Provoking a Conversation Around Students' and Supervisors' Expectations Regarding Workplace Learning.

Construct: This study presents a tool that can facilitate a conversation about students' and supervisors' expectations concerning responsibilities during workplace learning. Background: It is often unclear who is responsible for facilitating learning opportunities in the workplace. In order to increase learning opportunities, it is important that expectations are discussed and alignment is reached between the student's and supervisor's expectations. This study collected and interpreted validity evidence for a tool that aims to provoke such a conversation. Approach: Three types of validity evidence were collected: response process, content, and consequences evidence. Educational leaders, medical teachers, and students of four medical schools were involved. The data collection consisted of cognitive interviews, a modified Delphi approach (with three rounds of inquiry), completed tools, and narrative comments. Findings: This study showed that the expectations of most students and supervisors were not initially aligned. The conversation, for which the tool aims to be a catalyst, facilitated better alignment of expectations about responsibilities during workplace learning. Moreover, the students' perceived degree of consensus and satisfaction after the conversation were very high. Conclusions: This study underlined the relevance and usefulness of a tool that facilitates conversation about expectations regarding responsibilities, potentially enhancing learning opportunities at the workplace.

Supporting Students With Electronic Health Record-Embedded Learning Aids: A Mixed-Methods Study.

BACKGROUND: Students often perceive workplace-based learning as disconnected from what they learn in medical school. Interventions that deal with this issue regularly involve feedback and/or learning aids. Feedback has frequently been encouraged in previous research, whereas the use of aids is less understood. OBJECTIVE: This study aims to investigate the added value of learning aids in making the connection and enhancing the transfer of learning between medical school and workplace-based learning. METHODS: First-year students in postgraduate general practice training participated in a mixed-methods study. Within a quasi-experimental design, two conditions were investigated: (1) students having access to electronic health record (EHR)-embedded learning aids and feedback and (2) students only receiving feedback. Semistructured interviews were conducted and analyzed according to the thematic analysis approach. RESULTS: Forty-four students participated in this study. No significant difference was found between the two conditions (t42=-0.511, P=.61, 95% CI -4.86 to 2.90). Nevertheless, students used the aids frequently and found them useful. Given that the aids were familiar to students and contained practice-based instructions in an easily accessible format, they were perceived as feasible to use during workplace-based learning. They also appeared to stimulate transfer of learning, self-confidence, reflection, and interaction between student and supervisor. CONCLUSIONS: Access to EHR-embedded learning aids offers additional support during, but also before and after, patient encounters. The aids can be easily implemented into workplace-based learning.

A Qualitative Exploration of Multiple Perspectives on Transfer of Learning Between Classroom and Clinical Workplace.

Phenomenon: Transfer of learning between classroom and workplace appears to be difficult. Various conceptions about learning in either the classroom or the workplace exist among stakeholders, yet little is known about their conceptions of the transfer of learning between both settings. This study explored stakeholders' conceptions about transfer of learning between classroom-based learning and workplace practice. APPROACH: Homogeneous focus groups with students, medical teachers, and workplace supervisors were conducted using a constructivist grounded theory approach. FINDINGS: The 54 participants' conceptions mainly related to their beliefs about who was responsible for (a) preparing for transfer of learning, (b) being at the workplace and connecting back to classroom-based learning, and (c) reflecting on transfer of learning and continuing the process. A continuum was recognized between those who held medical teachers/workplace supervisors responsible and those who held students responsible. Insights: There appears to be a variety of conceptions about who is responsible for enabling the transfer process. These conceptions may influence learning and instructional activities. Hence, it may be necessary to make these beliefs explicit in order to better align stakeholders' conceptions. To this end, the conceptual framework created in this study may be a useful tool.

Enhancing the connection between the classroom and the clinical workplace: A systematic review.

