Reasons for why Medical Students Prefer Specific Sleep Management Strategies.

OBJECTIVES: Insomnia symptoms are common among medical students. This study explored the perspectives of medical students about which sleep management strategies to use. METHODS: Medical students responded to an online survey on their thoughts about the use of various sleep management strategies. RESULTS: Of the 828 respondents, 568 (69%) provided responses to questions about the most preferred strategies and 450 (54%) provided responses about their least preferred strategies. About 48.5% felt their insomnia symptoms were too mild to see a clinician and 23.9% did not think their symptoms warranted sleep medication. Over 40% of students could not avoid work before sleep, have consistent sleep/wake times, or engage in regular exercise because of their busy and inconsistent schedules. Approximately 40-60% could not improve their sleep environment (e.g. better heating and bed) because of the associated costs. Over 80% reported an inability to change their pre-sleep habits (e.g. using electronics close to bedtime, using bed for activities other than sleep or sex). Half of the students disliked relaxation techniques or felt they would not help. Around 30-50% did not believe that changing caffeine and/or alcohol intake would affect their sleep. CONCLUSIONS: Medical students may benefit from additional sleep education. Clinicians may need to discuss which strategies individual students prefer and modify their recommendations accordingly.

Supporting Bystanders and Other Staff Exposed to Negative Workplace Behaviour: Developing and Testing the IMO Intervention Framework in the Clinical Workplace.

Background: Medical student and health-care staff bullying remain international concerns. Our understanding about what might solve such problems is still developing. A common approach suggested for bystanders to bullying is that they challenge or "stand up" to the bully. At the same time, the considerable risks should they act (eg, verbal rebuke) are rarely acknowledged, and neither is the potential for considerable cognitive dissonance should they choose not to. Methods: Drawing on a substantial literature review, we developed an interventional program, initially with medical student bullying in mind, that generally employed a discourse for values cultivation. We implemented and evaluated this program through 6 cycles of action research methodology in 6 different departments of one tertiary teaching hospital. Data include individual interviews, discussions with key participants plus freehand comments from wider staff's workshop evaluations. Results: Alongside others, an early serendipitous finding was the "IMO" [Indirect, focus on Me, focus on Outcome] framework, intended for bystanders to student bullying. From using this framework, participants reported developing confidence in tackling negative behaviours, that interactions had better outcomes and that the workplace atmosphere felt more relaxed. It's use also significantly reduced cognitive dissonance. Encouragingly, participants went on to use IMO for staff-staff bullying incidents, and other common negative behaviours. We attribute IMO's utility to its memorability, simplicity and for catering to the many possible causes of bullying, including values issues, without perpetuating or creating conflict. Conclusion: The IMO framework is offered as a widely usable framework for all staff in a clinical environment - a useful addition to popular frameworks used in the clinical workplace, ideas from which might also help these be further refined. Further evaluation would establish whether IMO invites long-term change and its utility in other contexts.

Sleep Management Strategies Among Medical Students At the University of Otago.

OBJECTIVES: We aim to investigate factors which might affect the sleep of medical students, and how they currently manage their sleep. METHODS: An online survey was sent to medical students at the University of Otago. RESULTS: After adjusting for gender, ethnicity and age, depressive symptoms (Mild: odds ratio (OR) = 6.3; Moderate: OR = 18.1; Severe: OR = 15.6), and sleep hygiene (OR = 1.07) were associated with insomnia symptoms. Commonly endorsed strategies for sleep management by students were undertaking regular exercise (80.1%), having consistent sleep-wake time (71.3%), and limiting caffeine intake (70.3%). Few were willing to see a clinician (23.4%) or take medication (22.3%). Participants with insomnia symptoms were more likely to prefer limiting their alcohol intake (OR = 1.8), limiting daytime naps (OR = 1.5), seeing clinicians (OR = 1.9), and taking sleep medication (OR = 4.0), but less likely to prefer avoiding intense work (OR = .71) or minimizing using electronics (OR = .60) close to bedtime than those without insomnia symptoms. High sleep self-efficacy was associated with lower odds for having insomnia symptoms (OR = .74 (.70, .77)). CONCLUSIONS: Increased awareness and greater resources are needed to support the sleep health of medical students.

Medical students' experience of studying while working part-time and the effects of COVID-19.

