Jennifer Plant

Interprofessional Team Training in Pediatric Resuscitation: A Low-Cost, In Situ Simulation Program That Enhances Self-Efficacy Among Participants

Introduction. Simulation-based interprofessional team training is important to ensure high-quality, safe patient care, but several barriers exist, including diverging learning needs and schedules as well as limited available resources. Methods. The authors developed an in situ, simulation-based interprofessional team training program around pediatric emergencies for physicians, nurses, respiratory therapists, and pharmacists at their institution and performed an analysis of the program’s impact on self-efficacy in resuscitation skills among pediatric residents and nurses. Results. The results showed that with a design based in best principles of team training and simulation education, interprofessional team training is feasible and sustainable. The program had a beneficial effect on self-efficacy in resuscitation skills among both residents and nurses at the authors’ institution and received widespread acceptance. Conclusions. A collaborative approach to design and implementation of interprofessional team training can lead to a sustainable program that serves both patient safety and training requirements set forth by professional organizations.

Validation of a self-efficacy instrument and its relationship to performance of crisis resource management skills

Self-efficacy is thought to be important for resuscitation proficiency in that it influences the development of and access to the associated medical knowledge, procedural skills and crisis resource management (CRM) skills. Since performance assessment of CRM skills is challenging, self-efficacy is often used as a measure of competence in this area. While self-efficacy may influence performance, the true relationship between self-efficacy and performance in this setting has not been delineated. We developed an instrument to measure pediatric residents’ self-efficacy in CRM skills and assessed its content validity, internal structure, and relationship to other variables. After administering the instrument to 125 pediatric residents, critical care fellows and faculty, we performed an exploratory factor analysis within a confirmatory factor analysis as well as a known group comparison. The analyses specified four factors that we defined as: situation awareness, team management, environment management, and decision making. Pediatric residents reported lower self-efficacy than fellows and faculty in each factor. We also examined the correlation between self-efficacy and performance scores for a subset of 30 residents who led video recorded simulated resuscitations and had their performances rated by three observers. We found a significant, positive correlation between residents’ self-efficacy in situation awareness and environment management and their overall performance of CRM skills. Our findings suggest that in a specific context, self-efficacy as a form of self-assessment may be informative with regards to performance.

Promoting self-directed learning through portfolios in undergraduate medical education: The mentors’ perspective

Background: Medical students need to acquire self-directed learning (SDL) skills for effective lifelong learning. Portfolios allow learners to reflect on their progress, diagnose learning needs and create learning plans, all elements of SDL. While mentorship is deemed to be essential for successful portfolio use, it is not known what constitutes effective mentorship in this process. In-depth understanding of the SDL construct seems a prerequisite. Aims: The aim of this study was to examine how portfolio mentors perceive and approach SDL. Methods: Interviews with faculty members who mentored medical students in portfolio were audio-recorded, transcribed and analysed for themes. Results: Eight mentors participated. Qualitative analysis revealed six major themes around mentors’ definitions of SDL, their perception of innate SDL abilities of medical students, their own approach to SDL, their understanding of the value of learning plans, their perceptions of students’ engagement with the portfolio and the impact of the portfolio process on the mentoring relationship. Conclusions: This study revealed tensions between mentors’ beliefs regarding the importance of SDL, their own approach to SDL and their perceptions of students’ SDL skills. Based on our analysis of these tensions, we recommend both explicit faculty development and institutional culture change for successful integration of SDL in medical education.

Understanding self-assessment as an informed process: residents’ use of external information for self-assessment of performance in simulated resuscitations

