Effects of a Nudging Cue Targeting Food Choice in a University Cafeteria: A Field Study.

Many students approaching adulthood often choose high-calorie food products. Concurrently, health interventions applied during this life phase can potentially lead to a healthier lifestyle. Nudge health interventions in experimental cafeteria settings have been found to improve eating behavior effectively, yet research in real-world settings is lacking. Accepting nudges as health interventions impacts nudge effectiveness. The present study applies a pretest-posttest design for a period of three consecutive weeks (no nudge, nudge, no nudge), testing the effectiveness of the so-called Giacometti cue on the number of calories purchased in a real-world cafeteria. Students were exposed to the nudge during the intervention week when entering the cafeteria and when choosing their meals. After purchasing a meal, their choice was recorded, and they completed a questionnaire. The Giacometti cue immediately reduced the number of calories purchased (comparing weeks one and two). After nudge removal, an effect was identified, increasing the number of calories purchased (comparing weeks two and three). Contrary to expectations, higher nudge acceptance resulted in more calories purchased. Neither awareness of the nudge's presence when buying food nor the interaction between acceptance and awareness played a role. We explore potential explanations for the Giacometti cue's effects.

Are You "Nudgeable"? Factors Affecting the Acceptance of Healthy Eating Nudges in a Cafeteria Setting.

Research has identified nudging as a promising and effective tool to improve healthy eating behavior in a cafeteria setting. However, it remains unclear who is and who is not "nudgeable" (susceptible to nudges). An important influencing factor at the individual level is nudge acceptance. While some progress has been made in determining influences on the acceptance of healthy eating nudges, research on how personal characteristics (such as the perception of social norms) affect nudge acceptance remains scarce. We conducted a survey on 1032 university students to assess the acceptance of nine different types of healthy eating nudges in a cafeteria setting with four influential factors (social norms, health-promoting collaboration, responsibility to promote healthy eating, and procrastination). These factors are likely to play a role within a university and a cafeteria setting. The present study showed that key influential factors of nudge acceptance were the perceived responsibility to promote healthy eating and health-promoting collaboration. We also identified three different student clusters with respect to nudge acceptance, demonstrating that not all nudges were accepted equally. In particular, default, salience, and priming nudges were at least moderately accepted regardless of the degree of nudgeability. Our findings provide useful policy implications for nudge development by university, cafeteria, and public health officials. Recommendations are formulated for strengthening the theoretical background of nudge acceptance and the susceptibility to nudges.

When theory joins practice: A design-based research approach for leader identity development.

INTRODUCTION: Inclusive educational leaders promote teacher team functioning. To support leader inclusiveness, we designed and implemented a faculty development programme focusing on leader identity formation. We investigated (1) how participants' leader identity developed throughout the programme and (2) how the design principles contributed to this process, according to participants. METHODS: A design-based research approach was followed. Participants were 7 course coordinators, leading an interdisciplinary teacher team. To study leader identity development, participants repeatedly filled out a validated questionnaire. To investigate how design principles contributed, observational field notes, facilitator debriefings, a programme evaluation questionnaire and a semi-structured focus group were used. Thematic analysis was applied for qualitative data. RESULTS: Participants gained broader views on leadership, moving from individual dominance towards engaging team members. Most participants initially experienced a deconstruction of their former leader identity and became motivated to improve leadership qualities. Competence-building, reflecting and receiving feedback on workplace experiences, and practicing in a safe environment were perceived to be key for identity development. CONCLUSIONS: We developed and evaluated a leader identity programme which can convert teachers' classic leadership views towards views incorporating social interactions and relationships. We demonstrated how social interactions provide opportunities to learn from pe.ers in the work environment.

Cafeteria Online: Nudges for Healthier Food Choices in a University Cafeteria-A Randomized Online Experiment.

Many people do not consume as much healthy food as recommended. Nudging has been identified as a promising intervention strategy to increase the consumption of healthy food. The present study analyzed the effects of three body shape nudges (thin, thick, or Giacometti artwork) on food ordering and assessed the mediating role of being aware of the nudge. Students (686) and employees (218) of a German university participated in an online experimental study. After randomization, participants visited a realistic online cafeteria and composed a meal for themselves. Under experimental conditions, participants were exposed to one out of three nudges while choosing dishes: (1) thin body shape, (2) thick body shape, and (3) the Giacometti artwork nudge. The Giacometti nudge resulted in more orders for salad among employees. The thin and thick body shape nudges did not change dish orders. Awareness of the nudge mediated the numbers of calories ordered when using the Giacometti or thin body shape nudges. These findings provide useful insights for health interventions in occupational and public health sectors using nudges. Our study contributes to the research on the Giacometti nudge by showing its effectiveness when participants are aware (it is effective under conditions where it is consciously perceived).

