using the teacher-directed model. These solutions are not effective in improving group work and the negative experiences persist. CONCLUSION: It is argued that teachers should hold on to the underlying educational philosophy when solving problems arising from group work in PBL, by choosing actions which are consistent with the student-directed view of education in PBL.

Testing a causal model for learning in a problem-based curriculum.

The aim of this study was to identify the relationship between elements that are important for the tutorial group process and the individual learning process in a problem-based curriculum. The variables under investigation were student-generated learning issues, individual learning process, reporting in the tutorial group, and achievement.A questionnaire containing 22 items was developed. Data were collected in the first year (N = 195) of the Medical School of the Maastricht University in the Netherlands during the academic year 1997-1998. The data were analysed using a structural modelling approach. The results indicate that the model fitted the data well. The path coefficients were moderately high, particular between the explanation-oriented approach and the depth of the reporting in the tutorial group. High path coefficients were also found between the depth of the reporting and achievement. In sum, the model gives insight into how important variables are related and it is recommended that data should be collected to test the model repeatedly.

Relationship of tutors' group-dynamics skills to their performance ratings in problem-based learning.

PURPOSE: A tutor's performance is often investigated as a stable teacher characteristic, isolated from the context in which the tutor functions. This study investigated the influence of a tutor's group-dynamics skills in differently functioning tutorial groups on performance ratings. METHOD: Students' ratings of tutors' performances collected from 75 tutorial groups at one school over four different academic years were compared with the independent variables, groups' cohesion scores and sponging scores (the degree to which some students let others do the work), and the intervening variable, tutors' group-dynamics skills. RESULTS: Tutors with strong group-dynamics skills were assigned mean tutor's-performance scores of 7.4 (SD = 0.8) and 8.2 (SD = 0.5), respectively, by groups scoring low and high on cohesion. Tutors with low group-dynamics skills were rated 7.0 (SD = 1.1) and 7.4 (SD = 1.1) by the same groups. The same pattern held for sponging scores. Tutors who had strong group-dynamics skills received mean tutor's-performance scores of 8.1 (SD = 0.6) and 7.4 (SD = 0.8), respectively, from groups with low and high sponging scores. Tutors with weak group-dynamics skills were scored 7.6 (SD = 1.0) and 6.9 (SD = 1.1) by the same groups. CONCLUSIONS: Tutors possessing group-dynamics skills were rated higher by students than were tutors who lacked these skills, irrespective of the quality of a tutorial group's performance. A tutor who evaluates tutorial-group function on a regular basis and makes appointments with students based on these evaluations is seen as performing better than a tutor who does not.

Students' perceptions of time spent during clinical rotations.

Some rotations during clinical education are characterized by a high number of hours spent per week in the hospital because students panicipate in a hospital on-call system, i.e. hours beyond usual working hours, e.g. at night. However, students complain about spending too many hours in the hospital on non-instructive activities. This study was undertaken to investigate differences among rotations in time spent in hospital, in on-call hours, in self-study and in non-instructive activities and to investigate the relationship between time spent on the various activities and the overall effectiveness as perceived by students. A questionnaire was administered to students at the end of various clinical rotations. Rotations differ considerably in time spent in hospital, on call (i.e. beyond usual working hours), on self-study and on non-instructive activities. In some rotations students report spending on average 18-20% of their time in the hospital on non-instructive activities. Furthermore, the numbers of hours spent in hospital do not correlate with the overall effectiveness as perceived by students, unless the numbers of hours spent in non-instructive activities are taken into account. The effectiveness of a rotation does not automatically improve if students spend more hours in hospital. The number of hours spent on non-instructive activities should be reduced in some rotations and should be kept as low as possible. Further research is needed to find out which activities are perceived as non-instructive.

Clerkship assessment assessed.

This article reviews consistent research findings concerning the assessment of clinical competence during the clerkship phase of the undergraduate medical training programme on issues of reliability, validity, effect on training programme and learning behaviour, acceptability and costs. Subsequently, research findings on the clinical clerkship as a learning environment are discussed demonstrating that the clinical attachment provides a rather unstructured educational framework. Five fundamental questions (why, what, when, how, who) are addressed to generate general suggestions for improving assessment on the basis of the evidence on assessment and clinical training. Good assessment requires a thoughtful compromise between what is achievable and what is ideal. It is argued that educational effects are eminently important in this compromise, particularly in the unstructured clinical setting. Maximizing educational effects can be achieved in combination with improvements of other measurement qualities of the assessment. Two concrete examples are provided to illustrate the recommended assessment strategies.

