Evaluation of a pilot "registrar-as-teacher" faculty development program at Stellenbosch University

Smit, Elizabeth Johanna (2014-12)

Thesis (MPhil)--Stellenbosch University, 2014.

Thesis

ENGLISH ABSTRACT: A. Background - Registrars play a significant role as teachers for undergraduate medical students and junior doctors in the clinical setting. (Jack et al. 2010; Busari & Scherpbier 2004). Many however teach ineffectively as registrars are rarely taught how to teach (Morrison et al. 2002, Busari et al. 2002; Thomas et al. 2002). This has prompted a number of universities to implement “Registrar-as-Teacher” training programs as part of faculty development (FD) initiatives (Leslie et al. 2014; Post et al. 2009, Hill et al. 2009). Although available evidence has demonstrated a positive impact of these programs on the teaching performance of registrars, large differences exist in the interventions, curricula content and participant characteristics. Few studies identified a conceptual framework that informed the design. Most studies focused on a quantitative approach to evaluate outcome; ignoring contextual factors that may shape the successful implementation of new knowledge and skills gained. At Tygerberg Hospital, education is a key performance area of registrar’s staff performance management agreement but no formal training program for registrars as teachers exists. The Centre for Health Professions Education at Stellenbosch University thus piloted a half-day workshop for newly appointed registrars from various disciplines with the aim to develop the clinical supervision skills of registrars as clinical educators. B. Research Design and Methodology - The overall aim of this study was to evaluate the outcome of a pilot “Registrar-as-Teacher” workshop at the University of Stellenbosch. The specific objectives included: - To evaluate registrar perceived relevance of workshop content - To evaluate registrar self-evaluation of teaching practices - To identify factors affecting the teaching practices of registrars - To observe and evaluate registrar teaching practices in the clinical setting - To increase the “Registrar-as-Teacher” workshop effectiveness A two-phased mixed method design was used, using semi-structured interviews and observation of registrars. Phase one comprised of semi-structured interviews to elicit both numerical and text-based data. Phase two included observer ratings to further explore the application of knowledge, skills and attitudes gained. The “Registrar-as-Teacher” program content was informed by the teaching roles described by Harden and Crosby (2000). As educational strategy, Knowles’ adult learning theory (1980) was applied. The study was conducted at Tygerberg Hospital, a Stellenbosch University Faculty of Health Sciences affiliated teaching hospital in Cape Town, South Africa. The study population included newly appointed registrars (year 1 and 2) from the Departments of Internal Medicine, Paediatrics, Obstetrics and Gynaecology, Surgery, and Orthopaedics. An inductive approach was used to analyze the qualitative data. Demographic, registrar self- evaluations and workshop evaluation data was analyzed using descriptive statistics. This study was approved by the Health Research Ethics Committee of Stellenbosch University (protocol number S13/10/177). C. Results - Seven of the fifteen registrars attending the pilot workshop agreed to take part in phase 1 of the study; five from the Department of Paediatrics and Child Health, and one from Surgery and Obstetrics & Gynaecology respectively. Five agreed to take part in phase 2 of the study; all from the Department of Paediatrics and Child Health. Participants reported satisfaction with the program and experienced the workshop as a positive learning experience (Kirkpatrick level 1). Participants self-reported positive changes in attitudes, including motivation, self-confidence, enthusiasm, and conceptions of teaching. Knowledge and skills were gained, as self-reported and observed. Individual benefits such as increased self-awareness of teaching ability and increased awareness of student needs were reported (Kirkpatrick level 2). Participants self-reported behavior changes in their teaching practices. Participants, bar one, demonstrated appropriate