Putting the pieces together: teaching undergraduate research from a theoretical perspective

PROBLEM/PURPOSE: Baccalaureate graduates are expected to utilize research across a wide variety of practice settings. While the literature reports a variety of teaching approaches, few studies examine baccalaureate students' comprehension of research content. Teaching techniques that focus on a conceptual or theoretical approach may foster research comprehension. Therefore, the purpose of this paper is to evaluate teaching/learning outcomes of an undergraduate nursing research course designed from a conceptual or theoretical approach. PROCEDURE/FINDINGS: Two classes of senior baccalaureate nursing students (n = 47) at a private institution, whose curriculum was based on the Roy adaptation model, were surveyed in 1990 and 1991 at the end of their undergraduate research course. The survey tool consisted of seven three-point Likert scale questions, four open-ended questions, and one unstructured comment. Findings showed that 72% strongly agreed that they would continue to read nursing articles in their practice field, 57% disagreed that they were intimidated by research language, and 55% agreed that they trusted their ability to use and utilize nursing research in practice. The most helpful learning activity was the research critique (34%) followed by group work (28%). The support of the teacher and Instructor's use of own research examples was also seen as most helpful (36%), while abstract cards (8%) were least helpful. Nonetheless, 23% requested more group activities, 13% wanted more class examples, and 11% asked for more time to comprehend definitions. IMPLICATIONS: Students who approached research from the perspective of a nursing conceptual framework indicated that they put the pieces of the research puzzle together by working in groups, being supported by the Instructor, and learning from a variety of teaching methods.     

Establishment of a convenient system for the long-term culture and study of non-neoplastic human salivary gland epithelial cells

Epithelial cells appear to play an important role in the initiation and maintenance of autoimmune lesions in the salivary glands of patients with Sjögren's syndrome. Therefore, the detailed study of immunological function of salivary gland epithelial cells (SGEC) may provide useful information for the understanding of Sjögren's syndrome pathogenesis. In this report we aimed to formulate a protocol for the establishment of human non‐neoplastic SGEC lines as a tool for the study of the physiology and pathophysiology of these cells. Pointing towards a practical approach, we sought to establish SGEC lines from quite a limited amount of biopsy tissue obtained during the diagnostic evaluation of patients. Herein, the favorable conditions for the long‐term maintenance of human non‐neoplastic SGEC lines are presented and involve the successive application of a serum‐containing and a serum‐free culture medium, supplemented with essential epithelial growth factors. This protocol has been found reliable and convenient, as attested by the reproducible establishment of non‐neoplastic SGEC lines. The analysis of SGEC phenotypic features, as well as a coculture system for the study of interactions between epithelial cells and lymphocytes, are also described. Such techniques may provide valuable means for the functional and molecular investigation of human SGEC and particularly for the study of Sjögren's syndrome and other disorders of glandular epithelia.     

Benefit-risk analysis: a proposal using quantitative methods

This is the first part of a two-article series which will introduce the theory and practice of a proposed set of quantitative methods for benefit-risk analysis. Adjustments to number-needed-to-treat (NNT) analysis and a new method, minimum clinical efficacy (MCE) analysis are presented and critically discussed. The goal of these methods is to condense into a summary metric the benefit-risk profile of a product so that manufacturers, regulators, clinicians and patients can better understand and participate in risk management. A second article will present examples of these methods.     

Utility of a dynamic termination criterion in the ZEST adaptive threshold method

Bayesian adaptive threshold procedures may be run for a fixed number of trials, or may be stopped when the calculated confidence interval for the threshold reaches a selected limit (a dynamic termination criterion). This study used Monte-Carlo simulations to determine whether the confidence interval is a useful predictor of errors in the estimated threshold. No difference was found between the distribution of errors in a fixed trial procedure versus a dynamically terminated procedure of the same average number of trials. In addition, the width of the confidence interval failed to usefully predict observer variability arising from a shallow psychometric function slope or increased false positive response probabilities. This study suggests that dynamic termination criteria are of little use in Bayesian adaptive threshold procedures.     

