Unpacking Medical Students’ Mixed Engagement in Health Systems Science Education

Abstract

Phenomenon: Medical education is better aligning with the needs of health systems. Health systems science competencies, such as high-value care, population health, and systems thinking, are increasingly being integrated into curricula, but not without challenges. One challenge is mixed receptivity by students, the underlying reasons of which have not been extensively explored. In this qualitative study, we explored the research question: “How do students perceive health systems science curricula across all four years, and how do such perceptions inform the reasons for mixed quality ratings?” Approach: Following large-scale health systems science curricular changes in their medical school, we used students’ open-ended comments obtained from course evaluations related to 1^st-, 2^nd-, and 4^th-year courses and performed a qualitative thematic analysis to explore students’ perceptions. We identified themes, synthesized findings into a conceptual figure, and agreed upon results and quotations. Findings: Five themes were identified: (1) perceived importance and relevance of health systems science education, (2) tension between traditional and evolving health systems science-related professional identity, (3) dissatisfaction with redundancy of topics, (4) competition with basic and clinical science curricula, and, (5) preference for discrete, usable, testable facts over complexity and uncertainty. The relationship between themes is described along a continuum of competing agendas between students’ traditional mindset (which focuses on basic/clinical science) and an emerging medical education approach (which focuses on basic, clinical, and health systems science). Insights: Health systems science education can be viewed by learners as peripheral to their future practice and not aligned with a professional identity that places emphasis on basic and clinical science topics. For some students, this traditional identity limits engagement in health systems science curricula. If health systems science is to achieve its full potential in medical education, further work is required to explore the adoption of new perspectives by students and create activities to accelerate the process.     

Systems-Based Practice: The Sixth Core Competency

Systems-Based Practice (SBP) is the sixth competency defined by the Accreditation Council for Graduate Medical Education (ACGME) Outcome Project. Specifically, SBP requires "Residents [to] demonstrate an awareness of and responsiveness to the larger context and system of health care and the ability to effectively call on system resources to provide care that is of optimal value." This competency can be divided into four subcompetencies, all of which are integral to training emergency medicine (EM) physicians: resources, providers, and systems; cost-appropriate care; delivery systems; and patient advocacy. In March 2002, the Council of Emergency Medicine Residency Directors (CORD-EM) convened a consensus conference to assist residency directors in modifying the SBP competency specific for EM. The Consensus Group modified the broad ACGME definition for SBP into EM-specific goals and objectives for residency training in SBP. The primary assessment methods from the Toolbox of Assessment Methods were also identified for SBP. They are direct observation, global ratings, 360-degree evaluations, portfolio assessment, and testing by both oral and written exams. The physician tasks from the Model of the Clinical Practice of Emergency Medicine that are most relevant to SBP are out-of-hospital care, modifying factors, legal/professional issues, diagnostic studies, consultation and disposition, prevention and education, multitasking, and team management. Suggested EM residency curriculum components for SBP are already in place in most residency programs, so no additional resources would be required for their implementation. These include: emergency medical services and administrative rotations, directed reading, various interdisciplinary and hospital committee participation, continuous quality improvement project participation, evidence-based medicine instruction, and various didactic experiences, including follow-up, interdisciplinary, and case conferences. With appropriate integration and evaluation of this competency into training programs, it is likely that future generations of physicians and patients will reap the benefits of an educational system that is based on well-defined outcomes and a more systemic view of health care.     

Integrating Climate Change in the Curriculum: Using Instructional Design Methods to Create an Educational Innovation for Nurse Practitioners in a Doctor of Nursing Practice Program

An applied epidemiology course for doctor of nursing practice students was revised to include a module on the impact of climate change on population health. The Analyze, Design, Develop, Implement, and Evaluate (ADDIE) model of instructional design is a gold standard framework for creating course content and guided the module development. A nurse content expert discussed the environmental impacts of climate change on health using literature, actual clinical scenarios, and the application of epidemiologic data. Topics included safeguarding workers and vulnerable populations within the context of the coronavirus disease 2019 pandemic. Students posted reflections on their understanding of module content in response to structured prompts electronically in the learning management system for review by the faculty. Faculty evaluation of responses identified the need to further develop and integrate environmental epidemiology and climate change content more fully within the doctor of nursing practice curriculum.     

Systems Survivor: A Program for House Staff in Systems-Based Practice

Background: The Systems-Based Practice competency expanded the scope of graduate medical education. Innovative approaches are needed to teach this material.

