Magister Pharmaceuticae - MPharm / The World Health Organisation (WHO) has stated that “there is no health without a workforce” (Campbell et al., 2013). The health workforce is essential for every health care system. The availability, accessibility and quality of health care workers play an important role in improving and overcoming health system challenges, in particular the call to universal health coverage (UHC) as stipulated in sustainable development goal 3. It has been observed that there is limited collaboration between healthcare systems and academic institutions. According to an article by Frenk et al., 2010, this limited collaboration has resulted in a mismatch between health care graduates’ competencies (such as inter-professional collaboration) and the needs of the population that they serve. One of the problems of health education institutions is the emphasis on curriculum content and learning methods as opposed to social purpose and moral obligations. / 2021-08-30

While the body of evidence supporting the use of simulation-based learning in the education of health professionals is growing, howor why simulation-based learning works is not yet understood. There is a clear need for evidence, grounded in contemporary educational theory, to clarify the features of simulation instructional design that optimize learning outcomes and efficiency in health care professional students. Cognitive Load Theory (CLT) is a theoretical framework focused on a learner’s working memory capacity. One principle of CLT is example based learning. While this principle has been applied in both traditional classroom and laboratory settings, and has shown positive performance and learning outcomes, example based learning has not yet been applied to the simulation setting. This study had two main objectives: to explore if the example-based learning principle could successfully be applied to the simulation learning environment, and to establish response process validation evidence for a tool designed to measure types of cognitive load. Fifty-eight novice students from nursing, podiatric medicine, physician assistant, physical and occupational therapy programs participated in a blinded randomized control study. The dependent variable was the simulation brief. Participants were randomly assigned to either a traditional brief or a facilitated tutored problem brief. Performance outcomes were measured with verbal communications skill presented in the Introduction, Situation, Background, Assessment, Recommendation (I-SBAR) format. Response process evidence was collected from cognitive interviews of 11 students. Results indicate participation in a tutored problem brief led to statistically significant differences at t(52)=-3.259, p=.002 in verbal communication performance compared to students who participated in a traditional brief. Effect size for this comparison was d=(6.06-4.61)/1.63 = .89 (95% CI 0.32-1.44). Response process evidence demonstrated that additional factors unique to the simulationlearning environment should be accounted for when measuring cognitive load in simulation based learning (SBL). This study suggests that example based learning principles can be successfully applied to SBL and result in positive performance outcomes for health professions students. Additionally, measures of cognitive load do not appear to capture all contribution toload imposed by the simulation environment.

Competence committees are groups of educators that monitor the progress of medical trainees and decide when they should be promoted to the next stage of training. They represent an important part of modern-day competency-based medical education programs, yet relatively little is known about their implementation and decision-making practices. This thesis seeks to fill a critical gap in the literature by generating empirical evidence with respect to competence committee implementation and decision-making practices across multiple programs. The first data chapter uses a multi-method approach to examine competence committee implementation practices at a Canadian institution over a three-year period. The second and third chapters examine how individuals and groups make promotion decisions, respectively. These chapters also consider the role of non-traditional data sources, such as anecdotal evidence, in competence committees’ decision-making processes. The final data chapter considers the role of social influences and power and examines how factors such as members’ position on the committee, gender, and race/ethnicity influence their contributions to the committee. This thesis provides insight into some of the challenges that exist with respect to competence committee implementation and offers potential solutions based on best practices across multiple programs. It also highlights factors that can influence competence committee decision making and discusses ways that their decision-making processes can be optimized. Broader implications of this thesis, including the role of groups in solving complex problems and the importance of diversity (both in terms of demographics and functional specialization) in ensuring good decision-making outcomes, are also discussed. / Thesis / Doctor of Philosophy (PhD) / Competence committees are groups of experienced health professionals and educators whose job is to determine whether physician learners (i.e., residents) are ready to progress to the next stage of training and responsibility. These committees are relatively new, and as a result, we do not know very much about how they make decisions. Given the importance of competence committees in ensuring that physicians are able to provide high-quality and safe patient care, the purpose of this thesis was to examine competence committee implementation and decision-making practices at a Canadian academic centre. This took place in two parts. First, we studied competence committees over a three-year period using surveys, interviews, and observations. This helped us understand some of their benefits and challenges. Next, we conducted a series of experiments to understand how competence committee members make decisions both individually and as part of a group. These experiments also helped us understand how competence committees make sense of different types of data, such as prior knowledge about a resident or their assessors. Finally, we examined how various aspects of members’ social identities, such as their position on the committee, their gender, and their race/ethnicity, influence their contributions to the committee. Collectively, the findings of this thesis help to advance the scientific literature in the areas of medical education and group decision making. They can also be used to optimize competence committee operations, which can in turn positively impact patients, healthcare, and society.

