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Guidelines on Transforming and Scaling up Health Professionals’ Education
Evidence tables
Recommendation 1: Health professionals’ education and training institutions should consider designing and implementing
continuous development programmes for faculty and teaching staff relevant to the evolving health-care needs of their communities.
Country
/institution
Health
professional
group
Population Intervention Comparison Study design and
methods
Reported results
(outcomes) Benefits/limitations
Values and
preferences?
Resource
use? Reference
USA Medicine,
paediatrics
Academic
general
paediatricians
A Relative Value
Units (RVU)
productivity-
based salary
programme that
compensated
physicians on
their clinical
productivity and
teaching activity.
The programme
included a base
salary that
corresponded to
the minimum
productivity
expectation and
was the same for
all faculty
members
regardless of
academic rank or
years of service.
Once sufficient
RVUs were
Before
intervention
Clinical productivity
was measured (see
paper).
Teaching productivity
was measured
through the number of
teaching sessions and
student ratings.
Clinical
productivity
improved (see
paper). The
number of
student and
resident sessions
was unchanged,
which indicated
that faculty did
not reduce their
teaching efforts
to enhance their
clinical
productivity.
Comparisons of
the average
Likert-scale
scores for three
questions
specifically
related to
students’
educational
experiences in
Not exactly the
specific
intervention – the
aim of the
programme was
not explicitly to
increase the
recognition and
rewards for
teaching
– – Andreae MC,
Freed GL. 2002.
Using a
productivity-
based physician
compensation
programme at
an academic
health centre: a
case study.
Academic
medicine:
Journal of the
Association of
American
Medical
Colleges,
77:894–899.
Epub
2002/09/14.
generated to
cover the base
salary, all
additional
WRVUs
generated were
paid, as an
incentive portion
of salary.
Teaching credits
were included in
the
compensation
programme to
offset estimated
losses in
productivity
incurred while
precepting
medical students
in the clinic. This
was based on
the assumption
that medical
students have a
net negative
primary care in
the year before
the new
programme and
the first year of
the programme
showed that no
significant
difference existed
between the two
sets of
evaluations
(although ratings
did fall, WHO,
2010c).
impact on
primary care
clinical
productivity.
The Department
of Medical
Education at the
institution
estimated this
loss in
productivity
ranged between
10% and 20%,
which was used
to develop a
formula to credit
faculty for
clinical teaching
The WRVU
teaching credits
were added to
the WRVUs
generated in
patient care.
USA
John
Hopkins
Medicine Physician
teachers
In the 2005–2006
academic year,
the Johns
Hopkins
University
School of
Medicine
(JHUSOM)
launched the
Colleges
Program,
recruiting 24
salary-supported
physician faculty
members to
serve as
advisers to
students as well
as teachers of
the second year
course, ‘clinical
skills’.
It was
hypothesized
that
Previous
ratings of
educators
(preceptors)
Student evaluations of
their paid college
faculty educators (CF)
(2005–2006) were
compared to previous
(2003-–2005) ratings
of preceptors.
Students were asked
to rate their
preceptors in the
following 6 areas: (1)
teaching history-
taking; (2) teaching
the physical exam; (3)
helping them to
establish rapport with
patients; (4) feedback
on write-ups; (5)
feedback on oral
presentations; and (6)
the overall quality of
the preceptor
experience.
Assessments were
made using 10-point
Scores for all six
evaluation
domains were
higher for CF
compared to
those from the
two previous
years combined
(all p<0.001). In
the fully adjusted
regression model,
only CF status
was
independently
associated with
high preceptor
evaluation scores
(Odds Ratio 4.3,
95% CI 1.01–
18.20). This
finding did not
change (all
differences
remained
significant) when
Colleges faculty
– – – Ashar B et al.
2007. An
association
between paying
physician-
teachers for
their teaching
efforts and an
improved
educational
experience for
learners.
Journal of
general internal
medicine,
22:1393–1397.
Epub
2007/07/27.
compensating
physician
educators would
have a
measurable
positive impact
on the students’
experiences in
this course. Until
2005, ‘clinical
skills’ preceptors
have exclusively
consisted of
faculty who
volunteered their
time to teach the
course. In return
for their efforts,
they were given
free registration
to the Medicine
Review Course
offered at
JHUSOM each
year.
For the 2005–
Likert scales (1 =
poor, 10 = excellent).
Students were given
these evaluations at
the time that they took
their final clinical
skills examination to
encourage full
participation. In
addition, students
who took the course
in 2005–2006 were
offered bonus points
for submission of
their evaluations. The
students’ evaluations
did not contain any
identifiable
information, and
students were
assured that data
would only be shown
to faculty members in
aggregate.
Multi-variable
regression analysis
(n=7) were
excluded from the
analysis (all
p<0.01).
For faculty who
had taught as
volunteers and
then as paid
College Faculty
no significant
differences in the
evaluation scores
were noted
between the
years when these
preceptors had
been
compensated for
their teaching as
Colleges faculty
and the prior
years when they
were volunteer
preceptors, thus
suggesting the
overall improved
2006 academic
year, the
JHUSOM
‘Colleges
Program’
provided salary
support to the
faculty teaching
the clinical skills
course. The
selection
process for the
Colleges faculty
included a
written
application,
letters of
support, and
interviews with a
selection
committee.
was used to identify
factors that were
independently
associated with
higher preceptor
evaluation score
(including rank, as a
proxy for years of
teaching
experience,
department/division,
previous experience
teaching the 'clinical
skills' course,
having received
intensive training,
affiliation with the
school of Medicine
(part- time vs. full-time
faculty), and Colleges
faculty status).
performance was
largely
attributable to the
new teachers the
programme
brought in.
Colleges’ faculty
were more likely
than preceptors
from the previous
2 years to have a
full-time affiliation
with the School of
Medicine (100 vs.
63%, p<0.01),
have an advanced
degree (48 vs.
15%, p<0.01), and
have been a
participant in the
Johns Hopkins
University Faculty
Development
Program in
Teaching Skills
(52 vs. 17%,
p<0.01).
USA
Medical
University
of South
Carolina
Medicine Medicine
department
In 2004, the
department
initiated an
annual strategic
planning process
for the core
missions of
patient care
education,
research and the
business of
medicine with a
strategic goal to
reward faculty
teaching.
Funding support
for education
was provided
through budget
Before
intervention
Several
characteristics of the
department are
compared before and
after the intervention
Eight of the 11
divisions
increased in
faculty size; 2
divisions
remained
unchanged, and
one decreased in
faculty size.
Educational value
units increased
over time in 8
divisions and
decreased in 3
divisions.
No results on
quality of
teaching from
faculty, only
amount of
teaching activity
– – Clyburn EB et al.
2011. Valuing
the education
mission:
implementing an
educational
value units
system. The
American
Journal of
Medicine,
124:567–572.
Epub
2011/05/25.
allocations to
divisions and
individual faculty
members.
The work group
decided to
weight the
division’s budget
allocation
initially so that
50% would be
based on the
division’s
educational
contribution,
30% on research
productivity, and
20% on the
number of
faculty full-time
equivalents.
Departmental
educational
contributions
were calculated
on the basis of
existing
databases of
medical students
and resident
teaching.
Lectures, small
group teaching,
physical
diagnosis, and
residency
interviewing also
were included.
On the individual
level an
educations value
unit system was
devised (see
paper) using a
time-based
system.
Conferences and
small group
teaching were
credited at an
hour for hour
basis with no
credit for
preparation.
Attendance at
grand rounds,
the premier
departmental
educational
conference, also
garnered
educational
value unit credit.
Delivering grand
rounds was
allocated
additional
educational
value unit credit
for preparatory
time. Residency
interviewing,
active
participation in
education
committees, and
faculty
development
activities also
received hour for
hour credit.
The educational
value unit work
relative value
unit equivalence
allowed
assignment of a
value of
US$41.00 per
educational
value unit or
US$82.00 per
hour for teaching
activities based
on AAMC median
salary for
academic
general
internists.
USA Family
medicine
Faculty A clinical relative
value unit was
designed so that
Before
intervention
Case study with
changes in the
distribution of points
Of the mean total
of 3980 points for
the year 1999, the
No significance
analysis
– – Cramer JS et al.
2000.
Implementing a
Buffalo
School of
Medicine
and
Biomedical
Sciences
it could be
translated to
equally value
and reward
faculty efforts in
patient care,
education and
research with the
aim of avoiding
the imposition of
a model that
could have
undervalued
scholarship and
teaching.
Only a small
financial
incentive was
necessary (in
1999, an
incentive pool of
4% of providers’
gross salary) to
motivate the
faculty to be
more productive
over time reported contribution from
teaching was
1146 or 29%,
compared with
25% in 1997.
comprehensive
relative-value-
based incentive
plan in an
academic family
medicine
department.
Academic
medicine:
Journal of the
Association of
American
Medical
Colleges,
75:1159–1166.
Epub
2000/01/11.
and to self-report
their efforts.
USA
University
of Florida
College of
Medicine
Medicine,
obstetrics
and
gynaecology
Faculty
members
A programme of
teaching awards.
To be eligible for
an award
educators must
have been
evaluated by and
submitted
grades for at
least half the
students. Eligible
educators with
an average score
of three or higher
are given awards
(a framed
Certificate of
Recognition for
Outstanding
Student
Before
intervention
The ratings of
educators is
compared over
different years before
and during the
programme
Since the
programme
began in 1990 a
higher
percentage of
faculty and
residents have
received awards
with each passing
year (faculty: 41,
61, 68 and 71%,
residents: 50, 57,
65 and 75%).
This is a result of
both an increase
in the number of
eligible educators
(i.e. those
handing in
grades) and in the
No significance
analysis. No
control for the
increasing
number of faculty
eligible for
awards.
– The
programme
cost
US$ 1990
the first
year,
US$ 3240
the second,
US$ 3734
the third
and
US$ 3940
the fourth
as more
awards
were given.
Ernest JM et al.
1995. Rewarding
medical student
teaching.
Obstetrics and
Gynecology,
86:853–857.
Epub
1995/11/01.
Teaching, a
Golden Apple pin
and a cash
award). Ineligible
educators may
be given awards
at the discretion
of the clerkship
director for
special
achievement
such as
improvement.
The clerkship
director also may
give non-
physicians, such
as nurses,
midwives, and
gynaecological
teaching
associates
involved in
student
education
awards. The
quality of their
teaching as
judged by the
students.
Teacher of the
Year award
(travelling silver
cup and a
substantial cash
award) is given
to a Faculty
member who, in
the chairman's
opinion, has
demonstrated
outstanding
undergraduate,
graduate and
continuing
education
activities. The
names of both
the faculty and
resident teachers
of the tear are
added to plaques
displayed
prominently.
USA
Harvard
Medical
School
Medicine,
primary care
Preceptors Stipends for
primary care
clerkship
preceptors were
raised from US$
600–900 (2003) to
US$ 2500 (2004)
and payments
were made
directly rather
than indirectly.
Before
programme
Retention rates were
compared before and
after stipends were
raised
Faculty were 2.66
times more likely
(P <0.0001) to
return to teach in
the highest pay
period than the
lowest, and
faculty receiving
direct payment
were more likely
to continue
teaching than
those receiving it
indirectly.
Only quantity, not
quality of
teaching
– – Peters AS et al.
2009. How
important is
money as a
reward for
teaching?
Academic
Medicine:
Journal of the
Association of
American
Medical
Colleges, 84:42–
46. Epub
2009/01/01.
USA
University
of
Cincinnati
General
internal
medicine
Faculty in the
Division of
General
Internal
Medicine
A value in
teaching units
was assigned to
each teaching
activity in
proportion to the
time expended
by the Faculty
and the intensity
Before
intervention
The distribution of
discretionary teaching
dollars was studied
Totally
discretionary
dollars increased
11.4% with the
programme’s
implementation.
Changes for
individual
divisions ranged
No measure of
quality of
teaching or
student learning
– – Rouan GW et al.
1999. Rewarding
teaching faculty
with a
reimbursement
plan. Journal of
General Internal
Medicine,
14:327–332.
of their effort.
The total
teaching units
were calculated
for each faculty
member in the
Division of
General Internal
Medicine and for
combined
Faculty effort in
each sub-
specialty
division.
After
determining the
dollar value for a
teaching unit
discretionary
teaching dollars
were distributed
to each faculty
member
according to the
total number of
from an increase
of 78% to a
decrease of
28.5%.
The distribution
of teaching units
among divisions
was similar to the
distribution of
questions across
sub-specialties
on the American
College of
Physicians In-
Training
Examinations (r =
0.67) and the
American Board
of Internal
Medicine
Certifying
Examination (r =
0.88).
Epub
1999/06/03.
teaching units.
USA Medicine A performance-
based compens-
ation and faculty
track programme
using Relative
Value Units with
Clinician
Educators track
(see paper).
Before
intervention
Student and Faculty
were surveyed
Some clinician–
educators felt
they spent less
time teaching but
the students and
house staff gave
high marks on
general measures
of availability and
quality. The
department met
all of its
substantial
teaching
obligations
without
disruption or
reductions of
effort.
The perceptions
of some faculty
that they did less
teaching were not
Intervention not
specifically
targeted at
education
mission
– – Tarquinio GT et
al. 2003. Effects
of performance-
based
compensation
and faculty track
on the clinical
activity,
research
portfolio, and
teaching
mission of a
large academic
department of
medicine.
Academic
Medicine:
Journal of the
Association of
American
Medical
Colleges,
78:690–701.
Epub
reflected in their
commitment to
assignments.
2003/07/15.
Recommendation 2: Governments, funders and accrediting bodies should consider supporting the implementation of higher
education policies for mandatory faculty development programmes that are relevant to the evolving health care needs of their
communities.
Country Institution
Health
professional
group
Population Intervention Comparison Study design and
methods
Reported results
(outcomes) GRADE-able
Benefits/li
mitations
Val
ues
and
pref
ere
nce
s?
Resource
use? Reference
USA University
of
Minnesota
Ambulatory
medicine
Volunteer
community
preceptors in
Ambulatory
Care Rotation
One full day
workshop for
prospective
community
preceptors and
periodic follow-up
activities aimed to
inform
participants of the
place of ACR in
the medical
curriculum, to
Volunteer
community
preceptors
(in other
areas of
medicine)
who did not
have the
intervention
Retrospective
pre- and post-
self ratings were
gathered from
preceptors on
teaching skills
and knowledge.
Student ratings
of the rotation
and teaching by
preceptors were
A significant
improvement in
self- rated
teaching skills
and knowledge
was observed
for all skill
areas (p<0.001).
Student ratings
of the ACR
course and the
Yes? Student
ratings of
ACR
preceptor
s are
only
compare
d to
ratings of
preceptor
s in other
areas.
97
%
rete
ntio
n
rate
sug
ges
ts
fac
ulty
are
– Keenan JM et
al. 1990. A
workshop
program to
train volunteer
community
preceptors.
Academic
Medicine:
Journal of the
Association of
American
inform about the
objectives of the
curriculum and to
increase the
clinical teaching
skills of the
participants.
Five such
workshops were
held between 1984
and 1987 for a
total of 60 faculty
members.
also used. preceptor
teaching
(n=165) was
high (1.358 for
the ACR
course, 1.371
for the
preceptors'
teaching and
1.567 for the
preceptors’
feedback (1 =
excellent, 5 =
poor).
This compared
with average
ratings from
other clinical
courses at the
same
university.
Examples are
given of
neurology,
internal
medicine and
Ideally,
they
would be
compare
d with
other
ACR
preceptor
s who
had not
complete
d the
training.
No
indicatio
n is given
as to if
these
differenc
es are
statistical
ly
significa
nt. Usual
limitation
s of both
sati
sfie
d
Medical
Colleges,
65:46–47.
Epub
1990/01/01.
surgery where
ratings by the
same group of
students
ranged from
1.40 to 2.22 for
the course, 1.67
to 1.77 for the
preceptors'
teaching and
1.76 to 2.61 for
the preceptors'
feedback.
Additionally,
97% of
preceptors’
attending the
workshops
continued to be
active teachers
in the ACR
course.
a
retrospec
tive and a
self-
rating
method.
USA Albany
Medical
Family 12 family
practice
One-day
workshop
Pre- Ratings were
collected from 82
The students'
mean ratings of
Yes – Tha
t
– Nathan RG,
Smith MF.
College,
New York
medicine faculty
members
conducted by the
University of New
Mexico designed
to promote
teaching methods
that use active,
student- directed
learning. Also a
three-month
follow-up
classroom visit for
each participant
was used to
provide feedback.
intervention third year
students from 14
classes. 25
ratings were of
teaching before
the workshop, 23
of teaching after
the workshop
but before the
follow-up visit
and 34 of after
the follow-up
visit. Ratings
were made on
three six-point
Likert scales.
The three Likert
scales had
anchors of
"lecture
presentation"
and "interactive
discussions";
"textbook
information" and
"case
teaching
increase
significantly
from "lectures"
(4.60) before
the workshop
towards
"interactive
discussion"
(5.03) after it
(p<0.05) with no
significant
change after
the follow-up
(4.95). Similarly,
there was a
significant
move away
from "textbook
information"
towards "case
applications"
with no change
after follow-up.
There was,
however, a
significant
stu
den
ts’
ove
rall
sati
sfa
ctio
n
wit
h
tea
chi
ng
fell
sug
ges
ts
the
tea
chi
ngs
skill
s
the
wor
ksh
1992.
Students'
evaluations of
faculty
members'
teaching
before and
after a teacher-
training
workshop.