INTRODUCTION: Although medical students are increasingly exposed to clinical experiences as part of their training, these often occur parallel with, rather than connected to, their classroom-based learning experiences. Additionally, students seem to struggle with spontaneously making the connection between these spheres of their training themselves. Therefore, this systematic review synthesized the existing evidence about educational interventions that aim to enhance the connection between learning in the classroom and its application in the workplace. METHODS: Electronic databases (AMED, CINAHL, EMBASE, ERIC, Medline, RDRB, PsycINFO and WoS) were screened for quantitative and qualitative studies investigating educational interventions that referenced a connection between the classroom and workplace-based experiences within undergraduate, graduate or postgraduate medical education. RESULTS: Three types of interventions were identified: classroom to workplace interventions, workplace to classroom interventions, and interventions involving multiple connections between the two settings. Most interventions involved a tool (e. g. video, flow chart) or a specific process (e. g. linking patient cases with classroom-based learning content, reflecting on differences between what was learned and how it works in practice) which aimed to enhance the connection between the two settings. DISCUSSION: Small-scale interventions can bring classroom learning and workplace practice into closer alignment. Such interventions appear to be the necessary accompaniments to curricular structures, helping bridge the gap between classroom learning and workplace experience. This paper documents examples that may serve to assist medical educators in connecting the classroom and the workplace.

4C/ID in medical education: How to design an educational program based on whole-task learning: AMEE Guide No. 93.

Medical education increasingly stresses that medical students should be prepared to take up multiple roles as a health professional. This requires the integrated acquisition of multiple competences such as clinical reasoning and decision making, communication skills and management skills. To promote such complex learning, instructional design has focused on the use of authentic, real-life learning tasks that students perform in a real or simulated task environment. The four-component instructional design model (4C/ID) model is an instructional design model that starts from the use of such tasks and provides students with a variety of learning tools facilitating the integrated acquisition of knowledge, skills and attitudes. In what follows, we guide the reader on how to implement educational programs based on the 4C/ID model and illustrate this with an example from general practice education. The developed learning environment is in line with the whole-task approach, where a learning domain is considered as a coherent, integrated whole and where teaching progresses from offering relatively simple, but meaningful, authentic whole tasks to more complex tasks. We describe the steps that were taken, from prototype over development to implementation, to build five learning modules (patient with diabetes; the young child with fever; axial skeleton; care for the elderly and physically undefined symptoms) that all focus on the integrated acquisition of the Canadian Medical Education Directives for Specialists roles in general practice. Furthermore, a change cycle for educational innovation is described that encompasses practice-based challenges and pitfalls about the collaboration between different stakeholders (students, developers and teachers) and the transition from traditional, fragmented and classroom-based learning to integrated and blended learning based on sound instructional design principles.

Can training improve laypersons helping behaviour in first aid? A randomised controlled deception trial.

BACKGROUND: There is limited evidence indicating that laypersons trained in first aid provide better help, but do not help more often than untrained laypersons. This study investigated the effect of conventional first aid training versus conventional training plus supplementary training aimed at decreasing barriers to helping. METHODS: The authors conducted a randomised controlled trial. After 24 h of conventional first aid training, the participants either attended an experimental lesson to reduce barriers to helping or followed a control lesson. The authors used a deception test to measure the time between the start of the unannounced simulated emergency and seeking help behaviour and the number of particular helping actions. RESULTS: The authors randomised 72 participants to both groups. 22 participants were included in the analysis for the experimental group and 36 in the control group. The authors found no statistically or clinically significant differences for any of the outcome measures. The time until seeking help (geometrical mean and 95% CI) was 55.5 s (42.9 to 72.0) in the experimental group and 56.5 s (43.0 to 74.3) in the control group. 57% of the participants asked a bystander to seek help, 40% left the victim to seek help themselves and 3% did not seek any help. CONCLUSION: Supplementary training on dealing with barriers to helping did not alter the helping behaviour. The timing and appropriateness of the aid provided can be improved. TRIAL REGISTRATION: The authors registered this trial at ClinicalTrials.gov as NCT00954161.