Introduction: Competency-based medical education (CBME) is a learner-centered outcomes-based approach. Competence by Design (CBD) is a hybrid time-based and outcomes-based CBME model that was adopted by all Royal College of Physicians and Surgeons of Canada-based residency training programs, with the primary objective of enhancing postgraduate medical education quality. However, preliminary findings suggest that residents experience higher levels of stress, anxiety, and exhaustion in CBD than with previous curricula. This thesis aims to identify and understand the emotional effects of CBME on residents, faculty, and administrative staff. Methods: This study used a qualitative approach, specifically hermeneutic phenomenology. Seven residents, six faculty members (several with education leadership roles), and one administrative staff member from a postgraduate Psychiatry program were recruited. Participants underwent semi-structured, one-on-one interviews where they were probed on their emotions with CBME. Interviews were transcribed and analyzed using a line-by-line approach that generated individual meaning units and, subsequently, themes. Results: Five themes were identified: 1) Education is an emotional experience; 2) The emotional toll of CBD; 3) CBD is a failed educational promise—Expectations vs. realities; 4) Structural and administrative burdens of CBD; and 5) Survival of educational demands—The quest for coping. Participants initially struggled to articulate their emotions, but expressed surprise at realizing they did have strong, often negative, emotions related to CBD. There was also a dissonance identified between the anticipated benefits and the execution of CBD. Furthermore, participants highlighted administrative and structural challenges of CBD, specifically regarding Entrustable Professional Activities, which were a burden and lacked much educational value. Participants discussed using various coping strategies to manage CBD’s demands. Conclusion: The findings of this work suggest that CBD has a negative emotional impact on residents and faculty, specifically due to tension between CBD’s theoretical benefits and its practical challenges, including increased emotional burden and structural challenges. / Thesis / Master of Science (MSc) / Competency-based medical education (CBME) is a learner-centered outcomes-based approach. Competence by Design (CBD) is a hybrid time-based and outcomes-based CBME model that was adopted by all Royal College of Physicians and Surgeons of Canada-based residency training programs, with the primary objective of enhancing the quality of postgraduate medical education. However, preliminary findings suggest that residents experience higher levels of stress, anxiety, and exhaustion in a CBD model than with previous curricula. This thesis aims to understand the emotional effects of CBME on residents, faculty, and administrative staff in a postgraduate Psychiatry program. In this qualitative study, participants underwent semi-structured, one-on-one interviews where they were probed on their emotions and experiences with CBME. The findings suggest that CBD has a negative emotional impact on residents and faculty, specifically due to tension between CBD’s theoretical benefits and its practical challenges, including increased emotional burden and structural challenges associated with the assessment methods.