Purpose: We have designed and implemented a rotation in Systems-Based Practice focused on the interrelationships of patient care, clinical revenue, and the physician's role within health care systems.

Methods: Experiential learning occurs during a 5-day rotation through 26 areas encompassing the clinical revenue cycle, guided by “expert” staff. Using a reversal of the TV show Survivor, house staff begin conceptually “alone” and discover they are members of a large, dedicated team. Assessment results, including a system knowledge test and course evaluations, are presented.

Results: Twenty-five residents from four clinical departments participated in Year 1. An increase in pretest to posttest knowledge scores of 14.8% (p ≤ 0.001) was observed, with high program evaluations.

Conclusions: “Systems Survivor” is successful in providing an innovative opportunity to explore complex health care systems and is an effective curriculum.     

护生临床实习健康教育效果评价表的设计和应用

为提高护生的健康教育能力,弥补临床护理人员不足导致的健康教育不到位,制定了护生临床实习健康教育效果评价表并将之应用到临床。通过一年多的实践证明,健康教育评价表的使用大大提高了护生的沟通能力、主动服务意识、自信心和责任感,同时也合理利用了人力资源,使健康教育覆盖率达100%,患者满意度大幅度提高。     

持续质量改进在骨科专科护士临床实践教学中的应用

目的探讨骨科专科护士临床实践教学质量持续改进的方法和效果。方法对广州军区广州总医院举办的全军骨科专科护士培训班临床实践期的教学质量进行持续改进,通过教学质量评分、满意度调查及专业考核通过率等指标对持续改进的效果进行评价。结果对第1期及经持续质量改进的第2、3、4期培训班的教学质量进行评估,2、3、4期培训班教学质量总分较1期明显提高,差异有统计学意义(P0.05)。对4个子项进行比较,4期培训班在环境中的实践单元工作和教学环境得分、大纲落实中的出科考试制度和教学查房制度落实得分差异有统计学意义(均P0.05)。4期培训班在教学安排满意度、临床带教小教员总体满意度、毕业考核通过率呈上升趋势,2、3、4期与1期相比差异有统计学意义(P0.05),2、3、4期间差异无统计学意义(P0.05)。结论通过持续质量改进方法的实施,骨科专科护士临床实践教学质量在学员考核通过率、教学安排质量、带教老师授课质量等方面有不同程度的提高,值得推广应用。     

The national continuous quality improvement tool for mental health education: Results of targeted and supported implementation in England

The national continuous quality assurance tool for mental health education and training has recently been developed. This paper describes the planned implementation of the tool across NHS Workforce Development Confederations (WDCs) in England. Large stakeholder groups in 15 WDCS were convened. The groups rated 29 programmes across a range of provisions including pre-qualifying programmes (social work and mental health nursing), post-qualifying programmes, new graduate mental health worker programmes and programmes run within NHS Trusts. Overall, the results indicate that the majority of rated programmes are relevant to the policy agenda and involve service users in a meaningful way. However, courses are less likely to engage with carers and to assess the impact of the programmes. Key factors are identified that promote the implementation of the new quality assurance tool and key barriers to implementation are also elicited. The paper concludes that the tool can provide a useful framework to assess the quality of a broad range of mental health education, furthermore, that it should be incorporated into existing quality assurance systems.     

Medical Student Perceptions of the Learning Environment in Medical School Change as Students Transition to Clinical Training in Undergraduate Medical School

Phenomenon: The learning environment is the physical, social, and psychological context in which a student learns. A supportive learning environment contributes to student well-being and enhances student empathy, professionalism, and academic success, whereas an unsupportive learning environment may lead to burnout, exhaustion, and cynicism. Student perceptions of the medical school learning environment may change over time and be associated with students' year of training and may differ significantly depending on the student's gender or race/ethnicity. Understanding the changes in perceptions of the learning environment related to student characteristics and year of training could inform interventions that facilitate positive experiences in undergraduate medical education. Approach: The Medical School Learning Environment Survey (MSLES) was administered to 4,262 students who matriculated at one of 23 U.S. and Canadian medical schools in 2010 and 2011. Students completed the survey at the end of each year of medical school as part of a battery of surveys in the Learning Environment Study. A mixed-effects longitudinal model, t tests, Cohen's d effect size, and analysis of variance assessed the relationship between MSLES score, year of training, and demographic variables. Findings: After controlling for gender, race/ethnicity, and school, students reported worsening perceptions toward the medical school learning environment, with the worst perceptions in the 3rd year of medical school as students begin their clinical experiences, and some recovery in the 4th year after Match Day. The drop in MSLES scores associated with the transition to the clinical learning environment (?0.26 point drop in addition to yearly change, effect size = 0.52, p < .0001) is more than 3 times greater than the drop between the 1st and 2nd year (0.07 points, effect size = 0.14, p < .0001). The largest declines were from items related to work–life balance and informal student relationships. There was some, but not complete, recovery in perceptions of the medical school learning environment in the 4th year. Insights: Perceptions of the medical school learning environment worsen as students continue through medical school, with a stronger decline in perception scores as students' transition to the clinical learning environment. Students reported the greatest drop in finding time for outside activities and students helping one another in the 3rd year. Perceptions differed based on gender and race/ethnicity. Future studies should investigate the specific features of medical schools that contribute most significantly to student perceptions of the medical school learning environment, both positive and negative, to pinpoint potential interventions and improvements.     