A web-based presentation of an undergraduate clinical skills curriculum

AIMS: The aim of this study was to use information and communications technology to present a curriculum of clinical skills in a user-friendly format. SETTING: A UK undergraduate medical school with a problem-based curriculum and a strong emphasis on proficiency in clinical skills. STUDY DESIGN: Case study describing the qualitative analysis of users' requirements and development of a web-based learning portfolio. EVALUATION: The study involved direct observation of users during a 'think-aloud' protocol, a validated software users' measurement inventory and a 17-item questionnaire designed to test whether 'SkillsBase' met its users' requirements. RESULTS: Students wanted a clear and flexible presentation of their skills curriculum that was easy to navigate, offered instructional material and standards for self- and peer assessment, offered useful Internet links, allowed them to compare their progress with school standards and peer norms, and could be used as a learning portfolio. During the think-aloud protocol, students made very few errors in data interpretation or navigation, and found SkillsBase easy to learn and aesthetically pleasing to use. They rated it higher on all measures of usability than standard commercial software. The questionnaire showed that it met most aspects of its design specification, although many students were doubtful that they would use its reflective function. It is available for inspection at http://www.skillsbase.man.ac.uk/. CONCLUSIONS: SkillsBase meets the design specification for a training and reflective aid to learning clinical skills and is very usable.     

Martin's Map: a conceptual framework for teaching and learning the medical interview using a patient-centred approach

OBJECTIVE: At the end of training, students seem to lack a basic understanding of how to take an organised, relevant medical and social history using a patient-centred approach. The aim of developing the map described in this paper was to provide a framework for such an approach. METHODS: Action research was used to continuously modify and refine an interview map that was used by medical clerks, family medicine residents, international medical graduates and practising doctors for teaching and learning purposes over a 10-year period. CONCLUSION: 'Martin's Map' provides a realistic framework for flexibly organising and integrating medical content with process that did not previously exist. The map provides medical educators with a standardised framework for talking about the medical interview, which helps learners understand how to use their medical knowledge with a patient-centred approach. Learners are able to visually see how they can take a focused medical and social history using a patient-centred approach, which subsequently seems to help them organise their thinking and approach during the medical encounter.     

Evaluating surgeons' informed decision making skills: pilot test using a videoconferenced standardised patient

BACKGROUND: Standardised patients (SPs) are effective in evaluating communication skills, but not every training site may have the resources to develop and maintain SP programmes. OBJECTIVES: To test whether videoconferencing technology (VT) could enable an interaction between an SP and an orthopaedic surgeon that would allow the SP to accurately evaluate the surgeon's informed decision making (IDM) skills. We also assessed whether this sort of interaction was acceptable to orthopaedic surgeons as a means of learning IDM skills. METHODS: We trained an SP to represent a 75-year-old woman considering hip replacement surgery. Orthopaedic surgeons in Chicago individually consulted with the SP in Philadelphia; each participant could see and hear the other on large television screens. The SP evaluated the surgeons' advice using a 23-item checklist of IDM elements, and gave each surgeon verbal and written feedback on his IDM skills. The surgeons then gave their evaluations of the exercise. RESULTS: Twenty-two surgeons completed the project. The SP was > or = 80% accurate in classifying 20 of the 23 IDM skills when compared to a clinician rater. Although 12 (55%) of the orthopaedic surgeons felt that some aspects of the technology were distracting, most were pleased with it, and 19 of 22 (86%) would recommend the videoconferenced SP interaction to their colleagues as a means of learning IDM skills. CONCLUSIONS: These results suggest that VT allows accurate evaluation of IDM skills in a format that is acceptable to orthopaedic surgeons. Videoconferencing technology may be useful in long-distance SP communication assessment for a variety of learners.     

CELT: a computerised evaluative learning tool for continuing professional development

OBJECTIVES: To evaluate a computerised, evaluative learning tool (CELT) designed to encourage self-directed learning and help users make changes in practice following learning. The study aimed to evaluate how CELT was used and to ascertain user perceptions of the program. DESIGN: Qualitative analysis of interviews and quantitative analysis of entries made using the software. SETTING AND SUBJECTS: West of Scotland region, comprising six Health Board areas with a total of 2176 general practitioners (GPs), 39 of whom took part in the study. RESULTS: Of the 39 GPs who started on the project, 34 used CELT. Of these 34, 28 GPs sent in files and six did not. Of the 28 GPs who sent in files, 25 entered data and 76% (22/29) considered the program easy to use. The program was used 7 days a week during the day and night. It raised participants' awareness of the educational value of everyday experiences and led to increased thought about learning. In 41% (45/111) of entries there was evidence that some action had been initiated by users as a result of learning. CONCLUSIONS: CELT was designed to encourage self-directed learning and help users make changes in practice following learning. The study has shown that it can be used to deliver individual continuing professional development. It encourages a disciplined approach to learning, promotes thought about learning needs and increases the ability of GPs to learn from everyday experiences. In some instances, users were able to apply what had been learned.     