The impact of student-generated learning issues on individual study time and academic achievement.

OBJECTIVES: The aim of this study was twofold. The first question concerns the way students make use of the learning issues they generate (as strict guidelines or as global guidelines) and whether this changes across years of training. The second question concerned the relationship between the way students make use of learning issues and the time spent on individual study and achievement on two tests of knowledge. DESIGN: A questionnaire was developed, containing seven items that measured to what extent students study strictly according to the student-generated learning issues and six items that measured to what extent students study beyond the student-generated learning issues. The questionnaire also contained one question in which students had to estimate the mean time spent on individual study. Achievement was measured by two forms of tests of knowledge, a block test assessing course content and a progress test assessing long-term functional knowledge. SETTING: Medical School of Maastricht University, the Netherlands. SUBJECTS: Medical students (response=69%) from the problem-based curriculum at the Maastricht University. RESULTS: During their first year students study strictly according to the content of the learning issues, whereas in later years students studied more according to their own learning needs and interests. In addition, students who tended to study beyond the generated learning issues spent more time on individual study and achieved better on both tests. CONCLUSIONS: Students in a problem-based curriculum seem to become better self-directed learners during the years of training.

Profiles of effective tutors in problem-based learning: scaffolding student learning.

OBJECTIVES: Research on tutoring in problem-based learning has not focused so far on the variation in tutoring and how this variation can be interpreted by conceptions about effective tutoring. DESIGN: This study focuses on the profiles of tutors generated by means of an instrument, the so-called Tutor Intervention Profile (TIP), and tries to determine which profiles are more or less effective. The TIP contains four dimensions of tutor behaviour: (1) elaboration; (2) directing the learning process; (3) integration of knowledge; and (4) stimulating interaction and individual accountability. SETTING: The medical school of the University of Maastricht, The Netherlands. SUBJECTS: Sixty-seven tutors who run 67 tutorial groups across three units (courses) in the academic year 1996-97. RESULTS: It appeared that high, average and low performing tutors differ in their performance on each of the four dimensions of the TIP. Several different profiles of tutor performance could be distinguished, which were more or less effective. One group of tutors demonstrated a tutor intervention profile that was characterized as relying more on the use of expert knowledge, whereas another group of tutors was characterized as relying more on their abilities to stimulate the learning process in the tutorial group. The tutor intervention profile that was perceived by students as most effective showed high scores on each of the four dimensions, as expected. Notably, a tutor stressing the learning process in the tutorial group was perceived as more effective than a tutor stressing content (expert tutor). This is especially true for a relatively poor scoring tutor. CONCLUSIONS: The results of this study are consistent with research on human tutoring and research on tutoring in problem-based learning.

Tutor intervention profile: reliability and validity.

An instrument has been developed to provide tutors with feedback about their performance in problem-based tutorial groups. This questionnaire consists of 33 statements reflecting the behaviour of the tutor in the tutorial group when students analyse the case and generate learning issues and the behaviour of the tutor when students report back to the tutorial group about their self-study. The statements are grouped on theoretical dimensions found in the literature about co-operative learning and problem-based learning. This study focuses on the validity and the reliability of this instrument. Confirmatory factor analysis showed that a four-factor model showed a weak fit, whereas each separate factor fitted the data reasonably well. The four factors are: (1) elaboration; (2) directing the learning process; (3) integration of knowledge and (4) stimulating interaction and individual accountability. These factors were strongly correlated with the overall judgement of the tutor at the end of the unit, so the concurrent validity of this instrument was high. Generalizability studies indicated that the rating scales provide reliable information with a sample size of student responses falling within the range of real tutorial group sizes. The results of this study show that the instrument for providing tutors with feedback is valid and reliable. This questionnaire can be used in staff development activities and also provides needs assessment for faculty development.