AIMS: The costs of being a medical student are large and increasing, and many students need to work part-time to meet financial pressures. This study explores the impact that part-time extracurricular paid work during the academic year has on medical student wellbeing, their interactions with the curriculum, and the effect of COVID-19 on work in 2020. METHODS: An online survey in 2020 gathered demographic, quantitative and qualitative information from medical students and their work experiences. Descriptive statistics analysed quantitative data; qualitative data were analysed using qualitative content analysis. RESULTS: Of the 36% (n=530) of students who responded, 255 (49%) reported undertaking paid part-time work, with 59 (24%) reporting they would not be able to remain studying if they did not work. When interacting with the medical programme, 43% of students reported their work conflicted with scheduled medical school commitments, and 70% reported conflicts between work and individual study. COVID-19 disrupted 57% of paid work during the year. Impacts on students' wellbeing were both positive and negative. Positive aspects included developing new skills, self-confidence and resilience. Working also provided an escape from the study demands of the medical programme. Negative aspects were predominantly about the increased stress working had on students, specifically on the impact of paid work on their own health. CONCLUSIONS: Almost half of medical students work part-time while studying. Understanding the perceived implications that part-time work has on student education and wellbeing could help medical schools provide appropriate advice and pastoral support for their students.

New Zealand medical students' views of euthanasia/assisted dying across different year levels.

BACKGROUND: Previous studies report a majority of the general public support euthanasia/assisted dying (EAD), while a majority of doctors are opposed. In considering policy decisions about EAD, some may discount the views of doctors because they take them to be based on personal values or tradition, rather than reasons that the general public might share. One way to explore this notion is to examine whether medical students' views change during their medical education. The objective of this study was to learn how New Zealand medical students view EAD and whether students at different year levels have different views. METHODS: An on-line survey of undergraduate medical students was conducted asking whether they supported a law change to allow EAD. Quantitative data was analysed using unadjusted and multiple logistic regression. Thematic analysis was conducted with the qualitative data. RESULTS: A total of 326 students replied to the survey. The overall response rate was 28%. 65% of 2nd year students were supportive of EAD, compared to 39% in 5th year. The odds of 5th year students supporting a law change compared to 2nd year was 0.30 (95% CI: 0.15-0.60). The predominant themes found in the qualitative results indicate that medical students support or oppose EAD for reasons similar to those found in the wider debate, and that their views are influenced by a range of factors. However, several at all year levels cited an aspect of medical school as having influenced their views. This was mentioned by participants who were supportive of, opposed to, or unsure about EAD, but it was the type of influence most often mentioned by those who were opposed. CONCLUSIONS: The quantitative findings show students at the end of 5th year were less likely to support EAD than students at the end of 2nd year. We suggest that this difference is most likely due to their time in medical education. This suggests that the lower support found among doctors is in part related to medical education and medical work rather than age, personality, or social context. The qualitative findings indicate that this is not related to a particular educational experience at Otago Medical School but a range.

Measuring exposure to bullying and harassment in health professional students in a clinical workplace environment: Evaluating the psychometric properties of the clinical workplace learning NAQ-R scale.

Background: Instruments that measure exposure to bullying and harassment of students learning in a clinical workplace environment (CWE) that contain validity evidence are scarce. The aim of this study was to develop such a measure and provide some validity evidence for its use.Method: We took an instrument for detecting bullying of employees in the workplace, called the Negative Acts Questionnaire - Revised (NAQ-R). Items on the NAQ-R were adapted to align with our context of health professional students learning in a CWE and added two new factors of sexual and ethnic harassment. This new instrument, named the Clinical Workplace Learning NAQ-R, was distributed to 540 medical and nursing undergraduate students and we undertook a Confirmatory Factor Analysis (CFA) to investigate its construct validity and factorial structure.Results: The results provided support for the construct validity and factorial structure of the new scale comprising five factors: workplace learning-related bullying (WLRB), person-related bullying (PRB), physically intimidating bullying (PIB), sexual harassment (SH), and ethnic harassment (EH). The reliability estimates for all factors ranged from 0.79 to 0.94.Conclusion: This study provides a tool to measure the exposure to bullying and harassment in health professional students learning in a CWE.