Enhancing Team Learning through Leader Inclusiveness: A One-Year Ethnographic Case Study of an Interdisciplinary Teacher Team.

PHENOMENON: Developing modern medical curricula requires collaboration between different scientific and clinical disciplines. Consequently, institutions face the daunting task to engage colleagues from different disciplines in effective team collaboration. Two aspects that are vital to the success of such teamwork are "team learning behavior" by all team members and "leader inclusiveness behavior" by the team leader. Team members display team learning behavior when they share information, build upon and integrate each other's viewpoints. The team leader can promote such team learning by exhibiting inclusiveness behavior, which aims to encourage diversity and preserve individual differences for an inclusive workplace, nurturing engagement in teamwork. There is a paucity of in-depth research on leader inclusiveness behavior in the field of medical education. This case study aimed to offer unique insight into how leader inclusiveness behavior manifests itself in a successful interdisciplinary teacher team, demonstrating team learning behavior in undergraduate medical education. APPROACH: We conducted a qualitative, ethnographic case study using different but complementary methods, including observations, interviews and a documentary analysis of email communication. By means of purposive sampling, we selected an existing interdisciplinary teacher team that was responsible for an undergraduate medical course at Maastricht University, the Netherlands, and that was known to be successful. Chaired by a physician, the team included planning group members and tutors with medical, biomedical, and social sciences backgrounds as well as student-representatives. In the course of one academic year, 23 meetings were observed and recorded, informal interviews were conducted, and over 100 email conversations were collected. All data were submitted to a directed content analysis based on team learning and leader inclusiveness concepts. FINDINGS: Leader inclusiveness behavior became evident from verbal and non-verbal interactions between the team leader and team members. Leader inclusiveness behavior that facilitated team learning behavior manifested itself in five actions undertaken by the team leader: coordinating, explicating, inviting, connecting, and reflecting. Similarly, team members facilitated team learning behavior by participating actively, speaking up behavior, and mimicking leader inclusiveness behavior. These behaviors demonstrated engagement and feelings of inclusion, and reinforced leader inclusiveness behavior by creating additional opportunities for the leader to exhibit such behavior. INSIGHTS: This case study responds to the need for inclusive leadership approaches in medical education. Our findings build upon theoretical knowledge on team learning and leader inclusiveness concepts. By studying behaviors, interactions and documents we obtained in-depth information on leader inclusiveness. Our findings are unique in that they demonstrate how leader inclusiveness behavior manifests itself when leaders interact with their team members. This study provides health professionals who are active in education with practical suggestions on how to act as a successful and inclusive leader. Finally, the behaviors identified open up avenues for future professional development initiatives and future research on team leadership.Supplemental data for this article is available online at here.

Working beyond disciplines in teacher teams: teachers' revelations on enablers and inhibitors.

INTRODUCTION: Health professions education faces transitions from monodisciplinary to integrated education and from soloist teachers to interdisciplinary teacher teams. Interdisciplinary teamwork has been found complex and prone to conflict. Teachers' perceptions of why some teams work and learn as a real interdisciplinary team and others do not are lacking in this setting. We studied the factors that teachers perceive as enabling and/or inhibiting interdisciplinary team learning. METHODS: In this exploratory, qualitative study, we conducted 17 semi-structured, vignette-guided interviews with teachers recruited from diverse disciplines in undergraduate health professions programmes at Maastricht University, the Netherlands, through maximum variation sampling. Team learning research informed data collection and template analysis. RESULTS: We identified three themes representing the factors that teachers perceived to influence interdisciplinary team learning: 'alignment/misalignment with the educational philosophy' (regarding personal attributes, tendencies and motivation), 'leadership practices' (encompassing team vision, responsibility and reflection), and 'involvement in organisational processes' (covering organisational decision-making, support and learning opportunities). For interdisciplinary team learning in development of integrated education, teachers emphasised their personal ability to move beyond disciplinary boundaries. Shared team leadership enabled the creation of a shared vision, shared responsibility, and team reflection. Lastly, teacher involvement in educational management, peer support and learning was considered important. DISCUSSION: To work beyond disciplines in health professions education, teachers should take an interest in integrated education, share responsibility and work in an environment where people continuously learn from others. Organisations can facilitate this by involving teachers in decision-making processes and providing faculty development aimed to foster shared leadership and team reflection.