ENGLISH ABSTRACT: The setting for this study was the University of the Western Cape, Faculty of Community and Health Sciences, first year undergraduate students. All students who participated in the compulsory interprofessional programme were from the following disciplines: Occupational Therapy; Physiotherapy; Psychology; Social Work; Natural Medicine; Dietetics; Human Ecology; Sports Sciences and Nursing. The objectives of this study were to measure the attitudes and perceptions of first year students who participated in an undergraduate interprofessional programme. The attitudes and perceptions were further measured in relation to the specific lecturers involved, the age of the students, their gender, race, background as well their specific discipline. This was primarily a quantitative study incorporating two qualitative questions in which 657 students were issued with a questionnaire designed to determine their attitudes and perceptions towards interprofessional education. A sample size of 264 students resulted in 95% confidence intervals with a maximum precision of 5%. The questionnaire was adapted, with permission, from Cameron; Rennie; DiProspero; Langlois & Wagner (2009). MS Excel was used to capture the data and STATISTICA version 9 (StatSoft Inc. (2009) STATISTICA (data analysis software system), www.statsoft.com.) was used to analyze the data from the questionnaires. Descriptive statistics was used to describe the main features of the sample of this study and summary statistics was further used to summarize the findings of this study in order to communicate the bulk of the information as simple as possible. Two open-ended questions were included at the end of the questionnaire and this was used to triangulate the data. The Kruskal-Wallace test was used to measure the results, whereby a p-value of <0.05 indicated statistical significance. Of all the factors used to measure the attitudes and perceptions of students, the following three were significant: Gender; Race and Discipline. No other factors impact on the attitudes and perceptions of students towards interprofessional education. Student attitudes and perceptions towards interprofessional education were found to be very positive. The findings revealed that the most significant factor in the study was the lack of understanding of various disciplines participating in the programme and their understanding of the relevance of the teaching approach (interprofessional) as well as their specific role in the health care team. This clearly illustrated the need to recommend to the co-ordinating unit of the programme that this be defined more clearly for the students and specifically the Sports Sciences students. / AFRIKAANSE OPSOMMING: Die studie het plaasgevind by die Universiteit van die Wes-Kaap, in die Fakulteit van Gemeenskap en Gesondheidswetenskappe, met eerste jaar voorgraadse studente wat die verpligte interprofessionele program doen. Studente sluit in die volgende dissiplines: Arbeidsterapie; Fisioterapie, Sielkunde, Maatskaplike Werk, Natuurlike Medisyne, Dieetkunde, Menslike Ekologie, Sport en Verpleegkunde. Die doelwitte van hierdie studie was om die houdings en persepsies van die eerste jaar studente wat deelgeneem het in 'n voorgraadse interprofessionele program te meet. Houdings en persepsies was gemeet met betrekking tot die ouderdom geslag, ras,agtergrond sowel dissipline van spesifieke studente. Daar was ook gekyk of die betrokke dosente ń invloed het op studente se houdings en persepsies teenoor die program. Die studie was hoofsaaklik kwantitatiewe met n kwalitatiewe komponent. Vraelyse was uitgereik aan 657 studente om hul houdings en persepsies teenoor interprofessionele onderwys te bepaal. 'n Steekproefgrootte van 264 studente het in 95% vertrouensintervalle met 'n maksimum akkuraatheid van 5%. Die vraelys is aangepas, met toestemming, van Cameron, Rennie; DiProspero Langlois & Wagner (2009). MS Excel was gebruik om die data op te vang en Statistica weergawe 9 [StatSoft Inc (2009) STATISTICA (data-analise sagteware stelsel), www.statsoft.com] is gebruik om die data van die vraelyste te analiseer. Beskrywende statistiek is gebruik om te beskryf die belangrikste kenmerke van die steekproef van hierdie studie. Opsommingstatistiek is verder gebruik om op te som die bevindinge van hierdie studie met die doel om die grootste deel van die inligting so eenvoudig as moontlik te kommunikeer. Twee oop vrae is ingesluit aan die einde van die vraelys en dit is gebruik om die data te trianguleer. Die Kruskal-Wallace-toets is gebruik om die resultate, waar 'n p-waarde van <0,05 aangedui word statistiese betekenisvolheid te meet. Van al die faktore wat gebruik was om die houdings en persepsies van studente te meet, was die volgende drie beduidende: geslag, ras en dissipline. Geen ander faktore impakteer op die houdings en persepsies van studente in interprofessionele onderwys. Studente se houdings en persepsies teenoor interprofessionele onderwys was beduidend positief. Die studie het bevind dat daar ń algemene gebrek aan begrip is vir die relevansie van die program. Dit sluit in hoekom die verskillende dissiplines aan die program deelneem as ook wat hulle spesifieke rolle in die gesondheidsorg span is. Die aanbeveling is dus dat die koördinerings eenheid van die program die kursus meer duidelik sal moet definieer om so doende die studente se kennis in terme van relevansie van die interprofessionele program uit te brei met spesifiek verwysing na die Sport studente.

