Exploring the influence of context on feedback at medical school: a video-ethnography study.

Feedback in medical education is complicated by the multiple contexts within which learning occurs. However, feedback research in medical education has typically focused on information provided by tutors to students with limited exploration of the influence of context. This research seeks to address this gap by exploring the influence of multiple contexts upon feedback processes. Employing video-ethnography methodology we explored feedback in two common contexts for medical student learning: the simulated clinical environment and the medical workplace. Learning and teaching sessions were filmed in each of these contexts, capturing diverse feedback processes. Data were analysed for key themes using a Framework Analysis approach and similarities and differences between the two contexts identified. In total 239 distinct feedback episodes across 28 different teaching and learning sessions were captured, with feedback processes relating to the patient, practice, educational and institutional contexts observed. In this paper, we concentrate on key similarities and differences in feedback processes between the two contexts with respect to six themes: feedback interlocutors, interlocutor positioning, feedback types, feedback foci, feedback styles and feedback milieu. We argue that feedback is inextricably linked to the multiple contexts in which feedback is enacted. It is only by exploring these contextual influences that feedback can be understood more fully. With such understanding we should be better placed to develop interventions capable of improving the long elusive experience of successful feedback.

From theory to practice in learning about healthcare associated infections: reliable assessment of final year medical students' ability to reflect.

BACKGROUND: Healthcare associated infection affects 9% of patients admitted to hospital. One of the greatest challenges in addressing this problem is transferring theory to practice in relation to hand hygiene. Developing the ability to reflect can promote this transfer. This study illustrates how an instrument to assess the reflective ability of final year medical students was applied to the context of hand hygiene within the infection control cleanliness champion programme (CCP) and demonstrated inter-rater reliability at all three levels of reflection. The results suggest behaviour change in relation to practice. METHODS: One hundred and thirty two reflective accounts were used for this study, provided by 44 5th year medical students. Each student had written three reflective accounts for each part of the hand hygiene unit. Results show that the inter-rater agreement was consistently high for all three levels of reflection. However, the least consistent was at reflective level three. CONCLUSIONS: These results suggest that the students were able to link theory to practice following the completion of the CCP. It could also indicate that assessors might require more skills and knowledge to enable effective and consistent examination of all areas of reflection.

The different levels of learning about dying and death: an evaluation of a personal, professional and interprofessional learning journey.

BACKGROUND: Although dying and death are common in practice, medical and social work students receive limited teaching on this topic. In addition, they have minimal experience of each others' role in the process, yet respecting the roles of other professionals in this delicate area is paramount to the delivery of high standards of care. In an attempt to address this, a pilot interprofessional 3 hour dying and death workshop was developed for senior social work and medical students using a constructivist approach to explore their own personal, uniprofessional and interprofessional roles in the dying and death process. METHODS: An expert group of health care professionals designed the workshop through an iterative process. The participants evaluated the workshop in relation to the levels of their learning journey at two time points using a combination of Likert scales and free text. RESULTS: An afternoon workshop was created comprising a trigger exercise to ascertain the students' own feelings, simulation of the practical aspects relating to a patient's death (confirmation of death, death certification and last offices), and discussion about the grief process, followed by case studies to consolidate their learning and highlight the interprofessional aspect. Eleven final year social work students and 14 medical students in their fourth year took part. Participants felt they gained most from the interprofessional aspect of their learning journey and suggested other topics for interprofessional learning. All students would recommend the workshop to their colleagues. CONCLUSIONS: This undergraduate interprofessional pilot dying and death workshop was well received and enabled learning on three levels--personal, professional and interprofessional. It promoted a greater understanding of the role of each student's own profession and appreciation of the role of other professionals in the dying and death process.

Developing professional clinical skills for practice - the results of a feasibility study using a reflective approach to intimate examination.

OBJECTIVES: To develop a student-selected component (SSC) for junior medical students, to evaluate the feasibility of incorporating the development of skills in carrying out an intimate examination, whilst developing professional thinking skills using a reflective approach. SUBJECTS: The student selected component was designed for a maximum of 6 students over a 4-week period in Phase 2 (year 2 and 3) of the undergraduate medical curriculum. SETTING: The Clinical Skills Centre, the Faculty of Medicine Nursing and Dentistry, University of Dundee, Scotland, UK. METHODS: The SSC consisted of a weekly patient clerking from the ward, an analysis of the clinical and communication skills for any intimate examinations the patient would require, and practice using simulators and simulated patients. Students were supported by timed periods of structured reflection, which enabled them to discuss ethical issues and their own professional conduct related to carrying out an intimate examination. The SSC was evaluated on 3 levels; student satisfaction, learning professional thinking using a reflective approach, and observing behaviour change in relation to skill development, using a ward simulation exercise. RESULTS: The evaluation at the levels of student satisfaction, learning professional thinking and changes in behaviour associated with intimate examination demonstrated that the SSC had been well received by the students, who felt they had improved their skills in intimate examinations in the context of a ward simulation exercise, in parallel with their professional thinking skills. CONCLUSION: It is possible to develop the professional thinking of junior medical students at the same time as developing their technical competence in relation to intimate examinations. It may be advantageous to introduce students early to this reflective approach, using simulation to promote the integration of theory with practice.