How Teachers Meet in Interdisciplinary Teams: Hangouts, Distribution Centers, and Melting Pots.

PURPOSE: To explore team learning processes among interdisciplinary teacher teams in the development of integrated health professions education and to investigate students' perspectives on the quality of the educational courses. METHOD: Using an exploratory, sequential mixed-methods design, the first author conducted 17 vignette-guided, semistructured interviews with teachers originating from diverse disciplines. These teachers worked in different courses of integrated, undergraduate health professions programs at the Faculty of Health, Medicine and Life Sciences, Maastricht University, the Netherlands. The interview guide and vignettes were based on team learning research. The interviews sought to establish how interdisciplinary teacher team members work together on integrated curricula. The vignettes reflected constructs of team learning processes: sharing, co-construction, and constructive conflict. Data were collected between November 2017 and March 2018 and analyzed using template analysis. Sequentially, course evaluation data were used to provide a descriptive analysis of students' perspectives on educational quality (course organization, structure, learning effect, and alignment). RESULTS: Three team approaches were identified. In fragmented teams or "hangouts," teachers individually worked on tasks that they were interested in, leaving their disciplinary mark. Framework-guided teams or "distribution centers" aimed to work within the given frameworks and organizational expectations, striving for disciplinary balance. Integrated teacher teams or "melting pots" used an interdisciplinary approach on all topics and put students at the center. Integrated teams reflected high-level team learning processes and were most satisfied with their (team)work. In contrast, fragmented and framework-guided teams mainly reflected low-level team learning processes. Students evaluated courses of integrated teacher teams highest on all investigated quality items (course organization, structure, learning effect, and alignment). CONCLUSIONS: Successful interdisciplinary teacher teams are represented by an integrated approach with high-level team learning behavior and the best course evaluations. Therefore, health professions education management should actively encourage and facilitate integrated teacher teamwork.

Interprofessional team management in pediatric critical care: some challenges and possible solutions.

BACKGROUND: Aiming for and ensuring effective patient safety is a major priority in the management and culture of every health care organization. The pediatric intensive care unit (PICU) has become a workplace with a high diversity of multidisciplinary physicians and professionals. Therefore, delivery of high-quality care with optimal patient safety in a PICU is dependent on effective interprofessional team management. Nevertheless, ineffective interprofessional teamwork remains ubiquitous. METHODS: We based our review on the framework for interprofessional teamwork recently published in association with the UK Centre for Advancement of Interprofessional Education. Articles were selected to achieve better understanding and to include and translate new ideas and concepts. FINDINGS: The barrier between autonomous nurses and doctors in the PICU within their silos of specialization, the failure of shared mental models, a culture of disrespect, and the lack of empowering parents as team members preclude interprofessional team management and patient safety. A mindset of individual responsibility and accountability embedded in a network of equivalent partners, including the patient and their family members, is required to achieve optimal interprofessional care. Second, working competently as an interprofessional team is a learning process. Working declared as a learning process, psychological safety, and speaking up are pivotal factors to learning in daily practice. Finally, changes in small steps at the level of the microlevel unit are the bases to improve interprofessional team management and patient safety. Once small things with potential impact can be changed in one's own unit, engagement of health care professionals occurs and projects become accepted. CONCLUSION: Bottom-up patient safety initiatives encouraging participation of every single care provider by learning effective interprofessional team management within daily practice may be an effective way of fostering patient safety.

Culture Matters in Successful Curriculum Change: An International Study of the Influence of National and Organizational Culture Tested With Multilevel Structural Equation Modeling.

PURPOSE: National culture has been shown to play a role in curriculum change in medical schools, and business literature has described a similar influence of organizational culture on change processes in organizations. This study investigated the impact of both national and organizational culture on successful curriculum change in medical schools internationally. METHOD: The authors tested a literature-based conceptual model using multilevel structural equation modeling. For the operationalization of national and organizational culture, the authors used Hofstede's dimensions of culture and Quinn and Spreitzer's competing values framework, respectively. To operationalize successful curriculum change, the authors used two derivates: medical schools' organizational readiness for curriculum change developed by Jippes and colleagues, and change-related behavior developed by Herscovitch and Meyer. The authors administered a questionnaire in 2012 measuring the described operationalizations to medical schools in the process of changing their curriculum. RESULTS: Nine hundred ninety-one of 1,073 invited staff members from 131 of 345 medical schools in 56 of 80 countries completed the questionnaire. An initial poor fit of the model improved to a reasonable fit by two suggested modifications which seemed theoretically plausible. In sum, characteristics of national culture and organizational culture, such as a certain level of risk taking, flexible policies and procedures, and strong leadership, affected successful curriculum change. CONCLUSIONS: National and organizational culture influence readiness for change in medical schools. Therefore, medical schools considering curriculum reform should anticipate the potential impact of national and organizational culture.