The SARS-CoV-2 pandemic disrupted health professions education on a number of different levels. Many health professions and pre-health professions students lost access to real-world clinical experience which has lead to disruptions in the healthcare workforce pipeline. At the University of Montana a diverse group of health professions educators designed an innovative experiential learning program, called Griz Health, that would allow UM students to engage in healthcare experiences while helping the campus with COVID-19 response. Because of the overwhelmingly positive response from students and community members that participated in this program, the Griz Health program was shifted from a volunteer response program to a year-long course. Students in the Griz Health course will work in small, interprofessional teams to engage in the innovation process to tackle local healthcare issues in underserved communities.

Social-comparative feedback (i.e., providing a learner with information regarding his/her performance relative to a group average) has been shown to influence a learner’s psychological and behavioural outcomes during motor skill acquisition (Avila, Chiviacowsky, Wulf, & Lewthwaite, 2012; Eliasz, 2012; Lewthwaite & Wulf, 2010; McKay, Lewthwaite, & Wulf, 2012; Stoate, Wulf, & Lewthwaite, 2012; Wulf, Chiviacowsky, & Cardozo, 2014; Wulf, Chiviacowsky, & Lewthwaite, 2010, 2012; Wulf & Lewthwaite, 2016). This research indicates that motor skill acquisition is facilitated when learners believe they are performing better than the average, regardless of their actual performance. It has been suggested (Wulf & Lewthwaite, 2016) that a better-than-average mindset enhances psychological factors such as self-efficacy and motivation and in turn, actual behaviour. However, there is also evidence to suggest that self-efficacy (having state-like properties) and motivation (having both state and trait-like properties) are related in terms of their affective influence on learning (Bandura, 1997; Schunk, 1990, 1991, 1995) but the relationship between the two constructs and its subsequent outcomes remain unclear. Even though individual differences in motivation have been suggested to influence self-efficacy beliefs, they have been largely ignored in this line of research. There is also evidence to suggest that learners possessing high levels of motivation (whether that may be at a trait or state level) may not interpret feedback in the same manner (Aronson, 1992; Festinger, 1957; Frey, 1986; Harmon-Jones, 2012; Harmon-Jones & Harmon-Jones, 2002; Harmon-Jones, Harmon-Jones, Fearn, Sigelman, & Johnson, 2008; Harmon-Jones & Mills, 1999; Harmon-Jones, Schmeichel, Inzlicht, & Harmon- Jones, 2011; Steele, 1988). Therefore, the goal of this dissertation is use both theoretical and applied perspectives to examine the degree to which social- comparative feedback affects psychological and behavioural outcomes in highly- motivated learners (e.g., medical trainees) learning procedural skills. Independent of actual performance, we provided manipulated feedback information to novice pre-clerkship medical trainees while they were learning motor skills to suggest that they were performing better or worse than the average. The first study used a basic sequential key-press learning task (Eliasz, 2012) and a basic suturing task to explore the role of social-comparative feedback in medical trainees and tested whether features of the task were important (i.e., basic laboratory task or technical skill task) during the interpretation of this feedback. The second study used the same experimental paradigm to extend our results to a relevant medical education context (i.e., medical trainees learning basic suturing techniques). The final study examined whether the credibility of the feedback provider (i.e., expert versus peer) played a role in how social-comparative feedback was being internalized by novice medical trainees. Our initial study demonstrated that, compared to those receiving positive or no social-comparative feedback, medical trainees receiving negative social- comparative feedback during motor skill acquisition had significant difficulties in learning both the laboratory and technical skill task. These findings suggested that compared to other learners, novice medical trainees (a subset of highly-motivated learners), responded differently to social-comparative feedback. The second study replicated this pattern and revealed that medical trainees receiving below-average feedback during technical skill acquisition experienced significant detriments to their performance, learning and self-efficacy. Our final study found that regardless of the feedback source (hypothetical expert versus another peer), the experience of receiving negative social-comparative feedback impacted self- reported psychological measures and the immediate performance of a basic surgical technique. This dissertation provides, to the best of our knowledge, the first demonstration that medical trainees, a subset of highly-motivated learners, interpret social-comparative feedback differently than other learners studied in the literature. More specifically, receiving positive social-comparative feedback did not facilitate the learning process as found in previous studies with non-medical learners, while the delivery of negative social-comparative feedback, irrespective of task or feedback provider, was psychologically and behaviourally detrimental to novice medical trainees learning motor skills. / Dissertation / Doctor of Philosophy (PhD) / This dissertation includes three original studies designed to examine the effects of social-comparative feedback during skill acquisition in highly- motivated learners (e.g., medical trainees). Regardless of actual task performance, novice medical trainees who were provided with feedback during the learning process indicating that they were performing worse than the group average, experienced significant detriments to their psychological and behavioural outcomes. This effect was present regardless of the task being learned (i.e., key- pressing or suturing) or who was delivering the feedback (i.e., a hypothetical ‘expert’ or ‘peer’). Receiving better-than-average feedback did not result in any additional psychological and behavioural benefits. Contrary to the research with non-medical students, where “you are above-average” social-comparative feedback facilitates learning and “you are below-average” social-comparative feedback is no different than a control condition, these studies suggest that the experience of receiving below-average feedback during the learning process can be detrimental for highly-motivated novice learners. These findings are important to consider in both the context of feedback delivery and remediation as they provide evidence that novice medical trainees, regardless of the task and feedback provider, experience difficulty in receiving information that they are performing relatively poorly compared to their peers.