Academic
medicine:
Journal of the
Association of
American
Medical
Colleges,
67:134–5.
Epub
1992/02/01.
applications";
and "did not
meet my
educational
needs" and "met
my educational
needs".
(p<0.05) decline
in student
perception that
overall
educational
needs were
being met. No
significant
change in exam
scores.
op
foc
use
d
on
are
not
tho
se
des
ired
by
stu
den
ts
USA Facilitators
from 12
institutions
trained at
the
Stanford
Faculty
Develop-
ment
Medicine 12 facilitators
from 12
institutions
trained at the
Stanford
Faculty
Development
Program.
They then
12 facilitators
from 12
institutions
undertook the 1
month long
Stanford Faculty
Development
Program in which
they were trained
to conduct
Pre-
intervention
ratings
Participating
faculty (at the
home
institutions)
completed self-
assessment
questionnaires
(5 point Likert
scales) before
and after the
For the
faculties' self-
ratings there
were
statistically
significant
(p<0.10)
increases
between the
pre-rating and
Yes – – – Skeff KM et al.
1992.
Improving
clinical
teaching.
Evaluation of a
national
dissemination
program.
Archives of
Program trained a total
of 107 faculty
at their home
institutions
instructional
improvement
seminars for their
fellow faculty to
assist them in
teaching house
staff and students.
These 12
facilitators then
conducted such
seminar series
(usually over a 7-
week period) in
their own
institutions. In
total 107 faculty
were trained. This
is called a
dissemination
model.
seminar series
rating their own
teaching
performance,
attitudes
towards teaching
and awareness
of their teaching
strengths and
weaknesses
(traditional
pre/post ratings).
Student
evaluations of
the teachers'
performances
before and after
the seminar
series were also
used.
(Usually these
were by different
students
because
rotations
post-rating
across the 3
years. Full
results in table
in paper.
Faculties'
ratings of their
general
teaching ability
also increased
(see paper for
detailed
results). For the
students
ratings of the
faculties'
teaching 12 out
of the 21
comparisons
showed
increases in
pre-rating to
post-rating that
either reached
(7) or
approached (5)
significance
internal
medicine,
152:1156–
1161. Epub
1992/06/01.
typically change
monthly,
therefore
independent t-
test comparison
had to be used.)
(p<0.10). (See
paper for
detailed
results.)
USA University
of Vermont
Paediatrics Second and
third year
paediatric
residents who
teach medical
students
Half-day
workshop to
provide residents
with 6 key clinical
teaching skills.
– Before and after
the intervention,
trained faculty as
they precepted
third year
medical students
in clinic
observed the
participants. 29
resident-student
teaching
encounters were
observed before
the workshop (8
different
residents) and 27
encounters in
The observed
teaching of
residents
improved in all
5 teaching
skills measured
(where, what,
why, whenever,
feedback)
although
significance is
not specified.
Even after the
workshop,
feedback was
still only given
– Significa
nce not
given.
Only
teaching
methods
are
measure
d not
outcome
s and not
it is
useful to
the
student-
– – White CB,
Bassali RW,
Heery LB.
1997. Teaching
residents to
teach. An
instructional
program for
training
pediatric
residents to
precept third-
year medical
students in the
ambulatory
clinic.
Archives of
the 10 weeks
after the
workshop (10
different
residents).
18% of the time. Pediatrics &
Adolescent
Medicine,
151:730–735.
Epub
1997/07/01.
USA Medical
College of
Wisconsin
Paediatrics Paediatric
faculty
Seven one-hour
conferences were
held for preparing
faculty during the
academic year
1994–95.
Conferences
include
discussion about
teaching in a
particular
situation to
videotapes of
clinical teaching
and live clinical
teaching.
Faculty who
did not
attend any
session
(n=31) (self
selected
control
group).
Participants'
evaluations were
used.
Student and
resident ratings
of faculty who
attended (at least
two sessions)
(n=25) were
compared with
those who did
not attend any
(n=31).
Faculty who
attended at
least two
conferences
had statistically
significant
improved
ratings in both
feedback (p=
0.01) and
overall teaching
effectiveness
(p=0.04).
There was no
significant
change in the
ratings of
faculty who did
Yes? Sampling
bias –
control/
participat
ion group
is self
selected
– – Lye PS et al.
1998. Clinical
teaching
rounds. A
case-oriented
faculty
development
program.
Archives of
Pediatrics &
Adolescent
Medicine,
152:293–295.
Epub
1998/04/08.
not attend.
USA Various Medicine 223
community
health centre
preceptors
from a variety
of disciplines.
57% of the
preceptors
were
physicians,
14.5% were
nurses, 10%
educators or
outreach staff,
7% physician
assistants and
11.5% "other
Primary Care
Futures
workshops were
held five times
throughout the
USA (each faculty
member attended
just one
workshop).
Workshop topics
included the
educational
planning process,
teaching styles
and evaluation
and feedback.
Pre-
intervention
Participants' pre-
and post-
intervention self-
assessments
were compared.
Participants’ pre-
and post-
intervention
performance in
analysing an
educational
encounter was
also observed.
The
participants'
self
assessments of
their knowledge
of 9 of the 11
teaching
concepts
measured
increased
significantly at
the p<0.01
level, this
increase was
retained on all
nine concepts
after 3 months.
– – – – Quirk ME et al.
1998.
Evaluation of
primary care
futures: a
faculty
development
program for
community
health center
preceptors.
Academic
Medicine:
Journal of the
Association of
American
Medical
clinicians". There was a
significantly
positive
(p<0.01)
increase
between the
preceptors
current and
anticipated use
of 8 of 11
teaching
behaviours.
After 3 months,
6 of the 8
changes
remained
positive (2
reverted to the
pre-workshop
level and one
decreased)
although for 5
of the 6 use
was
significantly
less than
Colleges,
73:705–707.
Epub
1998/07/08.
anticipated.
USA Stanford
University
School of
Medicine
Medicine Basic science
teachers,
pathology
The Stanford
Faculty
Development
Program's
seminars on
clinical teaching
were adapted for
basic science
instruction, 8
pathology faculty
participated in a
series of 9 small-
group seminars
designed to
provide teachers
with knowledge of
a framework for
analysing
teaching and
identifying areas
for improvement
and skill-based
training in specific
teaching
Pre-
intervention
Participant self-
assessment
(post-seminar
and after five
months, student
ratings of
participants and
blinded ratings
of pre- and post-
seminar
videotapes of
participants
classroom
teaching.
Very positive
participant
satisfaction
with the
programme
(see paper).
Both the post-
seminar and
five-month
follow-up
questionnaire
showed short
and long-term
positive effect,
with high
ratings for the
seminars'
impact on the
participants'
knowledge of
teaching
principles,
ability to
analyse
Yes Small
sample
size, only
patholog
y
teachers
– – Skeff KM et
al.1998. A pilot
study of
faculty
development
for basic
science
teachers.
Academic
Medicine:
Journal of the
Association of
American
Medical
Colleges,
73:701–704.
Epub
1998/07/08.
behaviours.
Each seminar
included brief
lectures, review of
videotaped re-
enactments of
teaching
interactions, role-
play exercises
with videotape
reviews and
formulation of
personal and
departmental
teaching goals.
teaching,
preparation for
teaching,
teaching
behaviours,
teaching
philosophy and
enthusiasm for
being a
pathology
instructor
(range 4.25-
4.88; 1=low,
5=high).
Participants'
ratings
indicated an
increased
awareness of
teaching
problems
(pre=2.63,
post=4.38,
p=0.002). The
pre- and post-
self-
assessment
ratings
indicated
statistically
significant
increase in
teaching
performance
related to all
but 2 of the 7
seminar topics
(see paper for
details). In the
5-month follow-
up
questionnaire,
the
participants'
ratings of their
teaching
performances
revealed
statistically
significant
retrospective
pre- and post-
seminar
increases for all
7 categories
(p=0.005). Also
following the
seminar
participants
were
significantly
less likely to
base their
teaching
methods on
tradition
(p=0.005) and
time
constraints
(p=0.05) and
were more
inclined to use
educational
principles
(p=0.002),
students' needs
(p=0.03) and
students'
course
evaluations
(p=0.06).
Student ratings
of all 7
participants'
lectures were
significantly
higher after the
seminar series.
(pre-mean=3.66,
post-
mean=4.16,
p=0.04).
Ratings by the
trained rater
indicated
teaching
improvements
for 5 of
the 7
participants
who had pre-
and post-
seminar
videotapes.
Teaching types
changed, 81%
of the pre-
seminar tape
segments were
classified as
lecturing only
compared to
52% of the
post-seminar
tape segments.
USA – Medicine
and
paediatrics
Clinician
educators in
medicine and
paediatrics
Programme
includes a 12-hour
course (focused
on skills in
precepting,
bedside teaching,
leading small-
group
discussions,
giving lectures,
designing
curricula and
giving effective
feedback), onsite
coaching of
teaching (on
Self-selected
control
group, non-
participants
in the
programme
Outcome
variable was the
ratings by
fellows,
residents and
medical students
of both the
experimental
faculty (those
that undertook
the programme)
and the control
group. To check
whether trainees
perceived
improvement in
Median post-
test rating for
participants
was
significantly
higher than the
median pre-test
rating (p =
0.002). The
median pre-test
rating for the
experimental
group (4.19)
was not
significantly
different to the
Yes? Sampling
bias, self-
selected
participa
nt/control
groups.
The
experime
ntal
group
were self-
selected
(likely to
already
be those
faculty
– – Hewson MG,
Copeland HL.
1999.
Outcomes
assessment of
a faculty
development
program in
medicine and
pediatrics.
Academic
Medicine:
Journal of the
Association of
American
Medical
wards, in
outpatients’
clinics or in formal
lectures) and
innovative
projects in clinical
medical
education.
the clinical
teaching of the
participants
when compared
with a control
group, pre- and
post-course
ratings were
collected. To
identify whether
trainees
perceived
differences in
their faculty's
clinical teaching
when comparing
participants with
a control group
post-course
ratings of the
two groups were
compared.
median for the
control group
(4.14). (The
mean ratings
do show a
greater
difference
though.) After
the
intervention,
the median
post-test score
(4.46 was
significantly
higher than the
median score
for the control
group (4.15) (p
= 0.006).
most
intereste
d in
improvin
g their
clinical
teaching)
.
Colleges,
74(Suppl.):S68
–S71. Epub
1999/10/28.
AND
Hewson MG.
2000. A theory-
based faculty
development
program for
clinician-
educators.
Academic
Medicine:
Journal of the
Association of
American
Medical
Colleges,
75:498–501.
Epub
2000/05/29.
AND
Hewson MG,
Copeland HL,
Fishleder AJ.
2001. What's
the use of
faculty
development?
Program
evaluation
using
retrospective
self-
assessments
and
independent
performance
ratings.
Teaching and
Learning in
Medicine,
13:153–60.
Epub
2001/07/31.
USA
(Connecticu
t, New
Hampshire,
Vermont,
New York,
Ohio,
Virginia)
– Medicine 282
community-
based clinical
teachers and
university-
based
teachers
5 regional 1- to 2-
day teaching
improvement
workshops for 282
faculty (49%
community based,
51% university
based).
Workshops were
conducted by
regional
facilitators trained
by the Stanford
Faculty
Development
Program using
large group and
small group
instructional
methods to teach
participants a
framework for
analysing
teaching, to
increase their
repertoire of
Pre-
intervention
Retrospective
pre- and post-
workshop self
assessments
Participants'
ratings
indicated that
the programme
had a positive
effect on their
knowledge of
teaching
principals, an
increase in their
teaching ability
(p<0.001) and
an increase in
their sense of
integration with
their affiliated
institution.
(p<0.001). See
paper for more
statistics.
No? – Part
icip
ant
s
had
a
sig
nifi
can
tly
gre
ater
sen
se
of
inte
grat
ion
wit
h
thei
r
affil
iate
d
inst
– Skeff KM et al.
1999. Regional
teaching
improvement
programs for
community-
based
teachers. The
American
Journal of
Medicine,
106:76–80.
Epub
1999/05/13.
teaching
behaviours, to
define personal
teaching goals
and to identify the
educational needs
of their teaching
site.
ituti
on
foll
owi
ng
the
wor
ksh
op
USA University
of
California
Medicine 57 second-
and third-year
internal
medicine
residents who
teach medical
students
One-hour session
on the One-Minute
Preceptor model
incorporating
lecture, group
discussion and
role-play given to
the intervention
group (n=28).
Randomly
sampled
control
group (n=29)
Residents' self
reports. Learner
ratings of
resident
performance of
the OMP
teaching
behaviours.
Residents
assigned to the
intervention
group reported
statistically
significant
changes in all
behaviours
(p<0.05).
Student rating
of teacher
performance
showed
improvements
in all skills
Yes Random
sampling
– Limited
resource
use, just a
one hour
workshop
Furney SL et
al. 2001.
Teaching the
one-minute
preceptor. A
randomized
controlled
trial. Journal
of General
Internal
Medicine,
16:620–624.
Epub
2001/09/15.
except
"Teaching
General Rules".
Learners of the
residents in the
intervention
group reported
increased
motivation to
do outside
reading when
compared to
learners of the
control
residents.
Ratings of the
overall teaching
effectiveness
were not
significantly
different
between the 2
groups.
USA San
Francisco
Medicine Two cohorts
of faculty
12 intensive
weekend sessions
Pre- Pre- and post-
programme self-
Self-ratings
significantly
– – – – Teherani A,
Hitchcock MA,
School of
Medicine,
University
of
California
(n=21 in year
one and n=15
in year two)
who
completed the
teaching and
learning
fellowship
modelled upon the
executive training
model used by
business schools.
Distance learning
was used between
weekend
sessions.
Participants
received
assignments
online, exchanged
drafts of projects
and developed
group
presentations
online or through
e-mail. Topics
included
curriculum
design, research
project
development,
small-group
teaching and
learner evaluation.
intervention ratings. Interview
and focus group.
Follow-up
interviews and
interviews with
supervisors and
colleagues.
increased in all
areas
questioned.
Interviews also
created very
positive
statements
about
participants
learning.
During the
follow-up
interviews, all
18 participants
responded that
the workshop
had positively
changed their
teaching
practices.
Interviews with
colleagues
corroborated
this.
Nyquist JG.
2001.
Longitudinal
outcomes of
an executive-
model
program for
faculty
development.
Academic
Medicine:
Journal of the
Association of
American
Medical
Colleges, 76
(Suppl.):S68–
S70. Epub
2001/10/13.
USA Harvard
Medical
School
Medicine Physician
educators
Harvard Macy
Program for
Physician
Educators
Pre-
intervention
Self-reported
teaching
behaviour
collected by
follow-up survey
77.8% of
respondents
reported that
participation
had
significantly
affected their
professional
development
including long-
term changes in
teaching
behaviours.
No – – – Armstrong EG,
Doyle J,
Bennett NL.
2003.
Transformativ
e professional
development
of physicians
as educators:
assessment of
a model.
Academic
Medicine:
Journal of the
Association of
American
Medical
Colleges,
78:702–708.
Epub
2003/07/15.
UK Medical
School,
University
Medicine Medical
educators
Teaching
Improvement
Evaluation System
Pre-
intervention
Machine-
readable
questionnaire
Highly
significant
improvements
– – – – Dennick R.
2003. Long-
term retention
of
Nottingham
(TIPS). Two-day
course.
was devised
asking
participants on
the TIPS course
to rate their own
ability to perform
specified
teaching and
learning-related
activities on a 1-
5 Likert scale. As
a control, one of
the abilities,
‘demonstrate
practical
procedures’, was
not a formal
feature of the
TIPs course.
Between a year
and two years
after the course
(depending on
when
participants took
the course), all
these
are recorded for
almost all the
abilities rated
(see paper for
table). The
largest
differences
were for using
learning
objectives and
structuring
learning
sessions. The
next highest
differences are
for confidence
in teaching and
teaching skills.
Two
differences: the
internal control
rating ‘the
ability to
demonstrate
practical
procedures’,
and
of teaching
skills after
attending the
Teaching
Improvement
Project: a
longitudinal,
self-evaluation
study. Medical
Teacher,
25:314–8.
Epub
2003/07/26.
AND
Dennick R.
1996. The
Teaching
Improvement
Project
System (TIPS):
servicing the
need for
teacher
training in
Higher
participants were
sent an identical
‘post-TIPS’
questionnaire
and asked once
again to rate
themselves. In
addition, they
were sent a free-
response form
asking them a
number of
closed (Yes/No)
questions and a
number of open
questions asking
them to describe,
in their own
words, what they
felt they had
learned on the
course, how they
had put their new
skills into
practice, how
they thought
their teaching
‘understand
learners
problems’ were
non-significant.
The written
comments
showed that
91% of the 47
written
respondents
indicated that
they had had an
opportunity to
put into
practice what
they had
learned on the
TIPS course;
60% indicated
that they felt
their students
had benefited
from their being
on the course,
32% felt they
had possibly
benefited and
Education.
New
Academic,
5:12–13.
AND
Dennick R.
1998. Teaching
medical
educators to
teach: the
structure and
participant
evaluation of
the Teaching
Improvement
Project.
Medical
Teacher,
20:598–601.
had improved
and whether they
felt their
students had
benefited.
6% were not
sure.
UK Faculty of
Medicine,
University
of
Southampto
n
Medicine,
general
practitioner
s
General
practitioner
educators
One day
workshop on
facilitating a
learner-centred
approach to
teaching
No control Immediate
evaluation.