educational practices and teaching skills (Kirkpatrick level 3). Participants in our study reported their expanded conceptions of the roles of a teacher as one of the most useful aspects of the workshop. Role modelling was singled out as the most useful session. Participants generally had a positive view on their contribution to student learning. They saw it as a formative influence on how students view the profession and discipline. Unique aspects of registrar teaching were highlighted as being more informal in nature, more practice orientated; and working in a closer relationship with students; thus complementary to the consultant teaching role. Participants recognized that they are still developing their clinical teaching skills. Most participants rely on observed teaching methods or borrow from their own experiences as students. Participants based their self-assessment of being a good teacher on their personal views that mirrored their conceptions of a good teacher; seldom asking for or receiving feedback on their teaching skills to shape their own learning or performance as clinical teachers. Most participants in our study asked for regular or follow up training where they could reflect on their development and also receive feedback on progress made. Few participants felt comfortable to give feedback to students or to use the ‘one-minute preceptor’ compared to other aspects of clinical teaching. Our FD program’s session on teaching in the clinical setting and the ‘one-minute preceptor’ thus worked less well. This speaks to how to increase the effectiveness of future workshops. Even though all participants enjoyed teaching students, reported barriers to effective teaching were many. Participants often felt frustrated and overwhelmed by their teaching task. Limited time with competing responsibilities such as huge service demands and administrative duties impacted negatively on participants’ ability to teach students. Participants mostly felt unsupported and undervalued as teachers by their various departments, with little guidance on the expected student teaching content, process or learning outcomes. Although the expectation to teach is clearly communicated by the various departments, there is no training, supervision structure, formative feedback, or appreciation of their teaching performance. This lack of orientation and communication was further highlighted by participants pointing to the explanation of the MBChB undergraduate curriculum structure as the second most useful component of the course after role modelling. D. Conclusion and Recommendations - Our study confirmed the important role of registrars as teachers in the clinical setting. Apart from sharing theoretical and on-the-job knowledge, registrars teach practical skills and act as role models for the profession. Participants perceived the pilot “Registrar-as-Teacher” workshop content as relevant and the workshop shaped their teaching conceptions and practices. But workplace barriers like limited time with competing responsibilities impacted negatively on participants’ ability to teach students. A reported lack of guidance and support from the respective departments further undermined their ability to develop as clinical teachers. Future “Registrar-as-Teacher” FD initiatives at Stellenbosch University should thus provide registrars with optimal approaches and best teaching practices for busy clinical settings; enabling them to merge teaching with work. Strengthening FD requires the adoption of a broader conceptual framework that does not just focus on the individual participant, but link FD to the development of the department or institution as a whole (Swanwick & McKimm 2012). Workplace communities that include departmental faculty members should be involved in FD programs; allowing for ongoing learning and professional development of registrars as clinical teachers (O’Sullivan & Irby 2011; Steinert et al. 2010; Webster-Wright 2009; Hunter et al. 2008; Thorndyke et al. 2006). This requires a longitudinal strategy. Our “Registrar-as-Teacher” FD program should thus move away from the one-time workshop and instead create multiple learning events with opportunities for application and reflection.