How competent do general practice residents feel and why?

BACKGROUND: General practice residency aims to produce competent general practitioners (GPs) who will practice independently, i.e. who demonstrate adequate levels of actual and self-perceived competence. PURPOSES: To measure self-perceived competence in GP residents at our institution and explore potential determinants. METHODS: We conducted a cross-sectional study of our GP residents. Self-perceived competence was measured in four domains. Independent variables included gender, postgraduate year, patient contacts, on-call duties, practice of specific tasks, self-assessed effort and knowledge. RESULTS: Between 1.6 and 37.8% of GP residents assessed their competence as less than average. Self-perceived competence was not consistently linked to any of the hypothesised factors. CONCLUSIONS: A significant proportion of residents reported less than satisfactory levels of self-perceived competence. Longitudinal studies should be conducted as well as qualitative studies focusing on the role of other factors in the development of high levels of self-perceived competence during general practice training.

Usable knowledge, hazardous ignorance - beyond the percentage correct score.

BACKGROUND: Little attention has been paid to the metacognitive ability of medical students. AIM: We used confidence marking to explore certainty of knowledge and ignorance. METHODS: One hundred and twenty-seven of 169 general practice trainees took part. Students sat a written multiple choice question (MCQ) test. Each answer was followed by a degree of certainty judgement. Answers attributed with a high degree of certainty were used to compute overall usable knowledge, hazardous ignorance, proportions of knowledge that is usable and of ignorance that is hazardous. The former variables were analysed according to MCQ score, year of training and gender. RESULTS: At a group level, the mean amount of usable knowledge on the MCQ was 21.13%, mean amount of hazardous ignorance on the MCQ was 5.21%, mean proportion of knowledge that was usable was 36.57%, mean proportion of ignorance that was hazardous was 14.32%. There were neither significant differences between highest and lowest quartiles of MCQ score, nor according to year of training. Men had higher levels of ignorance that is hazardous. CONCLUSION: A third of trainees' knowledge was partial. A sixth of their ignorance was hazardous. Confidence marking can aid formative assessment and could potentially be implemented into summative assessments.

Can ill-structured problems reveal beliefs about medical knowledge and knowing? A focus-group approach.

BACKGROUND: Epistemological beliefs (EB) are an individual's cognitions about knowledge and knowing. In several non-medical domains, EB have been found to contribute to the way individuals reason when faced with ill-structured problems (i.e. problems with no clear-cut, right or wrong solutions). Such problems are very common in medical practice. Determining whether EB are also influential in reasoning processes with regard to medical issues to which there is no straightforward answer, could have implications for medical education. This study focused on 2 research questions: 1. Can ill-structured problems be used to elicit general practice trainees' and trainers' EB? and 2. What are the views of general practice trainees and trainers about knowledge and how do they justify knowing? METHODS: 2 focus groups of trainees (n = 18) were convened on 3 occasions during their 1st year of postgraduate GP training. 2 groups of GP trainers (n = 11) met on one occasion. Based on the methodology of the Reflective Judgement Interview (RJI), participants were asked to comment on 11 ill-structured problems. The sessions were audio taped and transcribed and an adapted version of the RJI scoring rules was used to assess the trainees' reasoning about ill-structured problems. RESULTS: Participants made a number of statements illustrating their EB and their importance in clinical reasoning. The level of EB varied widely form one meeting to another and depending on the problem addressed. Overall, the EB expressed by trainees did not differ from those of trainers except on a particular ill-structured problem regarding shoulder pain. CONCLUSION: The use of focus groups has entailed some difficulties in the interpretation of the results, but a number of preliminary conclusions can be drawn. Ill-structured medical problems can be used to elicit EB. Most trainees and trainers displayed pre-reflective and quasi-reflective EB. The way trainees and doctors view and justify knowledge are likely to be involved in medical reasoning processes.

Effectiveness of nonresuscitative first aid training in laypersons: a systematic review.