Participants were
then contacted
between 3
months and 1
year following
the workshop.
70% of those
who replied
who had taught
fifth-year
students said
they had tried a
new teaching
method.
No No
control
– – Coles CR,
Tomlinson JM.
1994. Teaching
student-
centred
educational
approaches to
general
practice
teachers.
Medical
Education,
28:234–238.
Epub
1994/05/01.
USA University
of
Massachus
Medicine Community
preceptors
Faculty
development
workshop focused
Pre-
intervention
Pre- and post-
workshop written
test was used
Using
independent t-
tests no
– Only
learning,
no
– – Stone S et al.
2003.
Development
etts Medical
School
on improving
feedback skills
with one group
completing the
test before the
intervention and
the other after it.
statistically
significant
differences
between the
pre- and post-
test group were
found.
Grouping the
checklist items
according to
behaviors
explicitly
targeted in the
workshop,
however, found
statistically
significant
differences
between the
two groups for
score based on
items related to
the
development of
the action plan
(d = –.721, p =
indicatio
n of
whether
teaching
practices
changed
and
implementatio
n of an
objective
structured
teaching
exercise
(OSTE) to
evaluate
improvement
in feedback
skills following
a faculty
development
workshop.
Teaching and
Learning in
Medicine,
15:7–13. Epub
2003/03/14.
.03).
USA Various Medicine Teams from
110 teaching
hospitals were
trained to
implement
local faculty
development
in teaching
skills
Teams from 110
teaching hospitals
were trained to
implement local
faculty
development in
teaching skills
– A prospective
observational
study followed
the 110 teams for
up to 24 months.
Self-reported
implementation
was defined as
the time from the
training
conference until
the team
reported that
implementation
of their FD
project was
accomplished.
The median
follow-up was
18 months. 59
of the teams
(54%)
implemented
their local FD
project and
subsequently
trained over
1400 faculty, of
whom 599 were
community
based.
No No
outcome
s from
either
faculty
trained or
student
learning
– US$ 22 933
per
successful
team and
US$ 544
per faculty
member
trained
Houston TK et
al. 2004.
Outcomes of a
national
faculty
development
program in
teaching
skills:
prospective
follow-up of
110 medicine
faculty
development
teams. Journal
of General
Internal
Medicine,
19:1220–1227.
Epub
2004/12/22.
USA John
Hopkins
Bayview
Medical
Center
Medicine Faculty and
fellows
associated
with John
Hopkins
Medical
institutions
and other
institutions in
the region.
Nearly 399
learners have
participated in
the
programme
since it began
in 1987
including
general
internists,
family
physicians,
paediatricians,
psychiatrists
and
behavioural
9 month, 1 half
day per week
course designed
to give
participants
expertise in
concepts such as
learner
centeredness,
self-directed
learning and
creating a
supportive
learning
environment.
Participants met
in groups of 5–8
participants with
1–2 facilitators
between early
September and
late May to work
on modules that
varied in length
from 1–6 weeks.
Module topics
121 members
for a
comparison
group were
selected.
Participants
from 1988–
1995 were
instructed as
they entered
the
programme
to select a
non-
participant
for inclusion
in the
comparison
group who
was similar
to
themselves
in terms of
professional
status,
percentage
Pre- and post-
course self-
assessments
from participants
and the control
group were
compared. (See
paper for
detailed
thorough
method.)
Participants
were
significantly
more likely
(p<0.1) to rate
their skills in
giving
feedback,
eliciting
feedback as
very good or
excellent. There
was no
significant
difference in
other teaching
skills or overall
teaching skills.
It is noted that
although
attempts were
made to make
the comparison
group as
similar as
possible to the
Yes? Control
group
used but
evidence
shows it
is not
particular
ly similar
in initial
(perceive
d)
teaching
skills to
participa
nts so
usefulne
ss can be
question
ed
– – Knight AM et
al. 2005. Long-
term follow-up
of a
longitudinal
faculty
development
program in
teaching skills.
Journal of
General
Internal
Medicine,
20:721–725.
Epub
2005/07/30.
scientists. included giving
and eliciting
feedback,
precepting (one-
on-one teaching),
time management,
giving lectures
and presentations,
and small-group
leadership skills.
A wide range of
teaching methods
was used but
most commonly
included large
group
presentations,
small-group
discussions, and
skills practice.
of time spent
teaching,
faculty
appointment
level, age
and gender.
The non-
participants
could not be
enrolled in or
employed by
any Johns
Hopkins
Medical
Institution at
the time of
their
selection in
order to
avoid being
exposed to
programme
faculty or
participants,
and to
minimize the
likelihood
participants,
the comparison
group rated
their teaching
ability as
significantly
higher than
participants
prior to the
intervention.
that they
would
themselves
become
participants
at a later
date.
USA John
Hopkins
Medicine Clinician
educators
The Johns
Hopkins Faculty
Development
Program in
Teaching Skills
was first
implemented in
1987 as a
theoretically
grounded,
longitudinal model
for faculty
development of
clinician–
educators. It
comprises a set of
conditions
intended to
Comparison
group of 112
non-
participants
between
1988 and
1996 vs. 98
participants.
Comparison
group
selected as
above.
A pre–post
evaluation
design with
comparison
group measured
changes in self-
assessed
teaching and
professional
skills, teaching
enjoyment, and
learning
effectiveness. A
post-only
evaluation
design appraised
overall
programme
Programme
participants
had
significantly
greater pre- and
post-change
scores than
non-
participants for
all 14 outcomes
(p .05). Multiple
regression
modelling
indicated that
programme
participation
was associated
with pre–post
Yes? – Rep
orts
pos
itiv
e
imp
act
on
coll
eag
ue
rela
tion
shi
ps
– Cole KA et al.
2004. Faculty
development
in teaching
skills: an
intensive
longitudinal
model.
Academic
Medicine:
Journal of the
Association of
American
Medical
Colleges,
79:469–480.
Epub
promote reflective
learning.
Participants met
with facilitators
weekly for 9
months for 3.5
hours in stable
groups of four to
six individuals.
Educational
methods used
across 7 content
areas emphasized
relationships and
collaboration, and
included
information
provision,
experiential
learning with
reflection, and
personal
awareness
sessions.
quality,
educational
methods,
facilitation,
learning
environment,
and perceived
impact of
participation.
Multivariate
regression
modelling to
assess whether
personal
characteristics
affect the
relationship
between
programme
participation and
outcomes.
improvement in
all outcomes
except
administration
skills,
controlling for
all participant
and non-
participant
baseline
characteristics
(p .05).
2004/04/27.
Switzerland University
of Geneva
Faculty of
Medicine
Medicine PBL tutors Workshop using a
'tailored' approach
integrating
learner-centred
interactive and
reflective teaching
strategies in its
programme.
Self-selected
control
group, non-
participants
in the
programme
Outcome
measures were
the tutors'
evaluation of the
workshop,
tutors' self-
assessment in
changes in
teaching
strategies and
students' ratings
of tutors’
performance. A
quasi-
experimental
design was used
to compare the
96 tutors who
attended the
workshop with
the 30 who could
not attend. The
data consisted of
a total of 7938
ratings
performed by
Tutors found
the workshop
useful (see
paper for
stats.). Before
the workshop,
although tutors
who attended
the workshop
had a slightly
lower baseline
score for these
skills, both
groups (with
and without
workshop
attendance) did
not differ
significantly.
The differences
in scores over
time between
baseline and
one-month and
one-year scores
respectively
Yes? Sampling
bias, self-
selected
participa
nt/control
groups
– – Baroffio A et
al. 2006. Effect
of teaching
context and
tutor
workshop on
tutorial skills.
Medical
Teacher,
28:e112–e119.
Epub
2006/06/30.
450 students
from the classes
from 1998 to
2000. Students’
baseline ratings
were compared
of the 126 tutors
with the ratings
they received
one month and
one year after
the workshop.
were analysed
by multivariate
ANOVAs. It was
found that the
lower the
baseline score
of the tutor the
greater
improvement
there was in
student ratings
for content
knowledge,
overall
performance
and PBL guide.
Overall when
multivariate
analysis was
used, the effect
of the
workshop was
only found to
be significant
for changes in
students’
ratings of tutors
as a PBL guide,
and the
workshop and
teaching unit
together were
found to be
statistically
significant in
explaining
changes in
tutors' ratings
for content
knowledge, but
not for tutors’
overall
performance or
student
participation.
USA – Internal
medicine
8 internal
medicine
faculty
Stanford Faculty
Development
Program in
Clinical Teaching
on ambulatory
Pre-
intervention
Before and after
the intervention,
faculty were
videotaped
during a case
Among the 48-
videotaped
encounters,
there were a
total of 7119
Yes? Small
sample
size
– – Berbano EP et
al. 2006. The
impact of the
Stanford
Faculty
teaching
behaviour. 7 x 2
hour sessions of
faculty
development.
Each session
included didactic,
role-play and
videotaped
performance
evaluation.
presentation
from a
standardized
learner who had
been trained to
portray 3 levels
of learners: a
third-year
medical student,
an intern, and a
senior medical
resident. Teacher
and learner
utterances (i.e.
phrases) were
blindly and
randomly coded,
using the
Teacher Learner
Interaction
Analysis System,
into categories
that capture both
the nature and
intent of the
utterances.
Change in
utterances, with
3203 (45%) by
the teacher.
Examining only
the teacher, the
total number of
questions
asked declined
(714 vs. 426, P
= .02) with an
increase in the
proportion of
higher level,
analytical
questions (44%
vs. 55%,
Po.0001). The
quality of
feedback also
improved, with
less ‘‘minimal’’
feedback (87%
vs. 76%,
Po.0005) and
more specific
feedback (13%
vs. 22%)
Development
Program on
ambulatory
teaching
behavior.
Journal of
General
Internal
Medicine,
21:430–434.
Epub
2006/05/18.
teaching
behaviour as
detected through
analysis of the
coded utterances
was measured.
provided.
The
Netherlands
– Medicine Residents who
teach medical
students
Two-day
workshop on
teaching skills
Control
group (n=13)
randomly
assigned.
(Experimenta
l group n=14)
Using
standardized
questionnaires,
the teaching
abilities of all
participants
(control and
experimental)
were
anonymously
assessed by
medical students
before and after
the workshop.
A significant
improvement in
the teaching
abilities of the
medical
residents in the
experimental
group was
observed
following the
workshop (t =
2.68, p = 0.02).
The effect size
within the
experimental
group was large
(d = 1.17),
indicating that
the workshop
Yes Proper
randomly
selected
control
group
but small
sample
size
Me
ntio
ns
diffi
cult
ies
in
sec
urin
g
the
full
sup
port
and
coo
per
atio
n of
– Busari JO et
al. 2006. A
two-day
teacher-
training
programme for
medical
residents:
investigating
the impact on
teaching
ability.
Advances in
Health
Sciences
Education:
Theory and
Practice,
11:133–44.
led to a
measurable
positive change
in the medical
residents’
teaching
abilities. The
effect size
estimated from
the post-
intervention
scores on
teaching ability
of the two
groups showed
a moderate
improvement (d
= 0.57) in the
experimental
group
compared with
the control
group.
the
hea
ds
of
dep
art
me
nt
and
atte
ndi
ng
doc
tors
for
inte
rve
ntio
n.
Epub
2006/05/27.
USA – Internal 68 internal
medicine
Workshop on the
One Minute
Self-selected
control
Resident
anonymous
Faculty self-
assessment
Yes? Sampling
bias,
– – Eckstrom E,
Homer L,
medicine continuity
clinic
preceptors (44
control and 24
intervention
faculty) at a
university, a
veterans’
affairs
hospital, and 2
community
internal
medicine
training sites.
Preceptors
method. Each of
the 5 micro-skills
of the OMP was
taught during brief
didactic sessions.
Most of the
workshop time
was devoted to
case-based
practice.
group, non-
participants
in the
programme
ratings (using
Likert scales) of
participant and
control faculty
were collected
every 6 months
for 2 years and
were analysed
and compared.
Faculty self-
assessment was
also collected via
a questionnaire
on each of the 5
OMP skills using
Likert scales.
showed
statistically
significant
improvements
in 3 out of the 5
micro-skills
(p<0.05).
Residents'
rating of faculty
improved in 4
of the 5 areas
but none were
statistically
significant.
control
group
not
randomly
selected
Bowen JL.
2006.
Measuring
outcomes of a
one-minute
preceptor
faculty
development
workshop.
Journal of
General
Internal
Medicine,
21:410–414.
Epub
2006/05/18.
Switzerland University
of Geneva
Medicine PBL tutors Teaching
intervention on
giving feedback
Self-selected
control
group, non-
participants
in the
programme
Students rated
126 tutors of 13
one-month
teaching units
over 3
consecutive
years on their
ability to provide
feedback. A
One month
after the
intervention
tutors of the
control and
intervention
groups were
still rated
identically by
Yes? Sampling
bias,
control
group
not
randomly
selected.
No real
explanati
– – Baroffio A et
al. 2007. Tutor
training,
evaluation
criteria and
teaching
environment
influence
students'
quasi
experimental
design was used
by comparing
students' ratings
of the 30 tutors
who had no
intervention with
those of the 96
tutors who had
the intervention
students. After
one year it is
reported that
those tutors
with a high
baseline score
received
significantly
higher ratings
than those who
had not
attended.
on given
as to why
ratings
would
improve
a year
after the
interventi
on but
not after
one
month
and only
for high
baseline
tutors.
ratings of tutor
feedback in
problem-based
learning.
Advances in
Health
Sciences
Education:
Theory and
Practice,
12:427–439.
Epub
2006/07/19.
USA – Medicine PBL tutors for
gastrointestin
al
pathophysiolo
gy
PBL learning
course which
trained tutors to
be discussion
leaders rather
than facilitators
Pre-
intervention
Student ratings
of tutors were
gathered for the
3 years of the
study on Likert
scales. Students'
mean scores on
the USMLE were
In the third year
of the
programme
(2005) student
ratings
indicated that
their tutors
were
significantly
Yes Multivari
ate
analysis
not used
on exam
score
improve
ment
– – Shields HM et
al. 2007. A
faculty
development
program to
train tutors to
be discussion
leaders rather
than
also studied. better at
encouraging
student
direction of the
tutorials than in
the first year
(p<0.05). The
students
reported that
the tutorial
made a more
important
contribution to
their learning
(p<0.05) and the
course
objectives were
better stated
(p<0.05) and
met (p = 0.007).
Overall
satisfaction
with the course
also improved
significantly (p
= 0.006). Part
one
facilitators.
Academic
Medicine:
Journal of the
Association of
American
Medical
Colleges,
82:486–492.
Epub
2007/04/26.
gastrointestinal
system mean
scores of the
USMLE showed
a statistically
significant
increase in
2005 compared
with 2001 (p =
0.047) or 2002
(p = 0.024).
USA John
Hopkins
– Faculty A longitudinal
mentored faculty
development
programme in
curriculum
development.
Pre-
intervention
Pre- and post-
surveys from
participants and
non-participants
assessed skills
in curriculum
development,
implementation,
and evaluation,
as well as
enjoyment in
curriculum
development and
evaluation.
64 curricula
were produced
addressing
gaps in
undergraduate,
graduate, or
postgraduate
medical
education. At
least 54
curricula (84%)
were
implemented.
Participant self-
– – – – Windish DM et
al. 2007. A ten-
month
program in
curriculum
development
for medical
educators: 16
years of
experience.
Journal of
General
Internal
Medicine,
Participants
rated programme
quality,
educational
methods, and
facilitation in a
post-programme
survey.
reported skills
in curricula
development,
implementation
and evaluation
improved from
baseline (p
<0.0001),
whereas no
improvement
occurred in the
comparison
group. In
multivariable
analyses,
participants
rated their skills
and enjoyment
at the end of
the programme
significantly
higher than
non-
participants (all
p<.05). 80% of
participants felt
that they would
22:655–661.
Epub
2007/04/20.
use the 6-step
model again,
and 80% would
recommend the
programme
highly to
others.
Israel Sackler
Faculty of
Medicine,
Tel Aviv
University
Medicine Clinical
instructors
8-hour intensive
workshop in basic
instructional
skills. The
workshop
highlighted the
tutors' approach
to students, in
terms of providing
feedback on
student
performance and
demonstrating
enthusiasm,
warmth and good
communication
Comparison
group of 121
faculty who
did not take
part in the
workshop.
The group
was not
randomly
selected but
selected
from faculty
who had not
yet taken
part but an
effort was
Teaching
performance pre-
and post-
workshop was
measured by
student ratings
and the ratings
of the study
group and
comparison
group were
compared.
The
comparison of
pre- and post-
participation
scores in the 2
groups showed
significant
differences..
For the study
group, the
mean score for
“Overall
assessment of
instruction”
increased from
3.54 (standard
Yes – – – Notzer N,
Abramovitz R.
2008. Can brief
workshops
improve
clinical
instruction?
Medical
Education,
42:152–156.
Epub
2008/03/01.
skills. It also
focused on
professional
behaviour.
made to
ensure the
group was
similar in
terms of
background
characteristi
cs.
deviation [SD] ±
0.51) to 3.72
(SD ± 0.33) on a
4-point scale. In
addition, the
median post-
participation
score (3.80)
was
significantly
higher (P <
0.01) than the
median pre-
participation
score (3.67),
whereas the
comparison
group median
ratings were
unchanged
(3.50 post-
participation
versus 3.55 pre-
participation).