临床医学专业学生社会实践活动模式的研究

目的 探索临床医学专业学生社会实践活动模式。方法 安排医学生利用暑期回家乡所在地，根据其家乡的具体情况任选一所社区医疗服务点、各级医院或专科医院，进行为期2周的以护理服务为切入点的社会实践活动。结果 学生圆满完成以护理服务为切入点的早期接触临床、早期接触社会的社会实践活动。结论 帮助医学生把早期接触社会、接触临床两者结舍起来，加深了对医院工作的理解及理论与实践的结合，增强了学生的社会适应能力，从而提高了医学生的综合素质。     

The Nurse in Clinical Practice

Swedish colleges and universities are now adapting their syllabuses to the new open European labour market. In this respect the syllabus for training of nurses is to be reorganized. Thinking in terms of health will be very important in the training program and will require practical experience of nursing. The aim of this study was to examine the demands made on competent nurses working in clinical practice. An open question was asked and the results were analysed by the constant comparative method. The 23 nurses interviewed had to answer the question: “What do you require of a competent nurse?” From the empirical data, characteristics of six different ideal types were described. A competent nurse has the ability—to create a good atmosphere; concentrate on the patient and always to have an ethical and humanitarian approach; to teach and instruct; to organize, make priorities, cooperate and make documentations; to use her theoretical knowledge and be able to put it to use; to be keen on development and change. The study showed that a competent nurse has a wide field of knowledge, but also highlighted the complex of the nursing profession. If the nursing student can acquire these skills she will be well prepared for her central role in clinical practice.     

Implementation of healthcare accreditation in Danish general practice: a questionnaire study exploring general practitioners’ perspectives on external support

ObjectiveTo describe the use and perceived usefulness of implementation support provided to general practice during an accreditation process and to explore potential variations across clinic characteristics.DesignCross-sectional questionnaire study.Setting and subjectsAll Danish general practice clinics undergoing an accreditation survey from 27 September 2016 to 15 December 2017 (n = 608).Main outcome measuresUse and perceived usefulness of seven types of implementation support as reported by general practitioners (GPs). Clinic characteristics included practice type, number of GP partners and staff and employment of GP trainees.ResultsThe total response rate was 74% (n = 447). Most clinics (99.5%) used some type of implementation support (average: 4.8 different types). The most used types of support were peer support (80–92%) and various accreditation documents (85–92%). Support tailored to the individual clinic was most often considered useful (91–97%). However, this type of support was used relatively infrequently (16–40%). In most cases, clinic characteristics were neither significantly associated with the use of support nor with the perceived usefulness of the available support.ConclusionDuring the accreditation processes, each clinic used a broad variety of implementation support. Support tailored to the individual clinic was highly appreciated and should be promoted in future quality interventions in general practice. Discussions with peers were widely used, and it should be investigated further how peer discussions are best facilitated. The study calls for a multifactorial approach to future quality interventions in general practice to target the needs and capacities of the individual clinics.     

Research in general practice - achievements in the past and possibilities for the future

With our limited resources, the national colleges of general practice in the Nordic countries should select only a few important topics and only get involved in guideline preparations if they have a primary care perspective. We need not develop our own guidelines from scratch, but should take existing international GP clinical guidelines and literature reviews as a starting point and conduct the first steps in the guideline preparation jointly in the Nordic countries. More effort could then be directed towards the subsequent stages of guideline preparations and the implementation process. Key stakeholders should be involved at all stages in guideline development and at all levels of the health services to ensure commitment and improve the likelihood of implementation.