Why supervisors should promote feedback-seeking behaviour in medical residency.

BACKGROUND: Individual disposition of goal orientation and situational factors of the working context, both generate and modulate motives to seek feedback. AIM: We looked for correlations between feedback-seeking and individual goal orientation, motives or concerns of feedback-seeking, working context of medical residents. We focussed on how promotion of feedback-seeking by supervisors and educational environment influenced motives and behaviours of feedback-seeking in residents. METHODS: Web-based administration of a Likert-type composite questionnaire to residents of a tertiary care teaching hospital in Switzerland and mini-interviews. RESULTS: Fifty-six (45%) of 125 residents completed the questionnaire. After multiple regression analysis promotion of feedback-seeking through supervisors remained the sole predictor correlating with feedback-seeking through inquiry (R(2) = 16) and the motive of self-improvement (R(2) = 0.30). This predictor was also associated with reduced concerns of ego-protection (R(2) = 0.14) and impression-defence (R(2) = 0.18). Performance-avoid goal orientation was associated with concerns of impression-defence (R(2) = 0.36) and ego-protection (R(2) = 0.48). Women had significantly more concerns of ego-protection, residents with more than three years of experience more concerns of impression-defence. Disillusion that PG-training would ever improve, seemed the main reason to refuse participation CONCLUSIONS: Promotion of feedback-seeking through supervisors combined with delivery of high quality feedback may guide residents towards seeking feedback for professional self-improvement.

A medical school's organizational readiness for curriculum change (MORC): development and validation of a questionnaire.

PURPOSE: Because successful change implementation depends on organizational readiness for change, the authors developed and assessed the validity of a questionnaire, based on a theoretical model of organizational readiness for change, designed to measure, specifically, a medical school's organizational readiness for curriculum change (MORC). METHOD: In 2012, a panel of medical education experts judged and adapted a preliminary MORC questionnaire through a modified Delphi procedure. The authors administered the resulting questionnaire to medical school faculty involved in curriculum change and tested the psychometric properties using exploratory and confirmatory factor analysis, and generalizability analysis. RESULTS: The mean relevance score of the Delphi panel (n = 19) reached 4.2 on a five-point Likert-type scale (1 = not relevant and 5 = highly relevant) in the second round, meeting predefined criteria for completing the Delphi procedure. Faculty (n = 991) from 131 medical schools in 56 countries completed MORC. Exploratory factor analysis yielded three underlying factors-motivation, capability, and external pressure-in 12 subscales with 53 items. The scale structure suggested by exploratory factor analysis was confirmed by confirmatory factor analysis. Cronbach alpha ranged from 0.67 to 0.92 for the subscales. Generalizability analysis showed that the MORC results of 5 to 16 faculty members can reliably evaluate a school's organizational readiness for change. CONCLUSIONS: MORC is a valid, reliable questionnaire for measuring organizational readiness for curriculum change in medical schools. It can identify which elements in a change process require special attention so as to increase the chance of successful implementation.

Impact of national context and culture on curriculum change: a case study.

BACKGROUND: Earlier studies suggested national culture to be a potential barrier to curriculum reform in medical schools. In particular, Hofstede's cultural dimension 'uncertainty avoidance' had a significant negative relationship with the implementation rate of integrated curricula. AIMS: However, some schools succeeded to adopt curriculum changes despite their country's strong uncertainty avoidance. This raised the question: 'How did those schools overcome the barrier of uncertainty avoidance?' METHOD: Austria offered the combination of a high uncertainty avoidance score and integrated curricula in all its medical schools. Twenty-seven key change agents in four medical universities were interviewed and transcripts analysed using thematic cross-case analysis. RESULTS: Initially, strict national laws and limited autonomy of schools inhibited innovation and fostered an 'excuse culture': 'It's not our fault. It is the ministry's'. A new law increasing university autonomy stimulated reforms. However, just this law would have been insufficient as many faculty still sought to avoid change. A strong need for change, supportive and continuous leadership, and visionary change agents were also deemed essential. CONCLUSIONS: In societies with strong uncertainty avoidance strict legislation may enforce resistance to curriculum change. In those countries opposition by faculty can be overcome if national legislation encourages change, provided additional internal factors support the change process.