One year after
the workshop
post-
participation
median ratings
of the study
group on each
of the 5
dimensions of
instruction
(overall
assessment,
presentation of
theoretical
material,
contribution to
clinical training,
instructor-
student
relationship,
tutor availability
to students)
had all
increased
significantly
(p<0.01).
Germany Carl Gustav
Carus
Faculty of
Medicine,
University
of
Technology
Dresden
Medicine Faculty A faculty
development
programme in
teaching and
assessment
methods was
implemented as
part of a much
larger reform of
the medical
education offered
at the university
(including
organizational
change, quality
management
programme and
improved
infrastructure).
-– Case study Ratings by
students have
increase, as
has the schools
position in state
examinations.
However, there
is no way of
knowing what
is attributable
to the faculty
development
programme
No No way
to know
what is
attributab
le to the
faculty
develop
ment
program
me
– – Dieter PE.
2009. A
Faculty
Development
Program can
result in an
improvement
of the quality
and output in
medical
education,
basic sciences
and clinical
research and
patient care.
Medical
Teacher,
31:655–659.
Epub
2009/03/17.
Sweden Uppsala
University
Hospital
Medicine Physician
educators
from various
A Swedish
anaesthesiologist
at Uppsala
University
-– Retrospective
pre- and post-
seminar self-
assessments on
Seminar
participants'
mean self-
ratings of
Yes? – – – Johansson J,
Skeff K,
Stratos G.
2009. Clinical
departments Hospital, Sweden,
was trained at
Stanford
University. He
then delivered 5
faculty
development
seminar series at
Uppsala
University
Hospital to 40
physicians from
different
departments.
participants’
knowledge, skills
and attitudes
towards
teaching.
Retrospective
pre- and post-
seminar ratings
of 29 different
teaching
behaviours
related to the 7
educational
categories were
used to assess
effects on
participants’
teaching
behaviour. Likert
scales were
used.
teaching
performance
increased
significantly
(p<0.001) in all
educational
categories and
overall
teaching
improvement:
The
transportabilit
y of the
Stanford
Faculty
Development
Program.
Medical
Teacher,
31:e377–e382.
Epub
2009/10/09.
USA University Dentistry 12 faculty Two six-week None Post-intervention
classroom
The findings
revealed that
No No
comparis
– – Behar-
Horenstein LS,
of Florida members teaching seminars observation
(transcripts
analysed by an
active teaching
rubic) and
interview.
participants
frequently used
questions that
were open-
ended or
checked for
comprehension
. 7 of 9
instructors
made extensive
efforts to
engage the
students
interactively
throughout the
teaching
session. 6 of
the participants
infused the
description of
actual or
hypothetical
cases to
illustrate the
connections
between
teaching and
on in any
way,
either
pre- or
post-
control
group
Childs GS,
Graff RA. 2010.
Observation
and
assessment of
faculty
development
learning
outcomes.
Journal of
Dental
Education,
74:1245–1254.
Epub
2010/11/04.
patient care,
while 6 utilized
reflective
practices.
Findings from
the interviews
corroborated
the
observations.
Various
developing
countries
Various Various FAIMER
fellows (mid-
career faculty
members from
health
professional
schools in
developing
countries)
follow the
fellowship
programme
run by the
FAIMER
The FAIMER
Institute model
consists of a two-
year part-time
fellowship that
focuses on an
education
innovation project
in the fellow’s own
institution,
supported by the
institution’s
leadership.
Pre-
intervention
Fellows
completed a
retrospective-
pre- and post-
questionnaire at
the end of each
of the two face-
to-face
residential
sessions
(sessions 1 and
3). The first part
of the survey
asked
There were
significant
increases
between
fellows’
reported
‘‘before and
after’’ data
about
perceptions of
the importance
of, and their
own
competence in,
Yes? – Fell
ows
hav
e
alm
ost
100
%
rate
of
retu
rn
and
rete
Costs
shared
between
FAIMER
and
sending
institute
Burdick WP et
al. 2010.
Measuring the
effects of an
international
health
professions
faculty
development
fellowship: the
FAIMER
Institute.
Medical
Teacher,
institute.
The study
population
included all 55
graduates
from the first 5
classes of the
FAIMER
institute (the
2001–2002
through 2005–
2005 classes).
Participants
represented
46 health
professional
schools in 19
countries in
Africa, South
America and
South Asia.
The median
GDP per
capita for
participants’
countries was
This education
innovation project
is the focal point
for experiential
learning of
education
methods as well
as education
leadership and
management
concepts and
skills. Leadership
methods are
introduced
specifically in the
context of
facilitating
successful
introduction of the
innovation project
at the fellow’s
home institution.
The thesis is that
working to
promote
educational
curricula change
respondents to
‘‘rate the
importance to
you’’ of a series
of FAIMER
curriculum
topics on a scale
from1 (none) to 7
(very high), with
separate rating
scales for
‘‘before FAIMER’’
(retrospective
pre-test) and
‘‘today’’ (post-
test). The second
portion of the
survey asked
respondents to
‘‘rate your skills,
knowledge or
competence to
address’’ each of
the same topics
on a scale from 1
(none or no skill)
to 7 (expert,
all 8 curriculum
theme areas in
Session 1 and
all 5 curriculum
theme areas in
Session 3.
In all cases, the
effect sizes
ranged between
1.3 and 2.7 (p<
0.0001). In the
interviews with
fellows were
asked to
describe if and
how they had
applied
concepts and
skills learned at
the FAIMER
Institute to their
work.
98% mentioned
at least one
leadership skill
ntio
n.
The
y
are
gro
win
g
prof
essi
ona
lly
at
thei
r
inst
ituti
ons
.
Of
the
45
fell
ows
wh
o
hav
32:414–421.
Epub
2010/04/29.
US$ 2370, with
one-third of
the countries
under US$
1500 per
capita. 1
participant
was a faculty
member at a
nursing
school, the
rest were
medical
school faculty,
with 13 of the
55 in the basic
sciences.
requires not only
educational
expertise, but also
leadership and
management
skills.
Throughout the
programme there
are two residential
sessions partly
designed to
reinforce the bond
between fellows
by a variety of
high engagement
methods.
During non-
residential
sessions there is
telephone contact
every several
weeks.
A key idea of the
teach others),
also for ‘‘before
FAIMER’’
(retrospective
pre-test) and
‘‘today’’ (post-
test). The issues
and topics for
the retrospective
pre- and post-
survey were
chosen to be
reflective of the
learning
emphases and
goals of the
FAIMER Institute.
Minor changes to
the survey were
made following
each class to
adjust to small
changes in the
curriculum. For
the class of 2001,
the evaluation
did not begin
or method,
making this the
most frequently
mentioned
category of skill
used.
At least 1
education
method or
approach was
mentioned by
60% of the
fellows,
including
student
assessment,
small group
teaching,
clinical skills
assessment,
problem-based
learning, and
adult learning
theory.
e
co
mpl
ete
d
the
pro
gra
mm
e,
16
hav
e
ma
de
a
tota
l of
31
pre
sen
tati
ons
at
inte
rnat
ion
FAIMER model is
that FAIMER
fellows will go
onto train other
faculty members
in their own
institution and
implement
innovative new
educational
methods and
projects. See
Norcini and
McKinley 2007.
until the autumn
of 2002. There is,
therefore, no
Session 1 survey
data for the 2001
class. Two
members of the
external
evaluation team
(SK and MAE)
conducted an
individually
structured 1–2
hour interview
with each fellow
at the end of
their
second
residential
session (Session
3). Fellows were
asked about the
skills and
methods learned
during the
programme and
had used, their
al
me
etin
gs;
6
hav
e
pro
duc
ed
15
pee
r-
revi
ewe
d
pub
lica
tion
s;
and
13
gra
nts
and
15
awa
experiences
interacting with
other fellows,
impact on their
leadership, and
their interaction
with colleagues
since
participating in
the FAIMER
Institute. All 55
fellows
participated in
the interviews.
rds
in
me
dic
al
edu
cati
on
hav
e
bee
n
obt
ain
ed;
2
fell
ows
hav
e
obt
ain
ed
an
adv
anc
ed
edu
cati
on
deg
ree,
and
14
hav
e
rec
eive
d
an
aca
de
mic
or
ad
min
istr
ativ
e
pro
mot
ion
to
ass
oci
ate
or
full
prof
ess
or,
dep
art
me
nt
cha
ir,
sub
-
dea
n or
dea
n.
USA – Medicine – CD-ROM to
develop faculties'
One Minute
Precepting (OMP)
knowledge and
skills. The OMP
Pre-
intervention
A repeat-
measures
sequential
experimental
design was
conducted that
A total of 721
teacher–learner
interactions
were analysed
(baseline = 240;
pre-intervention
Yes – – Almost
zero
marginal
cost once
the CD-
ROM is
Ozuah PO et
al. 2010.
Impact of an
innovative CD-
ROM on
ambulatory
model was
adapted to
develop the 8-step
preceptor (ESP)
model by adding
behaviours
associated with
promoting self-
directed learning
and a positive
learning climate.
included: a 4-
week baseline
observation; a 2-
week ‘sham’
intervention
period with a
‘dummy’ faculty
development
workshop; a 4-
week pre-
intervention
observation; a 2-
week
intervention
period during
which the CD-
ROM was
distributed to
faculty members,
and a final 4-
week post-
intervention
observation.
Study was
restricted to the
same faculty
members (n=6),
= 233; post-
intervention =
248). Mean
faculty
experience was
8.2 years and
there were no
differences in
case mix or
duration of
teaching.
MANOVA
results
demonstrated
statistically
significant
improvements
in 5 educators’
teaching
behaviours
post-
intervention,
including:
“determined
what learner
knew” (baseline
= 1.70, pre-
developed.
Less time
intensive
for faculty
teaching.
Medical
Education,
44:517–518.
Epub
2010/06/04.
learners (n=13),
setting and
teaching
schedule.
Thus several
confounders
were blocked,
including
Hawthorne,
maturational,
variance,
environmental,
differential mix
and interaction
effects. Two
blinded
observers rated
faculty members
on the
application of
seven principles
of adult learning,
using a 4-point
Likert scale (1 =
never, 4 =
definitely).
intervention =
1.69, post-
intervention =
3.36); “asked
for
commitment”
(1.93 versus
1.99 versus
3.24); “provided
a generalisable
teaching point”
(2.55 versus
2.57 versus
3.79); “provided
timely
feedback” (2.80
versus 2.78
versus 3.72),
and
“interrupted”
(3.38 versus
3.41 versus
1.21) (all P <
0.0001). By
contrast, there
were no
differences in2
Multivariate
analysis of
variance
(MANOVA) for
repeat measures
tested mean
differences in
continuous
variables.
behaviours:
“asked for
supporting
evidence” (1.77
versus 1.84
versus 1.77; P =
0.69), and
“prompted
learner for own
objectives”
(1.00 versus
1.00 versus
1.02; P = 0.93).
Domains of
improvement
included
behaviours
previously
shown to be
most highly
correlated with
student
perceptions of
effective
teaching.
Various
developing
countries
Various Health
professions
FAIMER
fellows
FAIMER
fellowship
programme (see
above)
None A review of
fellow's projects
from all years of
the fellowship
programme and
from all 6
institutions.
Statistical
analysis was
conducted using
SPSS with each
project receiving
up to 2 project
emphasis codes.
Data from the
FAIMER
Professional
Development
Portfolio (an
online portfolio
where fellows
document their
professional
accomplishment
Project impact:
More than half
of responding
fellows from the
FAIMER
Institute
(Philadelphia)
identified
changes related
to increased
quality of
teaching and
collaboration in
education.
When asked to
identify
changes in their
schools or
communities
resulting from
their projects.
In addition, 41%
responded that
there was more
No? No
comparis
on
– Funding
for the
project is
from the
sending
institution
(not
FAIMER)
Burdick W,
Friedman SR,
Diserens D.
2012. Faculty
development
projects for
international
health
professions
educators:
Vehicles for
institutional
change?
Medical
Teacher,
34:38–44.
s and provide
follow-up
reflection and
information
about the
various aspects
of their FAIMER
experience). 1 of
the 4 sections of
the portfolio
addresses their
education
innovation
project and asks
questions
addressing the
project’s status
and impact of the
project in the
fellow’s school
and region.
Fellows
complete this
section of the
portfolio 6
months after the
second
faculty interest
in research in
education.
Other frequent
changes cited
by one-third or
more of
respondents
included
improvements
in assessment
and student
performance.
One-third noted
that the
curriculum was
better aligned
with community
health needs.
By contrast,
only 1/10th to
1/5th reported
increases in
knowledge in
rural health
care, working in
community
residential
session and
annually
thereafter. Data
on
institutionalizatio
n and replication
of projects were
collected during
2008–2010 from
2008 classes of
the FAIMER
Institute
(Philadelphia) as
well as 2007
classes of 4 of
the Regional
Institutes
(excluding
Southern Africa
FAIMER
Regional
Institute, which
did not begin
until 2008 class
year). Data
reported
settings, and
training of
community
health workers
or community
service among
students. Only
4% responded
that their
project had
resulted in
better health.
Institutionalizati
on and
Replication of
Projects: Where
fellows (from 5
of the 6
institutes)
reported on the
project status, a
majority of
projects were
reported to
have been
institutionalized
(incorporated
on the impact of
projects were
collected for the
first time during
Spring/Summer
2010 from 2001-8
classes of the
FAIMER Institute
(Philadelphia).
Earlier years of
Regional
Institutes before
2007 were
not included in
these data
because they
were not
consented into
the programme
evaluation.
into the
curriculum
and/or
incorporated as
an institutional
policy or
procedure)
(66/117, 56%) or
replicated
(replicated in
another
course/module/
year at the
fellow's
institution, in
another setting
in the fellow's
country,
and/or in a
setting in
another
country)
(72/117, 62%).
Singapore National
University
Medicine – 3-day intensive
programme on
Pre- Before the
programme,
The difference
between ability
No? – – – Amin Z et al.
2006.
of
Singapore,
Faculty of
Medicine
core
competencies in
medical
education. The
programme
structure was
based on
experiential and
collaborative
learning models.
Participants
contributed to all
activities and
emerged as
facilitators and
learners to gain
first-hand
experience of the
complex
educational
processes. Each
session was
sequential with a
brief plenary,
demonstration,
practicum and
intervention participants were
asked to identify
their perceived
current level of
ability and ideal
level of ability for
each topic using
a scale (1¼ least
able, 9¼ most
able). In this way,
the perceived
gap in their
ability was
identified. After
the programme,
participants were
given another
instrument
similar to the
needs
assessment
instrument
except that
participants were
asked to identify
their ability now,
i.e. after
achieved after
attending the
programme and
ability before
the programme
was statistically
significant (p <
0.05 for all
items). Of note,
the
participants’
ability after
attending the
programme was
slightly lower
than their
perceived ideal
ability.
Addressing
the needs and
priorities of
medical
teachers
through a
collaborative
intensive
faculty
development
programme.
Medical
Teacher,
28:85–88.
Epub
2006/04/22.
reflection.
completing the
programme.
USA Harvard
Medical
School
Medicine Medical
educators
Harvard Macy
Program for
Physician
Educators (HM-
PE)
Pre-
intervention
Structured
telephone
interviews were
conducted in
2001 with 16
Harvard Medical
School (HMS)
participants in
the Harvard
Macy Program
for Physician
Educators (HM-
PE): 5 who
completed the
programme in
1998, 5 in 1999,
and 6 in 2000.
Interviews were
also conducted
with 4 Faculty
Scholars, alumni
of the HM-PE
Of those
interviewed in
2001, 80%
responded to
the 2004 online
questionnaire;
13 of 16 (81%)
HMS
respondents
reported
increased
knowledge
about and
confidence
using learner-
centre teaching
methods; 10 of
16 (63%) said
they gave fewer
lectures and
added
alternative
No? – 13
of
16
(81
%)
rep
orte
d a
stro
nge
r
co
mm
itm
ent
to
the
fiel
d of
me
dic
al
– Armstrong EG,
Barsion SJ.
2006. Using an
outcomes-
logic-model
approach to
evaluate a
faculty
development
programme for
medical
educators.
Academic
Medicine:
Journal of the
Association of
American
Medical
Colleges,
81:483–488.
Epub
programme who
taught in
subsequent
programmes. In
2004, online
questionnaires
were sent to the
16 participants
and 4 faculty
scholars.
Immediate
outcomes, such
as greater use of
active learning
principles, and
intermediate
outcomes, such
as commitment
to medical
education, were
examined.
educational
methods.
edu
cati
on:
alm
ost
one
thir
d
felt
the
HM-
PE
pro
gra
mm
e
was
a
turn
ing
poi
nt
in
thei
r
car
eer
2006/04/28.
s.
Turkey Hacettepe
University
Faculty of
Medicine
Medicine By the end of
the spring
semester,
2003, 253
faculty
members had
participated in
the TSIP
courses at
HUFM (35.5%
from basic
science,
65.5% from
clinical
medicine;
46.2% were
men,
53.8%
women).
Teaching Skills
Improvement
Program (TSIP).
The basic goal of
TSIP in 1998 was
to strengthen
preclinical and
clinical teaching
in
undergraduate
and postgraduate
medical
education.
Before the TSIP,
medical educators
at HUFM, as well
as those in other
medical schools
in Turkey, had no
formal training on
how to teach.
Since 2002, HUFM
has required all
faculty members
– Participants’
satisfaction with
programme.