From physiotherapy to the army: negotiating previously developed professional identities in mature medical students.

Professional identity formation, the process of transformation from lay person to doctor, is at the heart of medical education. Medical student cohorts can include students who enter medicine from a previous career, i.e. with developed professional identities and who are usually older and more mature. Students with previously developed professional identities may have specific challenges in negotiating their new 'doctor' identity. This study examined the development of professional identity in mature medical students who had a variety of previous careers prior to entering medical school. A narrative inquiry was undertaken using interviews of mature medical students with backgrounds that included physiotherapy, clinical physiology, public health and nutrition, and the armed forces. A narrative analysis was conducted combining both thematic and structural perspectives using linguistics and positioning theory as interpretive tools. Three main themes emerged that portray the development processes that arise in this cohort as they develop their medical professional identity: holding back aspects of the previous self; foregrounding aspects of the previous self; and developing new aspects towards forming a 'new' self. These themes and their implications are discussed in the context of current literature, highlighting some of the specific challenges that this cohort faces in developing their medical identity. We argue that dedicated faculty and student development be offered, exploring how professional identity formation in mature medical students can be facilitated and supported, so staff and students are better equipped to engage and shape mature students' professional identity in a meaningful way.

Interventions addressing student bullying in the clinical workplace: a narrative review.

BACKGROUND: Student bullying in the clinical environment continues to have a substantial impact, despite numerous attempts to rectify the situation. However, there are significant gaps in the literature about interventions to help students, particularly a lack of specific guidance around which to formulate an intervention program likely to be effective. With this narrative review about student bullying interventions in the clinical learning environment, we examine and draw together the available, but patchy, information about 'what works' to inform better practice and further research. METHODS: We initially followed a PICO approach to obtain and analyse data from 38 articles from seven databases. We then used a general inductive approach to form themes about effective student bullying intervention practice, and potential unintended consequences of some of these, which we further developed into six final themes. RESULTS: The diverse literature presents difficulties in comparison of intervention efficacy and substantive guidance is sparse and inconsistently reported. The final analytical approach we employed was challenging but useful because it enabled us to reveal the more effective elements of bullying interventions, as well as information about what to avoid: an interventionist and institution need to, together, 1. understand bullying catalysts, 2. address staff needs, 3. have, but not rely on policy or reporting process about behaviour, 4. avoid targeting specific staff groups, but aim for saturation, 5. frame the intervention to encourage good behaviour, not target poor behaviour, and 6. possess specific knowledge and specialised teaching and facilitation skills. We present the themed evidence pragmatically to help practitioners and institutions design an effective program and avoid instigating practices which have now been found to be ineffective or deleterious. CONCLUSIONS: Despite challenges with the complexity of the literature and in determining a useful approach for analysis and reporting, results are important and ideas about practice useful. These inform a way forward for further, more effective student bullying intervention and research: an active learning approach addressing staff needs, which is non-targeted and positively and skilfully administered. (331w).

"They cared about us students:" learning from exemplar clinical teaching environments.

PURPOSE: In order to foster positive student experiences in the clinical learning environment, we wanted to better understand which teaching practices they regard highly. METHODS: In 2016, the authors undertook a paper 'exemplar' survey (ES) of all fifth year medical students at one tertiary teaching site. Students had experienced all assigned clinical rotations over a two year period. Following a 66% response rate, we identified two clear exemplar clinical areas (ECAs). Over 2016-7, six focus groups with multidisciplinary staff members from these clinical areas were held, with the aim to identify, discuss and understand their specific teaching practices in more detail. RESULTS: The authors present descriptions of positive student experiences and related staff practices, in five themes. Themes emerged around foundational logistic and personal factors: central to student and staff data is that 'welcome' on a daily, and ongoing basis, can be foundational to learning. Central to ECA staff data are universal practices by which all staff purposefully work to develop a functional staff-student relationship and play a part in organising/teaching students. Students and ECA staff groups both understood teacher values to be central to student learning and that cultivating a student's values is one of their major educational tasks. CONCLUSIONS: The framework formed by this thematic analysis is useful, clear and transferrable to other clinical teaching contexts. It also aligns with current thinking about best supporting student learning and cultivating student values as part of developing professionalism. Instigating such practices might help to optimise clinical teaching. We also tentatively suggest that such practices might help where resources are scarce, and perhaps also help ameliorate student bullying.