AFRIKAANSE OPSOMMING: A. Agtergrond - Kliniese Asssistente (KAs) speel ‘n belangrike rol as onderwysers vir voorgraadse studente en junior dokters in die kliniese omgewing (Jack et al. 2010; Busari & Scherpbier 2004). Baie gebruik egter oneffektiewe onderrigmetodes omdat hulle selde opleiding ontvang oor onderrig (Morrison et al. 2002, Busari et al. 2002; Thomas et al. 2002). Verskeie universiteite het die probleem aangespreek deur “KA-as-Onderwyser” opleidingsprogramme as deel van hul Fakulteitsontwikkelings inisiatiewe te loots (Leslie et al. 2014; Post et al. 2009, Hill et al. 2009). Alhoewel beskikbare bewyse dui op ‘n positiewe impak van die programme op die onderrig prestasies van Kliniese Assistente, kom groot verskille voor in die intervensies, kurrikulum inhoud en deelnemer eienskappe. Min studies het sover ‘n konseptuele raamwerk geidentifiseer wat die studie ontwerp belig. Meeste studies fokus ook op slegs ‘n kwantitatiewe benadering as evalueringsuitkoms; en ignoreer die kontekstuele faktore wat die suksesvolle implementering van nuwe kennis en vaardighede mag beinvloed. By Tygerberg Hospitaal is onderrig ‘n sleutel prestasie area vir Kliniese Assistente se personeel prestasie bestuur ooreenkoms, maar geen formele opleidingsprogram vir KAs bestaan nie. Die Sentrum vir Gesondheidsberoepe Onderwys by Stellenbosch Universiteit het dus ‘n halfdag werkswinkel geloots vir nuutaangestelde KAs van verskeie departemente met die doel om hul kliniese supervisie vaardighede te ontwikkel. B. Navorsingontwerp en Metodiek - Die oorkoepelende doel van die studie was om die uitkoms van die nuwe “KA-as-Onderwyser” werkswinkel by die Universiteit van Stellenbosch te evalueer. Die spesifieke doelwitte het ingesluit: - Om die KAs se relevansie van die werkswinkel inhoud te evalueer - Om KAs se self-evaluasie van hul onderrigpraktyke te evalueer - Om faktore te identifiseer wat onderrigpraktyke van KAs beinvloed - Om KAs se onderrigpraktyke in die kliniese omgewing te observeer en te evalueer - Om die effektiwiteit van die “KA-as-Onderwyser” werkswinkel te verbeter. ‘n Twee-fase gemengde metodiek ontwerp is gebruik wat die gebruik van semi- gestruktureerde onderhoude en observasies van KAs ingesluit het. Fase een het bestaan uit semi- gestruktureerde onderhoude om beide numeriese en teks-data te ontlok. Fase twee het ingesluit observasies en gradering van onderrig aktiwiteite om die toepassing van nuwe kennis, vaardighede en houdings te verken. Die “KA-as-Onderwyser” program inhoud is deur die onderwyser rolle soos beskryf deur Harden en Crosby (2000) toegelig. As onderrigstrategie is Knowles se volwasse leerteorie (1980) toegepas. Die studie is uitgevoer by Tygerberg Hospitaal, ‘n Stellenbosch Universiteit Fakulteit van Geneeskunde en Gesondheidswetenskappe geaffilieerde onderrighospitaal. Die studie populasie het ingesluit nuutaangestelde KAs (jaar 1 en 2) van die Departemente Interne Geneeskunde, Pediatrie, Obstetrie en Verloskunde, Chirurgie en Ortopedie. ‘n Induktiewe benadering is gevolg om die kwalitatiewe data te analiseer. Demografiese, KA self- en geobserveerde evaluasies, en werkswinkel evaluasie data is met behulp van beskrywende statistiese metodes geanaliseer. Die studie is goedgekeur deur die Gesondheids Navorsings Etiese Komitee van Stellenbosch Universiteit (protokol nommer S13/10/177). C. Resultate Sewe van die vyftien KAs wat die werkswinkel bygewoon het, het ingestem om deel te neem aan fase 1 van die studie; vyf van die Departement van Pediatrie en Kindergesondheid, en een elk van Chirurgie en Obstetrie en Verloskunde. Vyf het ingestem om deel te wees van fase 2 van die studie; almal van die Departement van Pediatrie en Kindergesondheid. Deelnemers was gelukkig met die program en het die werkswinkel as ‘n positiewe leerervaring beskryf (Kirkpatrick vlak 1). Deelnemers het positiewe veranderinge in houding, insluitend motivering, selfvertroue, entoesiasme, en opvattings van onderrig rapporteer. Beide selfbeskrywende en geobserweerde kennis en vaardighede is uitgebrei. Individuele voordele soos verhoogde self bewustheid van onderrig vermoeens en verhoogde bewustheid van studentbehoeftes is gerapporteer (Kirkpatrick vlak 2). Deelnemers het veranderinge in hul onderrig praktyke rapporteer. Alle deelnemers, behalwe een, het ook toepaslike onderrig praktyke en onderrig vaardighede