Participants'
learning was
assessed
through a
multiple-choice
test. On the last
day of the
workshop,
participants took
part in a
microteaching
exercise in which
they made 10-
minute
presentations (20
min. per peer
group) on a topic
of their choice
and received
both written and
oral feedback
On the MCQ
test,
achievement
was high, with
an overall mean
score of 25.25 ±
2.48 out of 30.
Ratings of
presentation
skills by course
trainers showed
that high
proportions of
participants
performed
proficiently in
the following
areas:
projected his or
her voice so
that all learners
could hear
(92.5%),
maintained eye
No? No
comparis
on, no
pre- or
post-
design
– – Bahar-Ozvaris
S et al. 2004. A
faculty
development
programme
evaluation:
From needs
assessment to
long-term
effects, of the
teaching skills
improvement
program.
Teaching and
Learning in
Medicine,
16:368–375.
Epub
2004/12/08.
who are teaching
to undergo the
certification
programme by
participating in
the TSIP course
as a condition for
academic
promotion.
from their
colleagues. This
feedback was
structured to
focus on two
competently
performed
aspects of the
talk and one
suggestion for
improvement.
During the
microteaching
session, the
trainers
evaluated
participants’
presentation
skills, using a 3-
point scale (1 =
needs
improvement, 2 =
competently
performed, 3 =
proficiently
performed). Self-
evaluation on
contact with
others (83.6%),
and used
audiovisuals
effectively
(83.6%). Almost
half of the
participants
were judged to
need some
improvement in
providing
opportunities
for application
or practice of
presentation
content (49.3%),
and using
trainer’s notes
or a
personalized
reference
manual (49.3%).
In the follow-up
self-evaluation
large
proportions of
changes in
teaching
practices
measured one
year after the
course.
the participants
reported that
they always
used the TSIP
techniques in
their
subsequent
teaching
activities. 75%
responded that
they always
used the
interactive
training
techniques,
whereas 25% of
them indicated
they used them
sometimes.
However,
approximately a
quarter of them
(24.1%) never
used
competency-
based
assessment
(knowledge-
and skill-based)
tools to assess
learners’
progress and
performance.
Canada – Emergency
medicine
Emergency
medicine
teachers
Participants
underwent a half-
day workshop
consisting of 1
large
group interactive
session and 3
small group
sessions using
role- playing,
practice reflection,
real
time review of
hard-copy
resources, and
brainstorming.
Pre-
intervention
Evaluation
included a post-
event ordinal
scale
questionnaire
and a 4-month
follow-up short
answer survey,
both measuring
participants’
perceptions of
workshop
effectiveness.
At 4 months, 10
out of 10
respondents
reported
success at
implementing
new techniques
and 8 reported
greater
confidence in
teaching. The
most common
new techniques
were: setting
better learning
objectives,
giving better
No Very
small
sample.
– – Bandiera G,
Lee S, Foote J.
2005. Faculty
perceptions
and practice
impact of a
faculty
development
workshop on
emergency
medicine
teaching.
Canadian
Journal of
Emergency
Medical Care,
7:321–327.
feedback,
actively seeking
teaching
opportunities,
and identifying
a teaching
point.
Epub
2007/03/16.
Nepal 4 different
medical
colleges in
Nepal
Medicine The workshop
was targeted
at middle and
entry level of
health
profession
teachers who
had not been
previously
exposed to
any teacher’s
training
programme.
3-day training
workshop on
“Teaching-
learning
methodology and
Evaluation” held
in 4 different
medical colleges
of Nepal. The
various
components, such
as teaching-
learning
principles, writing
educational
objectives,
organizing and
sequencing
Pre-
intervention
The collection
data had two
categories of
responses: (1) a
questionnaire
survey of
participants at
the beginning
and end of the
workshop to
determine their
gain in
knowledge; and
(2) a semi-
structured
questionnaire
survey of
participants at
The results
showed that all
participants
(n=92)
improved their
scores after
attending the
workshop (p <
0.001). The
majority of
respondents
reported that
the teaching-
learning
methods,
media,
microteaching
and evaluation
No – – – Baral N et al.
2007. An
evaluation of
training of
teachers in
medical
education in
four medical
schools of
Nepal. Nepal
Medical
College
Journal,
9:157–161.
Epub
2007/12/21.
education
materials,
teaching-learning
methods,
microteaching and
assessment
techniques, were
incorporated in
the workshop.
the end of
workshop to
evaluate their
perception on
usefulness of the
workshop.
techniques
were useful in
teaching/learnin
g. The
workshop was
perceived as an
acceptable way
of acquiring
teaching-
learning skills
but 39.4% of
participants
said that the
duration of the
workshop was
too short.
Nepal B. P.
Koirala
Institute of
Health
Sciences
Medicine,
dentistry,
nursing
PBL tutors Workshop on
principals of PBL
Pre-
intervention
Pre- and post-
questionnaire on
satisfaction and
gains in
knowledge
There was
significant gain
in reported
knowledge
following the
workshop
(p<0.001).
No – – – Beck E et al.
2008.Addressi
ng the health
needs of the
underserved: a
national
faculty
development
program.
Academic
Medicine:
journal of the
Association of
American
Medical
Colleges,
83:1094–1102.
Epub
2008/10/31.
USA 5 medical
schools
Medicine Faculty 18-month faculty
development
programme
designed to
enhance
humanistic
teaching
47 controls
drawn from
the same
schools vs.
29
participants.
Control
faculty
members
were similar
to
participants
in gender,
specialty,
and years of
10-item
questionnaire,
the Humanistic
Teaching
Practices
Effectiveness
Questionnaire
(HTPE), to be
filled out by
medical students
and residents
taught by
participants or
control faculty.
Items were
Faculty
participants
outperformed
their peer
controls on all
10 items of the
HTPE
questionnaire.
Results were
statistically
significant
(P<0.05).
– No
question
of overall
student
satisfacti
on with
teaching,
only
whether
teaching
humanist
ic values
– – Branch WT et
al. 2009. A
good clinician
and a caring
person:
longitudinal
faculty
development
and the
enhancement
of the human
dimensions of
care.
Academic
Medicine:
experience. designed to
measure
previously
identified themes
and domains of
humanism.
Journal of the
Association of
American
Medical
Colleges,
84:117–125.
Epub
2009/01/01.
Canada University
of Toronto
Department
of
Psychiatry
Psychiatry Residents who
teach medical
students
A Teaching-to-
Teach curriculum
was developed
with
separate tracks
for junior and
senior residents.
Topics covered
included one-to-
one teaching, the
one-minute
clinical preceptor
model,
challenging
teaching
scenarios, and
providing effective
Pre-
intervention
Questionnaire In 2007, 100%
of residents
who responded
to an evaluation
questionnaire
agreed or
strongly agreed
that the topics
covered were
relevant, and in
2008, 92% of
respondents
agreed that
topics were
relevant. In
2007, all
respondents
No No
control
or pre- or
post-
design
– – Dang K,
Waddell AE,
Lofchy J. 2010.
Teaching to
Teach in
Toronto.
Academic
psychiatry: the
Journal of the
American
Association of
Directors of
Psychiatric
Residency
Training and
the
Association
feedback. agreed or
strongly agreed
that they felt
more prepared
to teach. In
2008, 85% of
respondents
felt more
prepared to
teach. In 2007,
all respondents
felt that the
amount of
teaching was
good or too
little, but in
2008, 46% of
respondents
felt there was
too much
teaching.
for Academic
Psychiatry,
34:277–281.
Epub
2010/06/26.
USA Primary
care
medicine
Primary care
teachers
Faculty
development
programme. A
year long series of
Pre-
intervention
Survey post-
programme
Outcomes
attributed to the
programme
included
No No
control
group or
pre-post
– – Gjerde CL et
al. 2008. Long-
term outcomes
of a primary
5 weekend
workshops
focusing on the
preparation of
preceptors to
teach curricula
areas relatively
new to medical
education –
evidence-based
medicine,
teaching skills,
technology tools,
doctor-patient
communication,
quality
improvement, and
advocacy.
improvement in
teaching skills,
improvement in
clinical skills,
intrapersonal
growth and
increased self-
confidence, and
increased
interdisciplinar
y networking
and mentoring.
methodol
ogy
care faculty
development
programme at
the University
of Wisconsin.
Family
Medicine,
40:579–584.
Epub
2008/11/07.
USA University
of
Wisconsin
Family
medicine,
general
paediatrics,
general
internal
Medical
teachers
We developed a
year long series of
5 weekend
workshops. A
core group of
faculty provided 2-
to 4-
Pre-
intervention
Fellows self-
assessed their
ability to perform
skills at the
beginning and at
the end
of the year;
Participants
reported
improvements
in targeted
skills;
statistical
analyses
– – – – Gjerde CL et
al. 2004. A
weekend
programme
model for
faculty
development
medicine hour sessions on
topics including
evidence-based
medicine,
physician
leadership,
advocacy, doctor-
patient
communication,
quality,
technology tools,
and teaching
skills.
paired t tests
were used to
compare these
changes.
confirmed
many
significant pre-
post
improvements,
e.g. statistically
significant
improvements
in use of
instructional
design and
applying adult
learning
principles.
with primary
care
physicians.
Family
Medicine,
36(Suppl.):S11
0–S114. Epub
2004/02/13.
USA – Medicine Medical
educators
10-month, 1 half-
day per week
programme
offered annually
on curriculum
design, which
included a
mentored CD
project,
workshops on CD
Self-selected
control
group 64
non-
participants
vs. 64
participants
Baseline survey
and survey 6-13
years after
completion
58 participants
(91%) and 50
non-
participants
(78%) returned
completed
follow-up
surveys. In
analyses,
controlling for
– Problems
with
post-
survey
being 6-
13 years
after
interventi
on,
sampling
– – Gozu A et al.
2008. Long-
term follow-up
of a 10-month
programme in
curriculum
development
for medical
educators: a
cohort study.
steps, and a final
paper and
presentation.
background
characteristics
and baseline
self-rated
proficiencies,
participants
were more
likely than non-
participants at
follow-up to
report having
developed and
implemented
curricula in the
past 5 years
(65.5% versus
43.7%; odds
ratio [OR] 2.41,
95% confidence
interval [CI]
1.03–5.66), to
report having
performed
needs
assessment
when planning
a curriculum
bias- self
selection.
Medical
Education,
42:684–692.
Epub
2008/05/30.
(86.1% versus
58.8%; OR 5.59,
95% CI 1.20–
25.92), and to
rate themselves
highly in
developing (OR
3.57, 95% CI
1.36–9.39),
implementing
(OR 3.04, 95%
CI 1.16–7.93)
and evaluating
(OR 2.74, 95%
CI 1.10–6.84)
curricula.
USA – Psychiatry Residents who
teach medical
students
A 4-hour
workshop for
PGY-2 psychiatric
residents was
designed and
implemented to
improve residents’
- Residents
completed pre-
and post-course
self-
assessments of
their knowledge,
skills, attitudes,
Following
course
participation,
there was
statistically
significant
improvement in
– – – – Grady-Weliky
TA, Chaudron
LH, Digiovanni
SK. 2010.
Psychiatric
residents' self-
assessment of
self-assessment
of their knowledge
of the medical
student
curriculum and
core teaching
skills.
and values about
teaching.
Descriptive
statistics were
obtained on pre-
and post-course
data and were
analysed using t
tests assuming
unequal
variance.
residents’ self-
assessment of
their knowledge
of the medical
student
curriculum
(p<0.001), their
self-
assessment
regarding
perception of
peers’ view of
their teaching
ability (p<0.02),
and their
perceived
knowledge of
various
teaching
methods
(p<0.02).
teaching
knowledge
and skills
following a
brief
"psychiatric
residents-as-
teachers"
course: a pilot
study.
Academic
Psychiatry,
34:442–444.
Epub
2010/11/03.
USA University
of
Minnesota
Medical
Medicine Community
primary care
preceptors
An orientation
session for newly
recruited
community
Hospital-
based faculty
Student ratings
from students for
these new
preceptors and
Student ratings
for the new
preceptors
were not
– No
control
or pre- or
post-
– – Harris IB,
Kvasnicka JH,
Ytterberg SR.
1995. Faculty
School primary care
preceptors. This
session focused
on reflection
about effective
clinical teaching
by experienced
and new
preceptors. They
discussed their
personal views on
effective clinical
teaching, based
on their
experiences as
students and as
teachers
compared these
views with a
summary of
literature on
effective teaching
and discussed
how these
perspectives
applied to
teaching first year
hospital-based
faculty who had
taught students
throughout the
year and who
were mostly
experienced
teachers.
significantly
different from
the hospital-
based faculty.
design,
only
compare
d to
hospital
based
faculty.
development
for community
primary care
preceptors.
Academic
Medicine:
Journal of the
Association of
American
Medical
Colleges,
70:458–459.
Epub
1995/05/01.
medical students.
Additionally, a bi-
weekly newsletter
entitled
Perspectives was
sent to all the
preceptors which
included medical
school news,
curriculum
content, teaching
tips and a forum
for exchange of
teaching ideas
among the
preceptors
stimulated by
sample clinical
teaching
problems.
USA – Medicine Faculty in
internal
Direct observation
of competence
workshop
Comparison
group (n=23)
vs. n=17 in
Controlled trial.
Faculty self-
assessment and
37 faculty
members (16 in
the intervention
Yes? – – – Holmboe ES,
Hawkins RE,
Huot SJ. 2004.
medicine combining
didactic mini-
lectures,
interactive small
group and
videotape
evaluation
exercises, and
evaluation skill
practice with
standardized
residents and
patients.
intervention
group
ratings of 9
videotaped
encounters.
group and 21 in
the control
group)
completed the
study. Most of
the faculty in
the intervention
group (14
[88%]) reported
that they felt
significantly
more
comfortable
performing
direct
observation
compared with
control group
faculty (4 [19%])
(P< 0.04), and
all intervention
faculty rated
the training as
outstanding.
For 9
videotaped
clinical
Effects of
training in
direct
observation of
medical
residents'
clinical
competence: a
randomized
trial. Annals of
Internal
Medicine,
140:874–881.
Epub
2004/06/03.
encounters,
intervention
group faculty
were more
stringent than
controls in their
evaluations of
medical
interviewing,
physical
examination,
and
counselling;
differences in
ratings for
medical
interviewing
and physical
examination
remained
statistically
significant even
after
adjustment for
baseline rating
behaviour.
Japan (but
overseas
faculty
developmen
t
programme
s)
– Family
medicine
Family
medicine
faculty who
had completed
faculty
development
programmes
abroad
A variety of
overseas faculty
development
programmes
None Questionnaire Reported that
faculty
development
programmes
had influenced
their teaching
practices
No No
comparis
on
Bar
rier
s in
imp
lem
enti
ng
new
ide
as
afte
r
retu
rn
– Kitamura K,
Fetters MD,
Ban N. 2002.
The
experiences of
Japanese
generalist
physicians in
overseas
faculty
development
programs.
Family
Medicine,
34:761–765.
Epub
2002/11/27.
USA – Medicine Primary care
and genetics
professionals
Genetics in
Primary Care
(GPC) (a national
faculty
development
None Site visits were
performed at 9
sites and
individual phone
interviews at
Follow-up
achieved
responses at
19/20 sites, for
a site-level
No No
comparis
on,
mixture
between
– – Laberge AM et
al. 2009. Long-
term outcomes
of the
"Genetics in
initiative for
primary care
physicians with
teaching
responsibilities)
remaining sites.
The same
questionnaire
was used in both
settings. Content
analysis of
responses was
performed.
response rate
of 95%. All
respondents
reported having
made changes
to their formal
and informal
teaching
practices.
phone
and
onsite
interview
s
Primary Care"
faculty
development
initiative.
Family
Medicine,
41:266–270.
Epub
2009/04/04.
USA John
Hopkins
Psychiatry Residents who
teach medical
students
5 x 1-hour
seminars on
teaching medical
students in the
psychiatry
clerkship were
presented to
second
postgraduate year
(PGY-2) residents.
Topics included
how to teach
psychiatric
interviewing, the
mental status
examination, case
Pre-
intervention
Residents were
surveyed before
and after the
seminar series to
assess their
confidence
levels to teach
specific skills.
A greater
percentage of
PGY-2
residents rated
themselves as
“very
confident” in
teaching and
providing
feedback to
medical
students after
the seminar
series than
before the
series. The
No No
statistical
analysis
of
variance,
significa
nce
levels
etc.
– – Lehmann SW.
2010. A
longitudinal
"teaching-to-
teach"
curriculum for
psychiatric
residents.
Academic
Psychiatry,
34:282–286.
Epub
2010/06/26.
formulation,
giving feedback,
and evaluating
student work.
greatest
increases in
confidence
were seen in
teaching
interviewing
skills, the
mental status
examination,
psychiatric
formulation,
and evaluation
of students’
work.
USA – Medicine Faculty from
multiple
disciplines
Year-long
fellowship in
medical education
None A qualitative
analysis of semi-
structured
interviews
Study
participants
described post-
fellowship
changes in
knowledge,
self-
perceptions,
and behaviours
No No
comparis
on
Wit
h a
fou
nda
tion
of
prin
cipl
es
– Lown BA,
Newman LR,
Hatem CJ.
2009. The
personal and
professional
impact of a
fellowship in
medical
and
institutional
changes that
resulted from
education
projects.
and
skill
s,
the
fell
ows
’
con
fide
nce
and
ide
ntit
y as
edu
cat
ors
wer
e
stre
ngt
hen
ed
by
thei
r
sen
education.
Academic
Medicine,
84:1089–1097.