Improving lecture skills: a time-efficient 10-step pedagogical consultation method for medical teachers in healthcare professions.

BACKGROUND: Staff development initiatives proposed over the past few decades have, for the most part, suggested training environments such as workshops, short courses and seminar series. However, for many healthcare professionals, lecturing constitutes an ancillary activity, and a full-time occupation in the healthcare industry makes participation in such time-consuming programmes difficult to envision. AIM: To develop and offer for critical review a time-efficient pedagogical consultation method to improve lecture skills for medical teachers of healthcare professions. METHODS: Medical education literature was reviewed for factors known to facilitate successful pedagogical consultations. The result of this research was used to define the procedure of a consultation methodology. In subsequent trial runs, the consultation procedure was tested with eight healthcare professionals hired for lecturing in bachelor courses of healthcare professions. RESULTS: The key elements of successful pedagogical consultations were isolated in the literature, and a 10-step consultation method was developed based on specific methodological components. Eight trial runs indicated feasibility, time-efficiency and effectiveness of the method. CONCLUSION: The pedagogical consultation method presented here can help teachers to improve their lecture skills. It is a feasible model which can be easily adopted by medical educators to support staff development activities.

How interdisciplinary teams can create multi-disciplinary education: the interplay between team processes and educational quality.

CONTEXT: Many undergraduate medical education programmes offer integrated multi-disciplinary courses, which are generally developed by a team of teachers from different disciplines. Research has shown that multi-disciplinary teams may encounter problems, which can be detrimental to productive co-operation, which in turn may diminish educational quality. Because we expected that charting these problems might yield suggestions for addressing them, we examined the relationships between team diversity, team processes and course quality. METHODS: We administered a questionnaire to participants from 21 interdisciplinary teams from 1 Dutch and 1 German medical school, both of which were reforming their curriculum. An adapted questionnaire on team learning behaviours, which had been validated in business contexts, was used to collect data on team processes, team learning behaviours and diversity within teams. We examined the relationship between the team factors and educational quality measures of the courses designed by the teams. RESULTS: A total of 84 teachers (60%) completed the questionnaire. Bivariate correlation analysis showed that several aspects of diversity, conflict, working climate and learning behaviour were correlated with course quality. CONCLUSIONS: The negative effects of the diversity measures, notably, value diversity, on other team processes and course quality and the positive association between psychological safety and team learning suggest that educational quality might be improved by enhancing the functioning of multi-disciplinary teams responsible for course development. The relationship between team processes and educational quality should be studied among larger study populations. Student ratings should also be considered in measuring educational quality.

Trends in research on the tutor in problem-based learning: conclusions and implications for educational practice and research.

The tutor role in problem-based learning (PBL) has attracted the interest of many researchers and has led to an abundance of studies. This article reports on major trends in studies investigating the tutor during the past 10 years. Three major trends were observed by the authors while analysing the studies conducted: studies on the differential influence of content expert and non-content expert tutors on student achievement, studies on process variables, and studies on the relationship between tutor characteristics and differential contextual circumstances. The aim of this article is to summarize the main findings of the studies conducted so far within the three trends observed, to provide directions for educational practitioners and policy makers, and to suggest directions for future research questions. The studies included were selected by conducting a literature search in medical journals, which was complemented with the personal archives of the authors. The results of the studies conducted within the three trends of research have led to advanced insights in tutoring. The outcomes revealed that content expert tutors tend to use their subject-matter expertise more to direct the discussion in the tutorial group, whereas non-content expert tutors tend to use their process-facilitation expertise more to direct the tutorial group. Furthermore, a tutor's performance is not a stable characteristic but is partly situation specific. It is concluded that a tutor should both know how to deal with the subject matter expertise and should know how to facilitate the learning process. Faculty and policy makers should put substantial efforts into designing curricula and cases and developing tutors' skills by faculty development strategies that stimulate reflection. The research agenda should be driven more by modern educational theories of learning in which tutoring is a process aimed at stimulating constructive, self-directed, situated and collaborative learning by students. Furthermore, more qualitative studies should be conducted to gain better insights in teachers' conceptions about the tutor role and student learning to better understand their behaviours.