Thesis (MPhil)--Stellenbosch University, 2014. / ENGLISH ABSTRACT: Background - Student nurses indicated that the clinical environment was not conducive to learning because they were part of the ward staff ratio and clinical supervision was inadequate. Upon observations by the researcher and feedback from student nurses’ a study was planned to identify the clinical experiences and supervision. The study itself was conducted within private health care settings in the Western Cape Province of South Africa. Objectives - The objective of this study was to determine the experiences of student nurses of the clinical learning environment. To also identify the support and clinical supervision that the student nurses received from ward staff, clinical facilitators and lecturers. Methods and analysis - The CLES+T is a reliable and valid evaluation scale for the gathering of information on the clinical learning environment and supervision of student nurses. The CLES+T evaluation scale was completed by 234 student nurses within the selected sites. A quantitative, descriptive cross-sectional survey was conducted by making use of the CLES+T evaluation scale. The CLES+T evaluation scale is subdivided into three main sections with additional sub-sections: (1) the Learning environment, (2) the Supervisory relationship and (3) the Role of the nurse teacher (lecturer). Results - The clinical learning environment was experienced as mostly positive by the student nurses; however the format and type of clinical accompaniment and supervision students received varied. Conclusion - This study gave valuable insights into the status of the clinical learning environment, the clinical accompaniment and supervision of student nurses which can be useful to the nursing school in order to enhance existing nursing programmes.

Indiana University-Purdue University Indianapolis (IUPUI) / Although interprofessional education (IPE) opportunities can help prepare students for future practice and patient-centered care, many health professions students in the country are not educated in an environment with opportunities to learn with, from, or about students from other health professions. With upcoming curricular changes at the Indiana University School of Medicine (IUSM) and the Indiana University School of Nursing (IUSN), IPE remains at the forefront of these changes in both schools. To date, few studies have explored student, faculty, and administrators’ conceptualizations of IPE prior to formal implementation. Additionally, previous studies have not compared IPE conceptualizations across these groups. This multiple-case study explores and compares how groups of stakeholders from the IUSM (Indianapolis) and the IUSN (Indianapolis) conceptualize IPE. Data collection included the examination of discipline-specific public documents and one-on-one interviews (N=25) with pre-licensure students, clinical faculty, and administrators from each school. Coding and extraction of themes transpired through within-case and cross-case analysis and data supported the following findings: the ‘business of medicine’ may prevent IPE from becoming a priority in education; stakeholders’ conceptualizations of IPE are shaped through powerful experiences in education and practice; students desire more IPE opportunities at the institution; stakeholders at the IUSN have a long-standing investment in IPE; and the institution requires a ‘culture shift’ in order to sustain IPE efforts. The findings suggest that IPE belongs in all education sectors and IPE efforts deserve reward and reimbursement. The findings also insinuate that leadership, roles, and team training education belong in IPE and IPE culture requires all individuals’ (e.g., student, faculty, administrators, patients) commitment. Importantly, the institution must continue IPE development, research, and dissemination. These findings can help shape curricula as time progresses, increase the likelihood of developing a successful new curriculum, and prompt ongoing reflection about IPE. This information can influence how institutions approach IPE and may lead to a more successful and informed IPE curriculum in the first years of implementation. And, hopefully what is learned through IPE will be translated into healthcare practice environments.