Epub
2009/07/30.
se
of
self
-
effi
cac
y,
oth
ers’
per
cep
tion
s of
thei
r
cre
dibi
lity,
and
sup
port
fro
m a
co
mm
unit
y of
pee
rs
and
me
ntor
s.
Canada – Medicine Medical
educators.
Sample of
experienced
teachers was
chosen
The intervention
included a
workshop on
pedagogic
principles,
provision of a
workbook on
pedagogic
principles and free
access to
educational
consultants.
Pre-
intervention
Prior to the
workshop, each
participant
completed a 10-
item
questionnaire
containing open-
ended questions
about their
understanding
and beliefs about
their personal
teaching and
their knowledge
of education and
its practices.
Following the
workshop, each
Evaluation of
the impact of
the intervention
using
questionnaires
and semi-
structured
interviews
revealed three
notable
findings:
1. participants
were surprised
to discover the
existence of an
extensive body
of pedagogic
science
No No
significa
nce
analysis
– – McLeod PJ et
al. 2008. A
pilot study
designed to
acquaint
medical
educators with
basic
pedagogic
principles.
Medical
Teacher,
30:92–93.
Epub
2008/02/19.
participant was
sent a 20-item
retrospective
pre- and post-
questionnaire
asking them to
rate, on a 5-point
scale, their
understanding of
each of the 20
important
pedagogic
principles
addressed in the
handbook and at
the workshop.
Within 2 months
following the
workshop, one of
the authors
conducted
individual 30–60
minute semi-
structured
interviews with
each participant,
underlying
teaching and
learning;
2. they were
enthusiastic
about the
intervention
and expressed
interest in
learning more
about basic
pedagogic
principles;
3. the
knowledge
acquired had an
immediate
impact on their
teaching.
designed to
explore their
attitudes, self-
efficacy, and self
perceptions of
their knowledge
of pedagogy and
their teaching
behaviours
following the
intervention.
Each interview
was audio-taped
and transcribed
for subsequent
analysis.
Two of the
authors
independently
conducted a
qualitative
content analysis
of the pre-
workshop
questionnaire
responses then
met to discuss
and develop a
consensus on
the predominant
emergent
themes.
USA Lehigh
Valley
Hospital
and Health
Network
Internal
Medicine
Medicine Medical
educators
Faculty
development
programme based
on observation
and feedback.
Medical educators
trained in
observational
research practices
shadowed
teaching teams for
24 months and
observed 24
General Internal
Medicine faculty
teachers on
Faculty who
were not
observed.
Control (self
selection
unknown).
Observation
ratings over the
period were
compared. They
were also
compared to
student ratings
of medical
educators.
Teaching skills
were seen to
improve over
time after
feedback was
provided and
repeat
observations
occurred. More
than 3/4th of
the faculty
observed more
than once
showed
improvement
(i.e. fewer items
Yes? No
statistical
analysis
of
significa
nce of
findings
– – Regan-Smith
M, Hirschmann
K, Lobst W.
2007. Direct
observation of
faculty with
feedback: an
effective
means of
improving
patient-
centered and
learner-
centered
teaching skills.
Teaching and
inpatient rounds
and provided
timely written
feedback to
faculty. Within 48
hr, faculty
received a
completed
Observation
Feedback Sheet
and summary
comments.
that needed
improvement)
in the skills
documented.
Observation
ratings
mirrored the
results of the
established
Department of
Medicine
resident
ranking of
faculty
teaching.
Observed
faculty
receiving
feedback
improved their
ranking,
whereas faculty
not observed
did not.
The median
Learning in
Medicine,
19:278–286.
Epub
2007/06/28.
resident Best
Teacher
ranking of the
core faculty, all
of whom where
observed,
improved from
26 in 2003–2004
to 12.5 in 2004–
2005.
The median
resident Best
Teacher
ranking for the
12 observed
private teaching
faculty
improved from
85 in 2003–2004
to 52 in 2004–
2005.
The resident
ratings for 12
other private
GIM faculty who
were not
observed and
received no
feedback had
no
improvement,
and in fact
decreased, in
their median (95
in 2003–2004
and 100 in
2004–2005)
Best Teacher
rankings.
USA University
of
Massachus
etts Medical
Center
Paediatrics Residents who
teach medical
students
"Residents as
Teachers" retreat
based on the
institution's
faculty
development
programme for
clinical
preceptors. We
Pre-
intervention
Self-evaluations
(pre- and post-
retreat
questionnaires)
that included a
teaching
inventory and
student
For the 15-point
teaching
inventory, the
scores for each
cohort of
residents at the
original retreat
improved at the
6-month post-
Yes? No
statistical
analysis
of
significa
nce of
findings,
student
evaluatio
– – Roberts KB et
al. 1994. A
programme to
develop
residents as
teachers.
Archives of
Pediatrics &
Adolescent
focused on
clinical precepting
skills, including
evaluation/feedba
ck, and the ability
to prepare and
deliver a brief
presentation.
There was also an
hour-long
refresher
conference after 6
months.
evaluation. conference
assessment.
Scores then fell
as each cohort
entered the
next year of
residency, but
not back to
baseline.
Student ratings
of resident
teaching on
their written
evaluations of
the paediatric
clerkship
improved from
neutral or
dissatisfied to
very positive.
ns only
qualitativ
e.
Medicine,
148:405–410.
Epub
1994/04/01.
USA – Medicine – Seminar series Pre-
intervention
Student teacher
interactions were
assessed using
audiotapes of
94 encounters
with 18 577
utterances were
recorded, half
Yes? – – – Salerno SM et
al. 2002.
Faculty
development
teaching
encounters
coded through
qualitative
techniques and
surveys of
teacher, learner
and patient
satisfaction
before and half
after the
seminars.
After the
seminars the
proportion of
the utterances
that contained
feedback
increased from
17% to 22% (p =
0.09) and was
more likely to
be specific (9%
vs. 15% p =
0.02).
After the
workshops
teachers
reported that
the learning
encounters
were more
successful (p =
0.03), and that
seminars
based on the
one-minute
preceptor
improve
feedback in
the ambulatory
setting.
Journal of
General
Internal
Medicine,
17:779–787.
Epub
2002/10/23.
they were better
at letting
students reach
their own
conclusions (p
= 0.001) at
evaluating
learners (p =
0.03).
The workshop
had no effect
on the duration
of the
encounters or
on student or
patient
satisfaction
with the
encounters.
Russia Kazan State
Medical
Medicine 14 medical
teachers
4 seminars, based
on the 7
categories of the
Pre-
intervention
Participants’
self-reported
ratings of
At both
measured
times,
– – – – Wong JG,
Agisheva K.
2004. Cross-
University Stanford Faculty
Development
Program model.
The seminars
included mini-
lectures and
reviews of actual
videotaped
teaching scenario
re-enactment.
teaching ability
based on
validated pre-
test–post-test
questionnaires.
Measurements at
both 1 month
and 12 months
post-intervention
were completed.
statistically
significant
improvements
in the ratings of
global teaching
performance
and specific
teaching
behaviours
were reported.
cultural faculty
development:
initial report of
an
American/Rus
sian
experience.
Teaching and
Learning in
Medicine,
16:376–380.
Epub
2004/12/08.
Russia Kazan State
Medical
University
Medicine 48 medical
teachers
5 seminars, based
on the 7
categories of the
Stanford Faculty
Development
Program model.
The seminars
comprised mini-
lectures, reviews
of actual
videotaped
Pre-
intervention
Evaluation was
performed
through
participants’ self-
reported ratings
of teaching
ability based on
a retrospective
pre- and post-
test
questionnaire
and commitment
Global teaching
performance
improved (pre-
test ¼ 38.4, 1
month post-test
¼ 43.7, 12
months post-
test ¼ 42.5; P <
0.001), as did
ratings of
specific
teaching
– – – – Wong JG,
Agisheva K.
2007.
Developing
teaching skills
for medical
educators in
Russia: a
cross-cultural
faculty
development
project.
teaching scenario
re-enactments,
interactive role-
plays of teaching
situations, and
personalized goal
setting for future
teaching
performance.
of change (CTC)
statements
written by
workshop
participants.
Outcomes were
measured at
both 1 and 12
months post-
intervention.
behaviours
(pre-test ¼
100.2, 1 month
post-test ¼
121.3, 12
months post-
test ¼ 116.8; P
< 0.001).
Medical
Education,
41:318–324.
Epub
2007/02/24.
USA Stanford Medicine Faculty
trained by 4
faculty
members who
had completed
the Stanford
Faculty
Development
Program
Faculty were
trained to be
facilitators in
clinical teaching
improvement by
the Stanford
Faculty
Development
Programme (1-
month
programme). They
then taught
faculty at their
Pre-
intervention
Faculty
participants' self-
assessment
ratings before
and after the
entire seminar
series, faculty
self-assessment
ratings
completed 1
week after each
individual
seminar and
house staff and
Traditional pre-
and post-
seminar ratings
revealed
significant
differences in 4
of 7 educational
components
(learning
climate, control
of the teaching
session,
communication
of goals and
Yes – – – Skeff KM, et al.
1992.
Evaluation of a
Medical
Faculty
Development
Program: A
comparison of
traditional
pre/post and
retrospective
pre/post self-
assessment
ratings.
own institutions. medical student
evaluations of
the faculty
before and after
the entire
seminar series.
Both traditional
pre- and post-
design and
retrospective
pre- and post-
design were
used.
evaluation) with
1 change (for
learning
climate) being
in the negative
direction (this
began with the
highest pre-
intervention
mean of 4.24 on
a 5-point scale).
In contrast, all
of the
retrospective
pre- and post-
comparisons
showed
statistically
significant pre-
and post-
increases.
House
staff/student
ratings showed
statistically
Evaluation and
the Health
Professions,
15:350–366.
significant
increases
(p<0.05) and
two
components
approached
significance
(p<0.10).
Canada – Medicine Faculty
physicians
2-day workshop
on small group
teaching between
1988 and 1993 (10
participants were
randomly selected
out of 47 who had
attended the
workshops). The
main objectives of
the workshop
were to develop
small group
leadership skills
and an awareness
Self-selected
control
group. 10-
control
faculty were
randomly
selected out
of 45 faculty
members
who had not
attended.
Subjects
were
matched for
the number
The first
instrument was
that participants
were observed at
the beginning to
the study while
they taught a
group of 4–10
residents on a
topic of their
choice. Scoring
values were
"done", "not
done" and "n/a".
The second
The
observation
data showed no
significant
differences
either between
or within
groups for any
of the
behaviours.
Only one item
"puts together
points made by
members"
approached
Yes? Very
small
sample
sizes,
control
and
experime
ntal
groups
not
randomly
chosen
from
same
populatio
– – Nasmith L, et
al. 1995. Long-
term impact of
faculty
development
workshops.
Montreal,
McGill
University.
of group
dynamics. The
workshop
included
theoretical
didactic sessions
and small group
sessions
involving group
discussions,
hands-on practice
and role-plays.
of years of
teaching
experience.
instrument
consisted of 10
cases/scenarios
depicting
specific teaching
tasks all of which
had been
presented and
discussed in the
workshop. This
was done to
assess cognitive
learning using a
short answer
format. The
maximum
possible score
was 35. The third
instrument was a
structured
questionnaire
conducted twice,
once as a
retrospective
pre-intervention
and again as a
post-
significance (p
= 0.056). For the
scenario
results, the
experimental
group had a
mean rating of
11.85 vs. 9.15
for the control
group, this was
not, however,
significant (p =
0.3).
n. The
experime
ntal
group
had
chosen
to
participat
e in the
worksho
p.
intervention.
USA – Medicine,
Surgery
Surgeons who
teach medical
students
1-day workshop,
consisting of five
sections with
small group
discussions and
opportunities for
practical
application of
participants'
knowledge was
developed to
enhance the
teaching skills of
practicing
surgeons.
Pre-
intervention
Post-workshop
evaluations were
obtained from all
participants who
took the
workshop;
follow-up
surveys were
mailed 4–6
months later.
Follow-up
survey results
indicated that
many
participants
had
rarely/never
utilized cited
references,
looked for
additional
resources on
specific topics,
or referred to
the section
syllabus/hando
ut
materials
provided during
the workshop.
However,
100% of the
participants
who responded
No No
significa
nce
analysis
– – Andriole M et
al. 1998. Can a
one-day
workshop alter
surgeons'
teaching
practices?
American
Journal of
Surgery,
175:518–520.
reported that
they had
changed the
way they teach
as a result of
their workshop
attendance.
USA University
of Hawaii
Medicine Residents
who teach
medical
students
A training
programme to
improve the
teaching skills
of obstetrics
and
gynaecology
residents was
developed and
implemented.
Pre-
intervention
All residents
completed a
survey of their
teaching skills,
participated in
the programme,
and then
completed a
follow-up survey.
The surveys were
compared using
the Wilcoxon
The training
programme was
well received by
the residents.
Resident self-
rating scores
significantly
improved (P < .05)
in a number of
areas, such as
ability to teach
physical
Yes? – – – Barratt MS,
Moyer VA. 2004.
Effect of a
teaching skills
program on
faculty skills and
confidence.
Ambulatory
Pediatrics,
4:117–120.
signed rank test.
Medical students
also completed
surveys about
participating
residents’
teaching skills
either before or
after the
intervention.
examination skills,
and explaining
topics in a clear
and concise
manner. Students’
ratings of
residents’
teaching skills did
not improve.
UK – Medicine Consultants A 3-day Training
the Trainers
course,
averaging 12
consultant
attendees per
course has been
offered across
the Trent
region since
2000. The
course is
practical,
Control
group (n=23)
(controls
were selected
from the
waiting list,
more likely to
be similar to
participants)
vs. 54
participants
A questionnaire
was given to 120
consultants from
different
specialities in the
Trent region. 75
received the
questionnaire
immediately
before taking 1 of
the 3-day courses
offered in 2000
(participants), and
45 were sampled
As a group,
course
participants
showed an
improvement on
16 of the 18
teaching skills
(shown by the
positive median
score) and the
control group
showed an
improvement on 1
Yes? – – – Godfrey J,
Dennick R,
Welsh C. 2004.
Training the
trainers: do
teaching
courses develop
teaching skills?
Medical
Education,
38:844–847.
includes 3
micro-teaching
episodes
accompanied by
participants’
reflection on
their teaching
and the 3 course
days are
spread over a
few weeks to
encourage
application of
and reflection
on the new
learning.
from the course
waiting list
(controls). A
repeat
questionnaire was
distributed to the
2 groups 8–10
months later. All
non-respondents
received a second
questionnaire.
Both
questionnaires
were completed
by 54 participants
(63%) and 23
controls (51%).
The
questionnaires
itemized 18
teaching skills
that the course
aimed to develop.
For each skill,
respondents were
asked to rate: (1)
their ability using
a 5-point scale (1 =
skill. The
improvement in
the participant
group was
significantly
greater than in the
control group but
the increase in the
frequency with
which the
participant group
used the skills
was significantly
greater for only 4
of the 18 skills.
The majority of
individual course
participants
reported
improvement in
their teaching
ability on 4 or
more skills, with
the top 25% (14)
having improved
on 7 or more
skills, whilst the
low, 3 = moderate,
5 = high); and (2)
their frequency of
use of the skill on
a 4-point scale (>
10% = rarely, 10–
50% = sometimes,
51–90% = often, <
90% = always). A
global rating of
the levels of both
teaching
confidence and
effectiveness was
sought on a 5-
point scale.
Additionally, in the
second
questionnaire
respondents were
asked to describe
any changes they
had made to their
teaching since
completing the
first
majority of
individuals in the
control group
reported
improvement in
their teaching
ability on 1 skill,
the top 25% (6)
having improved
on 2 skills (Mann–
Whitney U-test
(MW) ¼ 252, P ¼
0.001). The range
of improved skills
was 0–18 in the
participant group
and 0–5 in the
control group.
Global ratings
showed that
teaching
confidence had
increased by 1
point for the
majority and 2
points for the top
25% of the
questionnaire.
For each skill, the
changes in ratings
on the scales for
ability and
frequency of use
were calculated
for the participant
and control
groups. These
changes were
analysed for
differences
between the 2
groups using the
Mann–Whitney U-
test. The total
number of rating
changes of 2 or
more,
on the scales for
ability and
frequency of use
of the skill were
calculated for
each individual.
The difference in
participants, with
no increase for
the majority and a
1 point increase
for the top 25% of
the controls (MW
¼ 326, P ¼ 0.017).
The majority of
participants also
reported an
increase in the
effectiveness of
their teaching
whilst the majority
of the control
group reported no
increase (MW ¼
309.5, P ¼
0.051).
the number of
individual
changes
between the
participants and
controls was
analysed using
the Mann–Whitney
U-test. Global
ratings of
confidence and
effectiveness were
analysed using
the same test.
USA Indiana
University
School of
Medicine
Medicine Clinical
teachers (42
attending
physicians
and 39
residents)
Intervention
faculty received
students'
ratings
augmented by
individualized
teaching
effectiveness
guidelines
based on the
Control
group
Randomized
control trial.
Linear models
were used to
analyse the
students' mean
ratings of
teaching
behaviours at
mid-month and
The intervention
group teachers
who had high
baseline scores
had higher
student ratings
than did the
control group
teachers with
similar baseline
– No
significance
analysis
– – Litzelman DK et
al. 1998.
Beneficial and
harmful effects
of augmented
feedback on
physicians'
clinical-teaching
performances.
Academic
Stanford Faculty
Development
Program
framework
end of month.