It's 'probably the teacher!' A strategic framework for clinical staff engagement in clinical student bullying intervention.

BACKGROUND: Student bullying in clinical practice persists, and poor outcomes continue: for learning, academic achievement and career goals, for their mental and physical health and potentially affecting all staff and patients in a clinical workplace. We describe an emergent framework for the strategic design of a bullying intervention, presented as a staff development opportunity. METHODS: CAPLE (Creating A Positive Learning Environment) was a bullying intervention designed around current best evidence about ameliorating student bullying in the clinical environment. CAPLE was also an action research project delivered in two eight- week cycles, one in 2016 & another in 2017. CAPLE's primary practical foci were to offer clinical staff in two separate hospital wards an opportunity to develop their clinical teaching skills and to guide them in reflection and cultivation of values around students and learning. Research foci were: 1. to gain insight into staff experiences of CAPLE as a development process and 2. to evaluate how CAPLE might best help staff reflect on, discuss and develop values around student learning, to include bullying. Staff undertook five active learning workshops combined with supportive contact with one researcher over the research period. Data include individual interviews, staff and researchers' reflective journals and a paper survey about staff experiences of the 2017 intervention. RESULTS: We confirm the effectiveness of best evidence from the literature and also that a strategic four-part framework of approach, process, content and person can further enhance a bullying intervention by increasing the likelihood of participant engagement, learning and values change. CONCLUSIONS: This research aggregates and adds weight to the current literature about student bullying and adds important pragmatic detail about best practice for bullying intervention design and delivery. Ultimately, this emergent framework offers insight to help move past some persistent barriers encountered by those wishing to improve workplace behaviour.

Time to stop making things worse: an imperative focus for healthcare student bullying research.

Student bullying in clinical practice remains a concern, and evidence regarding what works to specifically help the student appears rather piecemeal. At the same time, emergent literature indicates that some bullying interventions can be ineffective for behaviour change, or even deleterious to the staff which they target. Considering the potentially sizeable financial and personal costs associated with continued bullying and undertaking an intervention, it would seem sensible that any selected intervention method avoids those shown to be potentially ineffective or deleterious. Such avoidance would likely help to move the student bullying research forward, prevent further suffering and reduce the waste of valuable taxpayer resources.

Medical students' experiences of practising medical procedures on patients, other students and themselves.

AIM: Development of proficient procedural skills is vital to the training of young doctors. The aim of this project was to investigate the prevalence of different ways that medical students practise clinical procedures and the relationship with professional development. METHODS: A survey was made available online to the cohort of years 4-6 medical students at the Otago Medical School, University of Otago. Quantitative and qualitative data were collected and analysed. Statistical methods and qualitative content analysis were employed in order to categorise and infer student responses. RESULTS: Two hundred and eighty-four of 816 (35%) students responded to the survey. A total of 23 categories of procedural skills were reported, demonstrating procedures with varying complexity and degrees of invasiveness. A small proportion, 5%, indicated they had performed invasive procedures on themselves, with a majority of these reported to be unsupervised. 77% of students reported being directly observed when performing procedures on patients for the first time, while 32% reported being supervised when practising on peers. CONCLUSION: Students practise clinical procedures on patients, peers and in some cases themselves. Our findings suggest a need for clearer guidelines in the support and management of the safe practice of students, be it on patients, other students or on themselves.

That's not what you expect to do as a doctor, you know, you don't expect your patients to die." Death as a learning experience for undergraduate medical students.