STUDY OBJECTIVE: This study reviewed evidence on the effects of nonresuscitative first aid training on competence and helping behavior in laypersons. METHODS: We identified randomized and nonrandomized controlled trials and interrupted time series on nonresuscitative first aid training for laypersons by using 12 databases (including MEDLINE, EMBASE, and PsycINFO), hand searching, reference checking, and author communication. Two reviewers independently evaluated selected studies with the Cochrane Effective Practice and Organisation of Care Review Group quality criteria. One reviewer extracted data with a standard form and another checked them. In anticipation of substantial heterogeneity across studies, we elected a descriptive summary of the included studies. RESULTS: We included 4 studies, 3 of which were randomized trials. We excluded 11 studies on quality issues. Two studies revealed that participants trained in first aid demonstrated higher written test scores than controls (poisoning first aid: relative risk 2.11, 95% confidence interval [CI] 1.64 to 2.72; various first aid cases: mean difference 4.75, 95% CI 3.02 to 6.48). Two studies evaluated helping responses during unannounced simulations. First aid training improved the quality of help for a bleeding emergency (relative risk 25.94; 95% CI 3.60 to 186.93), not the rate of helping (relative risk 1.13; 95% CI 0.88 to 1.45). Training in first aid and helping behavior increased the helping rates in a chest pain emergency compared with training in first aid only (relative risk 2.80; 95% CI 1.05 to 7.50) or controls (relative risk 3.81; 95% CI 0.98 to 14.89). Participants trained in first aid only did not help more than controls (relative risk 1.36; 95% CI 0.28 to 6.61). CONCLUSION: First aid programs that also train participants to overcome inhibitors of emergency helping behavior could lead to better help and higher helping rates.

Introducing the concept of epistemological beliefs into medical education: the hot-air-balloon metaphor.

The authors draw attention to the need to introduce the concept of epistemological beliefs into medical education. Epistemological beliefs are the cognitions (i.e., understandings) individuals have on knowledge and knowing and determine how (new) knowledge is perceived and processed. Within educational psychology, three different frameworks have been used to study epistemological beliefs. The authors describe these three frameworks and discuss their applicability and their significance for phrasing and studying issues that intuitively seem essential to medical educators. The metaphor of a piloted hot-air balloon illustrates the different factors contributing to medical expertise: the hot-air balloon's basket symbolizes the well-organized knowledge base, the envelope (i.e., air bag) stands for the skills repertoire of the pilot, and the burners represent motivation, intelligence, and other noncognitive factors. The pilot needs to achieve sophisticated levels of epistemological beliefs and metacognitive skills to be able to reach the upper levels of expertise with his well-equipped balloon. The metaphor emphasizes the dynamic disposition of expertise and offers a visual framework for designing curricula, assessment procedures, and educational research projects. Future research into medical students' epistemological beliefs should focus on outcome measures that are relevant within the medical education setting, and must take into account a number of pitfalls and difficulties inherent both in the concept of epistemological beliefs and in research in medical education.

A computerized adaptive knowledge test as an assessment tool in general practice: a pilot study.

Advantageous to assessment in many fields, CAT (computerized adaptive testing) use in general practice has been scarce. In adapting CAT to general practice, the basic assumptions of item response theory and the case specificity must be taken into account. In this context, this study first evaluated the feasibility of converting written extended matching tests into CAT. Second, it questioned the content validity of CAT. A stratified sample of students was invited to participate in the pilot study. The items used in this test, together with their parameters, originated from the written test. The detailed test paths of the students were retained and analysed thoroughly. Using the predefined pass-fail standard, one student failed the test. There was a positive correlation between the number of items and the candidate's ability level. The majority of students were presented with questions in seven of the 10 existing domains. Although proved to be a feasible test format, CAT cannot substitute for the existing high-stakes large-scale written test. It may provide a reliable instrument for identifying candidates who are at risk of failing in the written test.