Independent
variables
included
performance
ratings,
interaction
status, teaching
status, teaching
experience and
interactions with
baseline ratings.
scores. The
intervention group
teachers who had
low baseline
scores were rated
lower than the
control group
teachers with
comparable
baseline scores.
Medicine,
73:324.
USA Medicine Clinical
teachers,
family
medicine
Individual
feedback
session
Pre-
intervention
Pre- and post-
intervention
consultations
with residents
were videotaped
and analyses for
teaching
behaviour and
resident ratings
Observed and
resident-reported
changes in
teaching
behaviour (e.g.
increased
reinforcement of
learner efforts and
use of open-
ended questions;
patients' ratings of
residents showed
some increases in
Yes – – – Marvel M. 1991.
Improving
clinical teaching
skills using the
parallel process
model. Family
Medicine,
23:279.
5 of 7 interview
behaviours.
USA University
of Hawaii
Medicine New PBL
tutors
Training
workshops
given to prepare
tutors for their
new role
Pre-
intervention
Pre- and post-
intervention
multiple choice
test
There were 1760
questions
assessing the
faculty trainees'
PBL knowledge;
1314 were
answered
correctly on the
pre-test
questionnaires
and 1498 were
answered
correctly on the
post-test
questionnaire.
– No
significance
analysis
– – McDermott Jr J,
Anderson AS.
1991. Retraining
faculty for the
problem-based
curriculum at the
University of
Hawaii, 1989-
1991. Academic
Medicine,
66:778.
UK University
of Oxford
Medicine,
Surgery
Surgeon
teachers
Surgeons in the
intervention
group were
instructed in the
4-step "Training
the Trainers"
Control
(random
assignment)
10 trainers from a
university
teaching hospital
were randomized
to train novices
on a one-to-one
Trainees who
were trained using
the specific
cognitive method
completed the
procedure in a
Yes – – – Murphy MA,
Neequaye S,
Kreckler S,
Hands LJ. 2008.
Should We train
the trainers?
model basis in a
simulated
procedure using
either a 4-step
cognitive method
or their own
unspecified
method. 30
trainees were
randomly
assigned to
either a cognitive
or standard
trainer. After
training, trainees
were assessed
on performing
the procedure
using a task-
specific
checklist, a
global rating
scale, and time
taken to
complete the
procedure.
faster time (mean
331 seconds [SD
37 seconds]
versus 426
seconds [SD 66
seconds]) and
with higher global
rating scores
(mean 23.25
seconds [SD 3.7
seconds] versus
20.5 seconds [SD
4.5 seconds])
compared with
those taught by a
standard method.
Results of a
randomized trial.
Journal of the
American
College of
Surgeons,
207:185–190.
Canada McGill
University
Medicine Lecturers A 4-hr workshop
has been offered
for 4
consecutive
years to faculty
members in the
Faculty of
Medicine at
McGill
University to
allow
participants to
explore
interactive
techniques and
incorporate
them into their
lectures
The
experimental
group
consisted of
the first 60
faculty
members to
register for
the
workshop,
and the
comparison
group
comprised
the 40
individuals
on the
waiting list
3 instruments
were used in the
evaluation. The
participants
completed a
workshop
questionnaire
immediately after
the workshop. 6
months after the
session, the
experimental and
comparison
groups that had
explored the use
of interactive
lecturing
techniques since
the workshop
completed a 6-
month post-
workshop
questionnaire. In
addition, 23
On the 6-month
post-workshop
questionnaire, the
only difference
found in the
demographic data
between the 2
groups was in the
number of years
of teaching
experience. The
experimental
group had given
more interactive
lectures over the
past 6 months and
had used more
audience
responses, certain
types of
questions,
audience surveys,
live interviews,
verbal and written
Yes? – – – Nasmith L,
Steinert Y. 2001.
The evaluation
of a workshop to
promote
interactive
lecturing.
Teaching and
Learning in
Medicine, 13:43.
individuals from
the experimental
group and 14
from the
comparison
group were
videotaped 6
months after the
session and were
scored on a
videotape
observational
grid by an
independent
rater.
cases, and study
guides (p < .05).
From the
videotape
observational
data, the
experimental
group scored
higher in
questioning and
engaging the
audience, and in
using nonverbal
gestures (p < .05).
This group also
received higher
ratings for their
interactivity and
for the students’
responsiveness.
Canada McGill
University
Medicine,
Family
medicine
– Workshop on
small group
teaching
Control
group (10 of
each)
Instruments were
designed to
measure
attitudes,
cognitive
The instruments
developed for this
study detected
differences
between the two
Yes? – – – Nasmith L et al.
1997. Assessing
the impact of a
faculty
development
learning and
teaching
behaviours
groups. The
experimental
group exhibited
more small‐group
teaching skills
and greater
knowledge about
small‐group
teaching than the
control group.
Differences
existed in the use
of and attitudes
towards this
teaching method.
workshop: a
methodological
study. Teaching
and Learning in
Medicine, 9:209–
214.
USA – Medicine Community-
based
hospital
faculty
Faculty
development
fellowship
programme for
community-
based hospital
faculty.
Principles of
adult learning
were taught to
Pre-
intervention
Quantitative data
were collected
through the
Principles of
Adult Learning
Scale (PALS)
developed by
Conti (1979).
Qualitative data
were also
Findings of this
pilot study
indicate that the
fellows' teaching
beliefs and
practices changed
from a teacher-
centred to a more
learner-centred
and collaborative
– – – – Pinheiro SO,
Rohrer JD,
Heimann C.
1998. Assessing
change in the
teaching
practice of
faculty in a
Faculty
Development
faculty
participants
over the
fellowship
period. These
included
instruction in
teaching
methods, group
facilitation and
curriculum
development.
collected through
review of
videotaped
teaching
sessions. The
PALS instrument
was administered
to 18 faculty
members in a
pre- and post-test
design, and
videotaped
sessions of 6
participants were
reviewed.
mode as a result
of the faculty
development
programme. This
change is
reflected in the
improvement in
their overall and
individual PALS
scores. Video
observations also
show change in
the application of
adult learning
principles in their
teaching.
Program for
Primary Care
Physicians:
Toward a Mixed
Method
Evaluation
Approach. Paper
presented at the
Annual Meeting
of the American
Educational
Research
Association (San
Diego, CA, 13-17
Apr.).
UK University
of
Birmingham
Medicine Hospital
doctors
An initial
introductory
half-day was
followed by 13
monthly one-
hour lunchtime
sessions in
teaching skills.
– Feedback form The majority felt
they had gained in
skills (see table)
– – The network of
colleagues
continues to
meet and is
actively
involved with
developments
in the
university
– Rayner H et al.
1997. Delivering
training in
teaching skills to
hospital doctors.
Medical Teacher,
19:209–211.
undergraduate
medical
curriculum.
Denmark – Medicine Hospital
doctors
3-day "Training
for trainers"
course
Pre-
intervention
The study was
designed as an
intervention
study with pre-,
post- and long-
term
measurements.
The intervention
group (I-group)
included 118
doctors from the
departments of
internal medicine
and
orthopaedic
surgery at one
university
hospital. The
control group (C-
group) consisted
of 125 doctors
from the
Knowledge about
teaching skills
increased in the I-
group by 25%
after the TTC and
was sustained at 6
months. Post-
course, the
teaching
behaviour of the I-
group
significantly
changed and its
learning climate
improved
compared with the
C-group. Scores
for use of
feedback and
supervision in the
I-group increased
from 4–5 to 6–7
Yes? – – – Rubak S et al.
2008. A
controlled study
of the short and
long term effects
of a Train the
Trainers course.
Medical
Education,
42:693–702.
corresponding
departments at
another
university
hospital. Gains in
knowledge about
teaching
skills were
assessed by a
written test.
Teaching
behaviour and
learning climate
were evaluated
by
questionnaires.
(maximum score =
9). This was
significantly
higher than in the
C-group.
USA Morehouse
School of
Medicine
Medicine Faculty and
community-
based
preceptors
(aimed at
ethnic
minorities)
The programme
trains faculty
and community-
based
preceptors in
teaching,
scientific
writing, grant
writing,
Pre-
intervention
Evaluation
measures include
participant
enrolment,
completion rate,
participant
feedback, and
self-reported
academic
A total of 113
participants
completed the
programme from
1992 to 2003. Only
7 enrollees failed
to complete the
programme. Of
113 graduates,
– – – – Rust G et al.
2006. The
Morehouse
Faculty
Development
Program:
evolving
methods and 10-
year outcomes.
research, and
minority career
issues. Formats
now include a 1-
year longitudinal
programme, 4–
6-week stand-
alone modules,
and an
executive
faculty
development
programme for
physicians from
across the
nation.
competencies
before and after
the programme.
104 (92.0%) were
ethnically African
American, Afro
Caribbean, or
African, while only
two were white,
non-Hispanic.
More than four out
of five (81%) now
spend at least
some time
teaching on a
regular basis, and
71% spend more
than 25% in
teaching roles.
Self-reported
before-after
competencies in
specific academic
skills such as
teaching, writing,
research, and
grant writing rose
from 2.7 to 4.1 on
a 5-point scale.
Family Medicine,
38:43–49. Epub
2005/12/27.
USA – Medicine Ambulatory
teachers
The faculty
development
programme
trained faculty in
either: clinical
teaching (CT);
medical
decision making
(MDM); or
preventive
medicine (PM).
10 facilitators
implemented a
faculty-
development
programme for
64 ambulatory
care faculty
members.
Pre-
intervention
Pre- and post-
surveys
For the CT
seminars,
statistically
significant pre- to
post-intervention
improvements
were found for all
7 categories of
teaching skills
covered (p <
0.001). For the
MDM seminars,
the participants’
content
knowledge
increased from a
pre-test mean of
49% correct to a
post-test mean of
70% correct (p =
0.01).
– – – – Stratos GA et al.
1997. Use of
faculty
development to
improve
ambulatory-care
education.
Medical Teacher,
19:285–292.
Sweden Karolinska
Institute
Medicine Medical
teachers
Staff
development
course on
medical
teachers’
thinking and
practice
Pre-
intervention
Data have been
gathered through
19 semi-
structured
interviews with
participants on
the course 1 year
after their
participation
All but one of the
respondents claim
to have changed
their teaching as a
result of the
course. The
developments
reported by the
respondents can
be categorized as
changes in
practice or
changes in
thinking.
The changes in
practice include
using new tools
and methods,
such as new
presentation or
evaluation
techniques, buzz
groups, peer-
assisted learning
and cases. The
– – – – Weurlander M,
Stenfors-Hayes
T. 2008.
Developing
medical
teachers’
thinking and
practice: impact
of a staff
development
course. Higher
Education
Research &
Development,
27:143–53.
changes aim to
activate the
students, to
motivate them to
approach the
content in a new
way, and to help
them get
a more complete
picture of the
content. Some of
the developments
the respondents
have made are in
the
implementation of
tools or methods
used in the staff
development
course. However,
many reported
changes were not
modelled during
the course.
Instead the
respondents
found inspiration
in the course to
create something
of their own or
implement
something else
they had heard
about.
USA – Medicine Ambulatory
teachers
"Arrows"
workshop.
Participants
explore 3 critical
strategies for
teaching during
outpatient care-
activated
demonstration,
3-minute
observation and
case
presentations
Pre-
intervention
Pre- and post-
test in which
ambulatory
teaching
scenarios were
presented and
participants had
to state what they
would most likely
do next
No significant
changes
– – – – Wilkerson LA,
Sarkin RT. 1998.
Teaching the
teachers: Is it
effective?
Arrows in the
quiver:
Evaluation of a
workshop on
ambulatory
teaching.
Academic
Medicine:
Journal of the
Association of
American
Medical
Colleges,
73:S67.
Recommendation 3: Health professionals’ education and training institutions should consider innovative expansion of faculty, through the recruitment of community-based
clinicians and health workers as educators.
County Institution Population Intervention Comparison Study design/sample size Methodological quality issues
Reported results
(outcomes) Additional comments Reference
USA Medical College of
Wisconsin
Emergency medicine
(EM) facility
To assess the relationship between measures of faculty clinical efficiency and teaching effectiveness.
No comparison group
Retrospective review of clinical and teaching data prospectively collected over the year [starting 1 January 2007 and ending 31 December 2007).
18 faculty members on staff during the study period, EM residents and senior medical students (sample size not shown) evaluated teaching effectiveness of each faculty member.
Retrospective review of clinical and teaching data from a single academic institution with an annual census of 55 000.
Faculty clinical efficiency was measured by two variables: the relative value unit (RVU)/h ratio and average 'door to discharge' time.
Teaching effectiveness was estimated by determining the average 'overall teaching' scores derived from anonymous EM resident and senior medical student evaluations. A 6-point Likert-type scale was used for the EM residents and a 10-point Likert-type scale was used for the medical students. Relationships were assessed using the Spearman's correlation coefficient.
Quality: There was no statistically significant relationship (p>0.05) between measures of faculty clinical efficiency and teaching effectiveness scores for either resident or senior medical student learners.
These data replicate previous findings that clinical productivity has no correlation with teaching effectiveness for emergency medicine faculty doctors. Efficient teaching doctors appear to be able to perform clinical duties in a busy ED environment without unduly sacrificing their ability to provide resident and student education.
Limitations:
It is a retrospective review looking at the association between several variables.
It was conducted at one institution and therefore only reflects the performance of one group of faculty.
The variables we used to estimate each of two domains (clinical teaching and clinical productivity) have limitations.
Begaz T et al. 2011. No relationship between measures of clinical efficiency and teaching effectiveness for emergency medicine faculty. Emergency Medicine Journal, 28:37–39.
Germany
University of Tuebingen
Tutors had taken part in the training programme for dissection course
To test whether there is a difference between the tutees’ perception of the tutors’ competences, comparing trained and untrained tutors.
Untrained tutors (control group)
Randomized, controlled, single blind study.
20 tutors (10 tutors had taken part in the training programme, 10 untrained tutors [control group]).
The acceptance of the training programme was measured with a questionnaire (11 items, 5-point Likert scale) where the tutees rated the technical and didactical competences of the tutors.
The tutees were blinded to the tutor’s training. The tutees were assigned to the dissection groups automatically and randomly by computer in the deanery of student affairs, who was not involved in the study. The tutors were randomized to the dissection groups by the course organiser.
Tutor self-assessment of the personal competencies was measured with a questionnaire (14 items, 5-point Likert scale). In order to measure the individual increase in knowledge or skills, the questionnaire was filled out by the participants directly before the beginning of the training (T1) and
Quality:
The tutees assessed the trained tutors better in all categories compared to the untrained tutors. A significantly better score (p < 0.05) was stated for the categories “conveying basic dissection techniques” (4.31±0.86 vs. 3.89±1.05), “positive group atmosphere” (4.69±0.73 vs. 4.44±0.88), “learning support” (4.24±1.03 vs. 3.79±1.16) and “visualisation” (3.99±1.11 vs. 3.56±1.17). In tutor self-assessment, the trained tutors rated themselves significantly better after the training compared to before in all categories.
The specific training curriculum for tutors in the dissection course, focusing on the improvement of content knowledge, technical and didactical competencies, was effective in the tutors’ and tutees’ perception. The programme appears to be a considerable basis for providing the university with a more valuable resource for teaching gross anatomy.
Shiozawa T et al. 2010. Does a combined technical and didactical training program improve the acceptance of student tutors in the dissection course? A prospective controlled randomized study. Annals of Anatomy, 192:361–365.
directly after the last training session (T2) in terms of a pre-post study.
Australia
Princess Alexandra Hospital
Nursing clinical practicum.
Clinical facilitators (experienced clinical educator/researcher)
To assess the impact of an intervention aimed to build capacity of registered nurses to enhance the clinical learning environment for undergraduate nursing students.
Pre-intervention A quasi-experimental design.
Second and third year undergraduate students (n = 62) studying a Bachelor of Nursing and clinical facilitators (sample size of experienced clinical educator/researcher is not shown).
Students who undertook their clinical practicum for registered nurses (RNs) in the two surgical wards, before, during and six months after the capacity-building intervention assessed the psychosocial learning environment at the time of their clinical practicum.
During both the control and intervention periods the students and RNs received assistance during the clinical practicum through a supernumerary clinical facilitator (ratio of 1 facilitator to 8 students).
The intervention period involved a further resource, namely an experienced educator/researcher, who conducted capacity building activities for the RNs. This intervention was a continuous process whereby every second day during the 6-week intervention period the researcher/educator visited the clinical area for 3–4 hours. During these visits an in-service would be conducted that built on discussions of previous in-services and talked to the RN with the student about the patients’ needs.
Measurement of students' perceptions of the psychosocial learning environment (42 items, 4-point Likert scale) during and outside of the intervention period was used to evaluate the capacity building intervention.
Quality:
Findings showed that students who undertook their clinical practicum during the intervention period rated the psychosocial clinical learning environment significantly higher than students who undertook their practicum at times outside of the intervention period (p < 0.05).
An experienced researcher/educator conducting capacity-building sessions can effectively assist and support registered nurses to engage with students.
Capacity-building sessions can improve practice, however, structures and processes that ensure continuation of practice change need to be embedded for improvements to be sustained. Limitations:
This study was limited due to its small sample size.
It was also specific to the workplace contingencies to the two areas where the intervention was undertaken.
Henderson A et al. 2010. Creating supportive clinical learning environments: an intervention study. Journal of Clinical Nursing, 19:177–182.