Towards valid measures of self-directed clinical learning

AIM: To compare the validity of different measures of self-directed clinical learning. METHODS: We used a quasi-experimental study design. The measures were: (1) a 23-item quantitative instrument measuring satisfaction with the learning process and environment; (2) free text responses to 2 open questions about the quality of students' learning experiences; (3) a quantitative, self-report measure of real patient learning, and (4) objective structured clinical examination (OSCE) and progress test results. Thirty-three students attached to a single firm during 1 curriculum year in Phase 2 of a problem-based medical curriculum formed an experimental group. Thirty-one students attached to the same firm in the previous year served as historical controls and 33 students attached to other firms within the same module served as contemporary controls. After the historical control period, experimental group students were exposed to a complex curriculum intervention that set out to maximise appropriate real patient learning through increased use of the outpatient setting, briefing and supported, reflective debriefing. RESULTS: The quantitative satisfaction instrument was insensitive to the intervention. In contrast, the qualitative measure recorded a significantly increased number of positive statements about the appropriateness of real patient learning. Moreover, the quantitative self-report measure of real patient learning found high levels of appropriate learning activity. Regarding outpatient learning, the qualitative and quantitative real patient learning instruments were again concordant and changed in the expected direction, whereas the satisfaction measure did not. An incidental finding was that, despite all attempts to achieve horizontal integration through simultaneously providing community attachments and opening up the hospital for self-directed clinical learning, real patient learning was strongly bounded by the specialty interest of the hospital firm to which students were attached. Assessment results did not correlate with real patient learning. CONCLUSIONS: Both free text responses and students' quantitative self-reports of real patient learning were more valid than a satisfaction instrument. One explanation is that students had no benchmark against which to rate their satisfaction and curriculum change altered their tacit benchmarks. Perhaps the stronger emphasis on self-directed learning demanded more of students and dissatisfied those who were less self-directed. Results of objective, standardised assessments were not sensitive to the level of self-directed, real patient learning. Despite an integrated curriculum design that set out to override disciplinary boundaries, students' learning remained strongly influenced by the specialty of their hospital firm.     

Development of clinical reasoning from the basic sciences to the clerkships: a longitudinal assessment of medical students' needs and self-perception after a transitional learning unit

BACKGROUND: To facilitate students' transition from basic, science-oriented, problem-based learning (PBL) to clinical reasoning-oriented PBL, the University of Geneva School of Medicine introduced a 12-week unit of Introduction to Clinical Reasoning (ICR) at the beginning of its fourth or clerkship year. PURPOSE: The aims of the present study were to determine, after 12 weeks in the ICR unit, to what extent students had: (1) identified the learning content set by the faculty while adapting to the hypothetico-deductive reasoning approach; (2) familiarised themselves with the clinical reasoning-oriented learning process, and (3) transferred and further developed this process during the clinical years. METHOD: Students' derived objectives from the problems were compared to the objectives preset by the faculty to determine acquisition of intended learning content. To assess their adaptation to the clinical reasoning-oriented PBL approach, students (n = 124) were asked to list and freely comment on aspects of the unit they felt most at ease with or had difficulty with, and to complete a questionnaire on the clinical reasoning process (CRP). The same questionnaire was administered 6 and 12 months later to assess the evolution of the students' self-perception during clerkships. RESULTS: On average, student objectives matched 62% of faculty objectives. Half of the missed (38%) objectives were in basic sciences. Students generated 16% additional objectives, also predominantly in the basic sciences category (41%). Free comments indicated that the difficulties perceived by students were very similar to those previously reported in studies on reasoning and errors, such as difficulty in gathering, interpreting and weighting relevant data, synthesising information, and organising it hierarchically. These results were confirmed with the CRP questionnaire administered at the end of the unit. For most of the competencies assessed on the CRP questionnaire, a gradual improvement was seen to have occurred by 6 and 12 months after the unit. CONCLUSIONS: To ease students' transition from the preclinical to clinical years, a learning unit should give them the opportunity to train their clinical reasoning processes on standardised and prototypical problems, before encountering real patients with more ill-structured problems during clerkships. Such a transitional structure should particularly emphasise a developed repertoire of problem representations, recognition of key findings and a hierarchical classification of working hypotheses. It should foster the creation of links between the acquired basic clinical knowledge and the diagnostic, management and therapy steps of problem solving.