Self-directed learning requires self-assessment of learning needs and performance, a complex process that requires collecting and interpreting data from various sources. Learners’ approaches to self-assessment likely vary depending on the learner and the context. The aim of this study was to gain insight into how learners process external information and apply their interpretation of this information to their self-assessment and learning during a structured educational activity. The study combined quantitative performance data with qualitative interview data. Pediatric residents led video-recorded simulated resuscitations and rated their crisis resource management skills on a validated 6-item instrument. Three independent observers rated the videos using the same instrument. During semi-structured interviews, each resident reviewed the video, rerated performance, discussed the self-assessment process, and interpreted feedback and observer scores. Transcripts were analyzed for themes. Sixteen residents participated. Residents’ self-assessed scores ranged widely but usually fell within two points of the observers. They almost universally lowered their scores when self-assessing after the video review. Five major themes emerged from qualitative analysis of their interviews: (1) residents found self-assessment important and useful in certain contexts and conditions; (2) residents varied in their self-directed learning behaviors after the simulated resuscitation; (3) quantitative observer assessment had limited usefulness; (4) video review was difficult but useful; and (5) residents focused on their weaknesses and felt a need for constructive feedback to enhance learning. The residents in our study almost uniformly embraced the importance of self-assessment for all medical professionals. Even though video review had a negative impact on their self-assessment scores and was perceived as painful, residents saw this as the most useful aspect of the study exercises residents. They were less accepting of the quantitative assessment by observers. Residents explained their tendency to focus on weaknesses as a way to create an incentive for learning, demonstrating that self-assessment is closely linked to self-directed learning. How learners can use video review and external assessment most effectively to guide their self-directed learning deserves further study.

Challenges of interprofessional team training: A qualitative analysis of residents' perceptions

Background: Simulation-based interprofessional team training is thought to improve patient care. Participating teams often consist of both experienced providers and trainees, which likely impacts team dynamics, particularly when a resident leads the team. Although similar team composition is found in real-life, debriefing after simulations puts a spotlight on team interactions and in particular on residents in the role of team leader. The goal of the current study was to explore residents′ perceptions of simulation-based interprofessional team training. Methods: This was a secondary analysis of a study of residents in the pediatric residency training program at the University of California, San Francisco (United States) leading interprofessional teams in simulated resuscitations, followed by facilitated debriefing. Residents participated in individual, semi-structured, audio-recorded interviews within one month of the simulation. The original study aimed to examine residents′ self-assessment of leadership skills, and during analysis we encountered numerous comments regarding the interprofessional nature of the simulation training. We therefore performed a secondary analysis of the interview transcripts. We followed an iterative process to create a coding scheme, and used interprofessional learning and practice as sensitizing concepts to extract relevant themes. Results: 16 residents participated in the study. Residents felt that simulated resuscitations were helpful but anxiety provoking, largely due to interprofessional dynamics. They embraced the interprofessional training opportunity and appreciated hearing other healthcare providers′ perspectives, but questioned the value of interprofessional debriefing. They identified the need to maintain positive relationships with colleagues in light of the teams′ complex hierarchy as a barrier to candid feedback. Discussion: Pediatric residents in our study appreciated the opportunity to participate in interprofessional team training but were conflicted about the value of feedback and debriefing in this setting. These data indicate that the optimal approach to such interprofessional education activities deserves further study.

Taking humanism back to the bedside

After attending The Arnold P. Gold Foundation’s “Barriers to Sustaining Humanism in Medicine” symposium in 1996, Steve Miller and Richard Sarkin proposed a Traveling Fellows program for the foundation. The program was approved, and Steve and Rich served as the program’s 2 Traveling Fellows until their untimely death on October 19, 2004. Steve and Rich, both Council on Medical Student Education in Pediatrics presidents known for their creativity and charisma, brought to our collective consciousness the need to promote humanism in our work as clinicians, teachers, and role models. When they died, Steve’s Chair at Columbia, John Driscoll, urged that their memory be honored by devoting time each October to promoting humanism.1 It is in this spirit that COMSEP Perspectives provides the following article. – Kenneth B. Roberts, MD Reflecting on our journey through medicine, we may recall pivotal moments that re-affirmed our commitment to the values of our profession. These moments may relate to the spirit of discovery inherent in the practice of medicine, to the recognition afforded by society to medical practitioners, or to service toward those who are suffering and in need of care. This last attribute, which encompasses a spirit of sincere concern for the centrality of human values in every … Address correspondence to Jennifer Plant, MD, MEd, Department of Pediatrics, University of California, Davis, 2516 Stockton Blvd, Sacramento, CA 95817. E-mail: jplant{at}ucdavis.edu

Reflective Practice in the Clinical Setting: A Multi-Institutional Qualitative Study of Pediatric Faculty and Residents