BACKGROUND: Experiencing the death of a patient can be one of the most challenging aspects of clinical medicine for medical students. Exploring what students' learn from this difficult experience may contribute to our understanding of how medical students become doctors, and provide insights into the role a medical school may play in this development. This research examined medical students' responses of being involved personally in the death of a patient. METHOD: Ten undergraduate medical students were followed through their three years of clinical medical education. A total of 53 individual semi-structured interviews were conducted. Grounded theory analysis was used to analyze the data. RESULTS: Students illustrated a variety of experiences from the death of a patient. Three main themes from the analysis were derived: (i) Students' reactions to death and their means of coping. Experiencing the death of a patient led to students feeling emotionally diminished, a decrease in empathy to cope with the emotional pain and seeking encouragement through the comfort of colleagues; (ii) Changing perceptions about the role of the doctor, the practice of medicine, and personal identity. This involved a change in students' perceptions from an heroic curing view of the doctor's role to a role of caring, shaped their view of death as a part of life rather than something traumatic, and resulted in them perceiving a change in identity including dampening their emotions; (iii) Professional environment, roles and responsibilities. Students began to experience the professional environment of the hospital by witnessing the ordinariness of death, understanding their role in formalizing the death of a patient, and beginning to feel responsible for patients. CONCLUSIONS: Along with an integrative approach to facilitate students learning about death, we propose staff development targeting a working knowledge of the hidden curriculum. Knowledge of the hidden curriculum, along with the role staff play in exercising this influence, is vital in order to facilitate translating the distressing experiences students face into worthwhile learning experiences. Finally, we argue that student learning about death needs to include learning about the social organization and working life of clinical settings, an area currently omitted from many medical education curricula.

Communities of clinical practice and normalising technologies of self: learning to fit in on the surgical ward.

This paper reports observational research of Fourth Year medical students in their first year of clinical training doing their surgical attachment. Previously, the authors have argued that medical curricula constitute normalising technologies of self that aim to create a certain kind of doctor. Here, they argue that a key mechanism through which these normalising technologies are exercised in the workplace is Etienne Wenger's communities of practice. In the clinical environment the authors identify communities of clinical practice (CoCP) as groups of health professionals that come together with the specific and common purpose of patient care. Fourth Year medical students join these transient communities as participants who are both peripheral and legitimate. Communities of clinical practice are potent vehicles for student learning. They learn and internalise the normative professional values and behaviours that they witness and experience within the disciplinary block of the medical school and teaching hospital; specifically, the authors suggest, it is through their participation in communities of clinical practice that medical students learn how to 'be one of us'.

Teaching and learning in the hospital ward.

AIM: To explore ways in which student learning during formal ward rounds can be enhanced. METHOD: Qualitative study of University of Otago medical students (Dunedin, New Zealand) involving observation of surgical teams during formal ward rounds, and indepth interviews with students and consultant surgeons. RESULTS: Teaching and learning opportunities on ward rounds were often missed by both clinical teachers and students as service provision and patient care took precedence. As a result, students often felt excluded and frequently expressed ambivalence about the educational value of formal whole team ward rounds. Students were more likely to consider themselves part of the team when they felt useful and were included in team discussions about patient care. They reported that they learned more effectively on smaller, more educationally focussed ward rounds that incorporated bedside tutorials and opportunities to practice examination skills. CONCLUSION: Students and clinical teachers know that students need to make the most of learning opportunities by being proactive, spending time on the ward, being useful, asking questions. Clinical staff can facilitate student learning by consciously including students in the business of patient care. This means inviting students to ask questions and examine wounds, physically guiding hands on examinations, encouraging students to pay attention to discussions among the clinical team, and explaining what is being discussed.

"You can do it late at night or in the morning. You can do it at home, I did it with my flatmate." The educational impact of an OSCE.

BACKGROUND: The use of an objective structured clinical examination (OSCE) has been a powerful influence on doctor training but assessments do not always drive study behaviour in predictable ways. AIMS: To investigate the impact an OSCE has on study behaviours by exploring how 5th year medical students identify what to learn for a summative OSCE and the role of the clinical environment in their preparation. METHODS: A semi-structured questionnaire survey asked about strategies used by students to prepare for the OSCE. Focus group interviews explored successful methods of preparation for the OSCE. Themes were identified and classified. RESULTS: The questionnaire response rate was 84%. Topic identification was usually from the list of examinable problems, past OSCE papers and a booklet prepared by a previous student containing a series of OSCE checklists. The study behaviours of students preparing for the OSCE exam were predominantly to practise on each other, and to rehearse routines. Strategic and efficient study habits were favoured over conscious utilization of the clinical environment. CONCLUSION: The expectation that an OSCE drives learning into the clinical workplace was not supported by this study. This suggests the role of clinical experience in helping students prepare for the exam may be more subliminal, or that an OSCE is more as a test of psychomotor skills than a marker of clinical experience. An unexpected benefit may be to drive more collaborative learning.