Attributes of trainers for postgraduate training in general surgery--a national consensus.

BACKGROUND: The aim of this study was to obtain consensus amongst consultant surgeons on the attributes of a good surgical trainer that can be used to inform continuing professional development programmes for trainers. METHODS: good trainer attributes were generated from an intensive qualitative study using a participative inquiry process with consultant general surgeons and specialist registrars in the Tayside region. These good trainer attributes were then used as the basis of a modified Delphi study; the early rounds of the Delphi simultaneously sought participants' views concerning stated attributes and sought to generate new attributes. A final Delphi questionnaire was sent to all 180 consultant general surgeons in Scotland to identify consensus. RESULTS: The first two rounds of the Delphi process produced 45 attributes covering seven themes: interest in training, trainer as a team member, communication, receptiveness to trainee needs, trainer as a role model, reflection on practice and clinical and operative competence. The final survey identified significant consensus among surgeons. Clinical and operative competence achieved the highest consensus with 89.2% of surgeons believing it to be an essential attribute. CONCLUSIONS: The results indicate that there is consensus on the seven themes identified as essential for a trainer in general surgery. The recognition of the importance by trainers of non-surgical trainer attributes in the changed training structure is encouraging. Surgeons' level of awareness of their roles as a trainer will help inform the level and direction of trainer training and support required as part of a flexible and continuing developmental process.

Training specialist registrars in general surgery: a qualitative study in Tayside.

BACKGROUND: Owing to decreased hours of work and duration of training, there is a need to refashion the training of surgical specialist registrars (SpRs) in the United Kingdom. This requires more guidance for trainers, but consensus regarding good trainer attributes does not exist. This study describes the training practices of Tayside general surgical trainers working with SpRs and highlights good training practice involving technical and patient management skills. METHODS: 1) Semi-structured interviews carried out with eighteen consultant trainers and twelve SpRs, 2) Action inquiry (i.e. observations and dialogue with participants) during ward, theatre, outpatient clinic and other hospital-based settings with eleven consultant and SpRs pairs. RESULTS AND CONCLUSION: Participants reflected on multiple training episodes and evaluated their impact. Relatively positive or negative impacts on their skill learning, self-esteem and relationship with the trainee or trainer were described. These are presented and discussed in terms of their implications for equipping trainers with techniques for training registrars and those factors which have hindered the adoption of successful strategies.

The use of interprofessional peer examiners in an objective structured clinical examination: can dental students act as examiners?

OBJECTIVE: To assess whether final year dental students could act as reliable examiners within an Objective Structured Clinical Examination (OSCE) by comparison with results obtained by an experienced member of staff. DESIGN: A station testing examination of the mouth was included in the second year medical undergraduate summative OSCE examination. SETTING: Concurrently run in three different examination venues on the Ninewells Hospital campus. SUBJECTS: 147 medical students and 3 pairs (A, B, C) of examiners. Each examining pairing consisted of one member of staff and one dental student (blind to each other's marking). METHOD: A checklist of 13 tasks to be performed was provided to the examiners. One mark awarded for a completed task, no mark for no attempt at the task, and half a mark for attempt at task. RESULTS: Paired results were available for 125 medical students. Using Mann-Witney analysis, the non-parametric 95% confidence intervals for the difference in scores between the 3 paired teams were group A (-0.5, 0), group B (-0.5, 0.5), group C (-0.5, 0). In only 4 students (out of 125) did the difference between the individual pair differ by 2 or more marks. CONCLUSION: On the basis of this pilot study final year dental students may be used as examiners in OSCEs where basic technical skills are to be evaluated. This development from peer group teaching provides further evidence supportive of interprofessional education.

Hardware implementation of CMAC neural network with reduced storage requirement.

The cerebellar model articulation controller (CMAC) neural network has the advantages of fast convergence speed and low computation complexity. However, it suffers from a low storage space utilization rate on weight memory. In this paper, we propose a direct weight address mapping approach, which can reduce the required weight memory size with a utilization rate near 100%. Based on such an address mapping approach, we developed a pipeline architecture to efficiently perform the addressing operations. The proposed direct weight address mapping approach also speeds up the computation for the generation of weight addresses. Besides, a CMAC hardware prototype used for color calibration has been implemented to confirm the proposed approach and architecture.