demonstreer (Kirkpatrick vlak 3). Deelnemers van ons studie het die nuwe opvattings oor hul rol as kliniese onderwysers as een van die waardevolste aspekte van die werkswinkel beskryf. Rolmodellering was uitgesonder as die mees waardevolste sessie. Deelnemers het in die algemeen ‘n positiewe siening van hul bydrae tot studente onderrig gehad. Hulle sien dit as ‘n formatiewe invloed op hoe studente die mediese professie en spesifieke dissiplines beskou. Unieke aspekte van KA onderrig wat uitgelig is was die meer informele aard van hul onderrig, dat dit meer prakties georienteerd is, en dat hul ‘n nouer verhouding met studente het; dus ‘n komplementere rol tot die onderrig rol van die konsultant. Deelnemers erken dat hul steeds ontwikkel as kliniese onderwysers. Meeste deelnemers maak staat op geobserweerde onderrigmetodes of leen van hul eie ervarings as student. Deelnemers baseer hul siening oor hulself as goeie onderwysers op hul persoonlike siening van ‘n goeie onderwyser en vra selde terugvoer oor hul onderrig praktyke om sodoende hul eie leer en prestasie as kliniese onderwysers te vorm. Meeste deelnemers in ons studie het egter gevra vir gereelde en opvolg opleiding sodat hulle oor hul eie onderrig praktyke kan reflekteer. Min deelnemers was gemaklik om terugvoer aan studente te gee of om die ‘one-minute preceptor’ strategie te gebruik in vergelyking met ander onderrig strategiee. Ons werkswinkel sessie oor onderrig en strategiee in die besige kliniese omgewing was dus minder suksesvol en sal in toekomstige werkswinkels aangespreek moet word. Alhoewel deelnemers studente onderrig oor die algemeen geniet, is baie hindernisse tot effektiewe studente onderrig beskryf. Deelnemers voel dikwels gefrustreerd en oorweldig deur hul onderrig taak. Min tyd, met kompeterende verantwoordelikhede soos dienslewering en administratiewe pligte beinvloed onderrig negatief. Deelnemers rapporteer dat hul nie voldoende ondersteuning ontvang van hul verskeie departemente nie, en voel ondergewaardeer as onderwysers. Min leiding word verskaf oor verwagte studente leeruitkomste, prosesse of kennis wat oorgedra moet word. Alhoewel die verwagting dat KAs moet onderrig gee duidelik gekommunikeer word deur die verskeie departemente, vind geen opleiding, supervisie of terugvoer oor hul prestasies plaas nie. Hierdie gebrek aan orientering en kommunikasie was verder uitgelig deurdat deelnemers die verduideliking van die MBChB voorgraadse kurrikulum struktuur as die waardevolste sessie naas rolmodellering beskryf het. D. Opsomming en Aanbevelings - Ons studie bevestig die belangrike rol van KAs as onderwysers in die kliniese omgewing. Behalwe dat teoretiese en praktiese kennis en vaardighede geleer word, tree hul ook as rolmodelle vir die mediese professie op. Deelnemers het die “KA-as-Onderwyser” werkswinkel inhoud as relevant beskou en rapporteer dat dit hul onderrig opvattings en praktyke positief beinvloed het. Werksplekhindernisse soos beperkte tyd en kompeterende verantwoordelikhede beinvloed onderrig van studente egter negatief. ‘n Gerapporteerde gebrek aan leiding en ondersteuning van hul onderskeie departemente ondermyn verder KAs se ontwikkeling as kliniese onderwysers. Toekomstige “Kliniese Assistent-as-Onderwyser” Fakulteitsontwikkelings-inisiatiewe by Stellenbosch Universiteit moet dus KAs voorsien van optimale strategiee en onderrig praktyke om werk en onderrig suksesvol te kan kombineer. Om Fakulteitsontwikkelings-inisiatiewe verder te versterk, moet ‘n breer konseptuele raamwerk aanvaar word wat nie net fokus op die individuele deelnemer nie, maar wat Fakulteitsontwikkeling koppel aan die ontwikkeling van departemente en instansies (Swanwick & McKimm 2012). Werksplek gemeenskappe wat departementele konsultante insluit, moet betrokke wees by Fakulteitsontwikkeling om KAs in staat te stel om professioneel te ontwikkel as kliniese onderwysers (O’Sullivan & Irby 2011; Steinert et al. 2010; Webster-Wright 2009; Hunter et al. 2008; Thorndyke et al. 2006). Hierdie vra vir ‘n longitudinale strategie. Ons “KA-as-Onderwyser” Fakulteitsontwikkelingsprogram moet weg beweeg van eenmalige werkswinkels en eerder veelvuldige leergeleenthede skep met geleenthede vir toepassing en refleksie.

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