Purpose To explore when and in what form pediatric faculty and residents practice reflection. Method From February to June 2015, the authors conducted focus groups of pediatric faculty and residents at the University of California, Davis; Stanford University; and the University of California, San Francisco, until thematic saturation occurred. Transcripts were analyzed based on Mezirow’s and Schon’s models of reflection, using the constant comparative method associated with grounded theory. Two investigators independently coded transcripts and reconciled codes to develop themes. All investigators reviewed the codes and developed a final list of themes through consensus. Through iterative discussions, investigators developed a conceptual model of reflection in the clinical setting. Results Seventeen faculty and 20 residents from three institutions participated in six focus groups. Five themes emerged: triggers of reflection, intrinsic factors, extrinsic factors, timing, and outcome of reflection. Various triggers led to reflection; whether a specific trigger led to reflection depended on intrinsic and extrinsic factors. When reflection occurred, it happened in action or on action. Under optimal conditions, this reflection was goal and action directed and became critical reflection. In other instances, this process resulted in unproductive rumination or acted as an emotional release or supportive therapy. Conclusions Participants reflected in clinical settings, but did not always explicitly identify it as reflection or reflect in growth-promoting ways. Strategies to enhance critical reflection include developing knowledge and skills in reflection, providing performance data to inform reflection, creating time and space for safe reflection, and providing mentorship to guide the process.

Illuminating exemplary professionalism using appreciative inquiry dialogues between students and mentors

Abstract Purpose: To explore the types of exemplary professional behaviors and the facilitators and barriers to professional behavior discussed by student–mentor dyads during appreciative inquiry (AI) dialogs. Materials and methods: We conducted a qualitative analysis of AI narratives discussing exemplary professional practice written by third-year medical students following a dialog with mentors. Narratives were thematically analyzed using directed content analysis to explore the types of exemplary professional behaviors discussed and the facilitators and barriers to professional practice. Narratives were coded independently by two investigators; codes were finalized, themes were derived, and a model on how exemplary professional behaviors are nurtured and reinforced was developed. Results: Themes addressed humanism toward others and excellence, with altruism being an underlying implicit guiding principle behind professional behavior. Humanism toward self was infrequently discussed as an aspect of professionalism, but when discussed, was perceived to foster resilience. Principle-based attitudes and emotional intelligence facilitated professional behaviors. Programmatic scaffolds facilitated professional behavior and included curricula on reflective practice, mentorship, promoting learner autonomy and connectedness, and a safe environment. Conclusions: AI is an effective strategy that can be used to stimulate learner reflection on professionalism, humanism, and wellness and promote learner acknowledgement of positive aspects of the learning environment.

Authors reply to commentary by Dolmans

The authors would like to thank Dr. Dolmans for her thoughtful commentary on our study examining residents’ use of external information during self-assessment of their performance (Plant et al. 2012). In her piece entitled ‘‘Self-assessment and dialogue: can it improve learning?’’, Dr. Dolmans (2012) discusses the importance of dialogue in the self-assessment process. As she points out, residents in our study had the opportunity to discuss their performance during facilitated debriefings immediately following a simulation exercise and some took the initiative to discuss their experiences with peers outside of the formal learning activity. These dialogues undoubtedly provided external information and an opportunity for active interpretation of information, crucial aspects of self-assessment (Sargeant et al. 2010). Interestingly, the study interview itself allowed for a dialogue between the interviewer and interviewee and may have affected the self-assessment process as well. While the interviewer did not provide any formal feedback, the social interaction of the interview allowed the residents to monologue and reflect on their performance. Our study demonstrates that it may be impossible to examine self-assessment in action without affecting the process itself. Dr. Dolmans also comments on the good correlation between the residents’ selfassessment scores immediately after the simulation exercise and the observers’ ratings of their performance. The residents’ completed their first self-assessment after the group debriefing and their scores may, in part, reflect the feedback they received during the group debriefing. This leads Dr. Dolman’s to comment that the debriefing may improve the ‘‘accuracy’’ of their self-assessment and to question why the subsequent video review made them less accurate. We agree that the effect of video review on this process is an interesting area for further investigation. In this study, however, we avoided drawing any conclusions