Netherlands
University of Applied Sciences Utrecht
Physiotherapists educated by expert tutor
To determine the influence of tutor expertise on the uptake of a physiotherapists’ educational programme intended to promote the use of outcome measures in the management of patients with stroke.
Physiotherapists educated by non-expert tutor
Randomized controlled trial.
30 physiotherapists involved in the management of patients with stroke were randomly assigned to a group taught by an expert tutor (N = 15) or a group taught by a non-expert tutor (N = 15).
30 voluntarily participating physiotherapists involved in stroke management were randomized into 2 groups and participated in 5 tutor-guided educational sessions (the Physiotherapists’ Educational Programme on Clinimetrics in Stroke, PEPCiS). Groups differed from each other with respect to tutors: one experienced and one inexperienced in stroke care.
The primary outcome of this study was ‘actual use’, measured by the frequency of data of the recommended outcome measures in the patient records of the participating physiotherapists in their own practice routine. Secondary outcomes were:
Quality:
The actual use of instruments shifted from a median of 3 to 6 in the expert tutor group and from 3 to 4 in the non-expert tutor group (P=0.07).
Physiotherapists educated by the expert tutor used a broader variety of instruments and appreciated the educational programme, their own knowledge gain and all 3 scales of tutor style aspects significantly more than
Limitations: Tutors were not blinded and the physiotherapists, who were unaware of the precise objectives of the study, were semi-blinded.
The sample size in this study is quite small and highly selected, which makes it difficult to use a regression analysis and to generalize the conclusions.
Van Peppen RP et al. 2009. Promoting the use of outcome measures by an educational programme for physiotherapists in stroke rehabilitation: a pilot randomized controlled trial. Clinical Rehabilitation, 23:1005–1017.
(1) self-reported use of outcome measures by participants; (2) participants’ appreciation of the tutoring style of their allocated tutor. Actual use and self-reported use were assessed at baseline and after the end of the 14-week intervention period.
their colleagues of the non-expert tutor group (all P<0.05).
Univariate analysis on the entire set of data revealed 8 factors, including tutors’ performance, that were associated with a change score of the use of 2 or more outcome measures by individual physiotherapists after the educational programme.
Therefore, tutors with content expertise seem to be more effective in educating physiotherapists to change their professional behaviour than tutors without content expertise.
Pakistan
The Aga Khan University Hospital
Medical faculty To compare the teaching skills of residents with faculty in facilitating small group Problem Based Learning (PBL) sessions.
Residents Quasi-experimental descriptive comparative study. 5 residents in postgraduate year 4 and 5 senior faculty members were selected from the section of Gastroenterology, Department of Medicine.
Final year medical students (sample size not shown) evaluated to rate the teaching skills of residents and the faculty.
The study was conducted with all phase III (final year) students. These students are required to rotate through gastroenterology PBL curriculum for two weeks during their phase III with 5 students present in each rotation.
All the residents and faculty members were selected from the same discipline, so that the two groups were similar regarding the topics of teaching sessions. In order to achieve uniformity, all residents were in their 4th year of training, i.e. having similar work experience.
The same standards were also used for selection of faculty members, i.e. they all had more than 10 years teaching experience.
The residents and faculty members received introductory training over 1 month (one 3-hour session each week for a total of 12 hours). There were a total of 12 training hours in teaching skills at the beginning for both groups.
Different aspects of teaching skills of residents and faculty were evaluated by students on a questionnaire (graded on Likert Scale from 1 to 10) assessing i) Knowledge Base-content Learning (KBL), ii) Problem Based Learning (PBL), iii) Student Centered Learning (SCL) and iv) Group
Quality:
There were 33 PBL teaching sessions in which 53% students in the residents group completed 120 evaluation forms and 47% in the faculty group.
The results for student evaluation forms revealed that the faculty was better facilitators in two of the five teaching domains.
The faculty showed a statistically significant rating in "knowledge based learning" (faculty 8.37 vs. residents 7.94; p = 0.02), "group skills" (faculty 8.06 vs. residents 7.68; p = 0.04).
Differences in faculty and resident facilitators' scores in "the problem based learning process", "student centred learning" and in "students' clinical evaluation" were not statistical significant (p > 0.05). The overall score of faculty facilitators, however,
With specific education in teaching methods, residents are an effective supplement to faculty members for facilitation of PBL sessions. With specific education in teaching methods, residents can be helpful in facilitating PBL sessions. Facilitation of the PBL module and participation in teaching workshop also appears to have improved the teaching performance of residents. Involvement of residents in PBL sessions may help institutions identify additional facilitators who can help resolve a shortage issue.
Jafri WT et al. 2007. Improving the teaching skills of residents as tutors/facilitators and addressing the shortage of faculty facilitators for PBL modules. BMC Medical Education, 7:34.
Skills (GS). was statistically greater than for resident facilitators (p = 0.05).
USA
University of Pennsylvania
Medical faculty To examine relationships between (a) residents’ ratings of faculty clinical excellence and teaching effectiveness and (b) track-related performance differences.
No comparison group
Cross-sectional questionnaire survey. 3713 evaluations for 399 faculty provided by 436 different residents.
This study was conducted within 15 residency-training programmes at a large, academic health system. Items for clinical teaching effectiveness were developed through a consensus process that included representatives of all clinical departments. The content of the 8 common items for clinical teaching effectiveness items covers availability/
accessibility, teaching effectiveness, ability to teach subject manner, ability to teach critical thinking, ability to teach clinical skill/judgement, teaching communication, teaching professionalism and overall teaching effectiveness. Each item was rated on a 5-point scale. The topics of the 5 items for clinical excellence covers medical knowledge, clinical communication, clinical professionalism and overall clinical excellence. Each item was rated on a dichotomous scale using 0 (no) and 1 (yes).
Relationships between teaching effectiveness and clinical excellence ratings were examined with Spearman correlations and phi coefficients.
Quality: Teaching effectiveness and clinical excellence ratings were correlated: Spearman correlation between global teaching effectiveness and clinical excellence ratings was 0.59 (p < 0.0001) and between the scale scores for teaching effectiveness and clinical excellence was 0.55 (p < 0.0001). Although the data are skewed, there are clearly some faculty who receive low ratings in clinical excellence and teaching effectiveness.
The moderate correlations between teaching and clinical domain scores suggests more thought should be given to how to use both types of data for identifying the lowest and highest performing faculty.
Differences in means for the teaching effectiveness ratings by faculty track (clinical faculty, staff faculty and tenure track) were not significant. There were differences for the ratings of clinical excellence showing that clinical faculty received higher ratings than staff physicians for the global (p = .005) and scale scores (p = .001). In addition, there was no difference between ratings given to faculty in the clinical or tenure tracks.
(Faculty tracks are as follows: clinical faculty = academic clinicians and clinician educators who are promoted based on excellence in clinical work/research and teaching; staff faculty = health system clinician who are employees of the health system and not required to be considered for promotion; tenure track = faculty who are primarily independent researchers and spend little time in clinical work or teaching).
McOwen KS, Bellini LM, Shea JA. 2007. Residents' ratings of clinical excellence and teaching effectiveness: is there a relationship? Teaching and Learning in Medicine, 19:372–377.
Denmark
Copenhagen University Hospital
Medical faculty (clinical associate professors)
To compare student teachers and clinical associate professors regarding the quality of procedural skills teaching in terms of participants’ technical skills, knowledge and satisfaction with the teaching.
Student teachers Randomized controlled study 59 first-year medical students (31 in the student teachers group and 28 in the associate professor group), 6 associate professors and 6 student teachers were asked to teach.
This study compared the quality of teaching of student teachers and associate professors regarding participants’ technical skill and satisfaction with the teaching. Two skills were chosen for the experiment, IV-access and bladder catheterization.
All teachers received written and oral information and materials on expected class content and were instructed in how to use the manikins available for the classes. Each teacher was requested to teach only 1 of the 2 skills mentioned above.
Learning outcome was assessed by a pre- and post-testing (practical and written tests) of the participants’ knowledge and skills.
The examiners were blinded as to whether the participants had been taught by an associate professor or a student teacher. The group of examiners were not part of any of the 2 teacher groups. Participants evaluated satisfaction with
Quality:
The students taught by student teachers performed just as well as the students taught by associate professors.
Regarding practical performance of bladder catheterization, the group taught by student teachers had significantly higher mean difference in post- minus pre-test score, 65.5 (SD 12.9) compared to the group taught by associate professors, 35.0 (SD 23.3), p<0.0001.
There was no significant difference between groups in learning outcome regarding the practical IV-test or in any of the two written tests.
Therefore, this study
Student teachers receive significantly more positive evaluations than associate professors on several statements. Despite limited clinical experience student teachers may possess substantiate tacit pedagogical knowledge.
So, using trained medical students as teachers makes high quality small group teaching more feasible and may be a valuable additional teaching resource in clinical skills centres.
Tolsgaard MG et al. 2007. Student teachers can be as good as associate professors in teaching clinical skills. Medical Teacher, 29:553–557.
teaching on 9 statements immediately with 6-point Likert-scores after the teaching.
showed that student teachers were just as proficient – and in some cases better – than associate professors in teaching clinical skills.
The student teachers being closer in experience to the students taught compared to senior clinicians could explain this. In addition, student teachers may be more enthusiastic compared to senior clinicians in teaching clinical procedures using a systematic approach in teaching a skill step-by-step.
USA
Brigham and Women’s Hospital
Medical faculty To compare teaching quality between obstetrics/gynaecology resident and faculty preceptors in ambulatory gynaecology as determined by medical student evaluation.
Residents A prospective comparative study in which 48 third-year medical students evaluated preceptors (11 faculty members and 13 senior residents) during their obstetrics/gynaecology clerkship.
A prospective assessment of medical student evaluations of resident and faculty preceptors in ambulatory gynaecology was conducted at Brigham and Women’s Hospital.
During their 5.5-week core obstetrics/gynaecology clerkship, the clerkship coordinator assigned 3rd-year Harvard Medical School students to an average of 3 ambulatory gynaecology sessions (half-day) with a senior resident (3rd- or 4th-year resident) and 2 sessions with a faculty member.
Students voluntarily and anonymously completed evaluation forms (15 teaching quality items, 5-point Likert-type scale) at the end of the rotation for each resident and faculty preceptor to whom they were assigned.
Students also reported the number of pelvic examinations, breast examinations, and Papanicolaou (Pap) tests performed with each preceptor per session.
The primary outcome of the study was to compare teaching quality between obstetrics/ gynaecology resident and faculty preceptors in ambulatory gynaecology as determined by medical student evaluation.
Quality: Faculty scores were statistically higher than resident scores on 4 of the 15 teaching quality items; acting as an appropriate clinical role model (4.83 vs. 4.67, P <0.05), emphasizing evidence-based learning (4.55 vs. 4.39, P <0.05), being enthusiastic about teaching (4.73 vs. 4.58, P <.05) and patient care (4.85 vs. 4.72, P <0.05). For faculty, there was no effect of academic rank or formal education role on individual teaching behaviour scores or on total teaching scores. Students performed significantly more Papanicolaou tests (2.78 vs. 1.01, P<0.001) and pelvic (3.07 vs. 1.28, P<0.001) and breast examinations (1.02 vs. 0.34, P<0.001) during ambulatory sessions with residents than with faculty.
Therefore, both residents and faculty contribute important and different aspects of teaching experiences for medical students in ambulatory gynaecology.
The students were found to perform significantly fewer Pap tests, pelvic, and breast examinations with older faculty preceptors (P <0.05) and fewer breast and pelvic examinations with those faculty members with higher academic rank (P <0.05 for breast and pelvic examination only, P = .081 for Pap test).
Students performed significantly more pelvic examinations with faculty who were female, held an advanced degree, and had received a teaching award (P <0.05).
This suggests that the ideal model for ambulatory teaching in gynaecology is a combination of faculty and residents as preceptors.
Limitations:
It was conducted at a single institution with a single class of medical students.
The numbers of faculty and resident preceptors were small because of the limited pool of clinical preceptors available.
Johnson NR, Chen J. 2006. Medical student evaluation of teaching quality between obstetrics and gynecology residents and faculty as clinical preceptors in ambulatory gynecology. American Journal of Obstetrics and Gynecology, 195:1479–1483.
Canada
Faculty of Medicine at the University of
Clinician medical teachers
To study whether teaching capability is associated
No comparison group
Multicentre retrospective cross-sectional study of 40 clinician
All doctors who had attended on a clinical teaching unit at the general
Quality:
The median TES of the
Institutions and governments need to be
Canada
Toronto with altered short-term patient outcomes
teachers who had attended on the general internal medicine services in hospitals affiliated with the University of Toronto
internal medicine services in hospitals affiliated with the University of Toronto between 1999 and 2001.
We retrieved the medical records (n = 4377) of consecutive patients admitted under the care of the participating doctors with the following most responsible diagnoses: congestive heart failure (CHF), community-acquired pneumonia (CAP), gastrointestinal bleeding (GIB) and chronic obstructive pulmonary disease exacerbation (COPD).
These conditions were chosen because they are among the most common admission diagnoses to general internal medicine at the affiliated hospitals.
Information on patients was extracted from an electronic database at each hospital containing patient demographics, comorbidity, procedure, mortality and readmission and discharge destination information.
____
Medical residents completed voluntarily an evaluation of their supervising doctors at the end of every clinical rotation. The teaching effectiveness score (TES) used at the University of Toronto contains 15 items that describe different aspects of effective clinical teaching using a 5-point rating scale (n = 677). The correlation between the TES, patient data and doctor characteristics was analysed using Spearman’s rank correlation coefficient (r).
entire group was used to divide doctors into 1 of 2 groups so that 20 doctors were classified as low-rated (mean TES = 8.73) and 20 as high-rated (mean TES = 9.52).
These 2 groups of doctors did not differ with respect to age, years since graduation, academic rank, clinical speciality or average number of evaluations.
There was no correlation between the teaching effectiveness scores and the mean length of stay for those patients treated for CAP (high-rated = 10.3 versus low-rated = 8.1 days, P = 0.058), CHF (high-rated = 10.1 versus low-rated = 9.9 days, P = 0.978), COPD (high-rated = 9.4 versus low-rated = 9.9 days, P = 0.419) and GIB (high-rated = 6.3 versus low-rated = 6.8 days, P = 0.741).
In addition, we observed no significant correlation between teaching effectiveness scores and 7-day, 28-day and 1-year readmission rates, in-hospital mean length of stay and mortality for all pre-specified diagnoses.
aware of the important contribution of clinical teachers to the mission of academic medical centres.
The data suggest that effective clinical teachers do not provide substantially better or worse clinical care than less effective clinical teachers.
The analysis is based on a single university and focuses on general internal medicine clinical teaching units and relies on a teaching evaluation scale that may differ from other institutions.
The time that a student spends with a teacher may also influence a students’ rating of their clinical teacher, and this factor is not accounted for by the TES.
The analysis did not take into account the role of resident’s ability and experience in patient care.
USA
University of Iowa Medical faculty To identify the factors associated with students receiving higher clinical skills’ experience during their 3rd-year family medicine preceptorship.
No comparison group
Longitudinal observational study 1419 3rd-year medical students at the University completed their required family medicine preceptorship and 179 different preceptors over the 9 academic years.
Students rotated one on one with a community-based, board-certified, family physician preceptor, while the remainder rotated with several family physician supervisors in a family medicine residency programme.
Prior to teaching a third-year medical student, community-based preceptors were required to attend a 3-hour training workshop taught by our department’s pre-doctoral faculty and staff.
The workshop covered course goals and objectives, teaching in the busy office setting, evaluation procedures, and how to give
Quality: Both years of experience as a preceptor and total number of previous students taught were positively associated with students' total clinical skills scores (P <0.01).
Students who rated their preceptor higher on any of the six teaching characteristics achieved significantly higher mean total skills scores (P <0.001).
Students received more clinical skill experience when they rotated during the second half of the academic year, with rural preceptors (as opposed to with urban preceptors or at residency sites), and when they rated their preceptor’s teaching high on opportunity for clinical procedures and appropriate delegation of responsibility. Male students received significantly less experience with female-specific skills.
Levy BT, Merchant ML. 2005. Factors associated with higher clinical skills experience of medical students on a family medicine preceptorship. Family Medicine, May, 37:332–340.
formative and summative feedback to learners.
Immediately after completion of their preceptorship, students rated their level of experience with 57 clinical skills on a 5-point scale.
Student ratings were summed to obtain scores for total clinical skills (n = 57), procedural skills (n = 22), and female-specific skills (n = 9). Mean levels of students’ total clinical skills experience according to student, course, and preceptor variables were analysed using t tests or ANOVA as appropriate.
In addition, students gained more experience, "opportunity for clinical procedures", "delegation of appropriate responsibility", and "preceptor conveyed expectations clearly", with preceptors who were rated higher on teaching qualities (P <0.001).
Limitations:
These data are self-reported from students at a single Midwestern medical school and thus are not necessarily applicable to other institutions.
There was no direct observation of the skills with which students stated they had experience.
The preceptors did not verify the skills reported by students.
USA
Emergency Medicine, Emory University School of Medicine
Emergency medicine (EM) faculty
To determine if there is an inverse relationship between clinical productivity and teaching evaluations.
No comparison group
Prospective observational double-blind study.
70 senior medical students who enrolled in their emergency medicine (EM) clerkship evaluate 53 EM attending physicians who precepted them at 3 academic emergency departments.
The rotation includes 12 shifts at three hospitals, including an inner-city public hospital, an academic affiliate community hospital, and a tertiary-care university hospital.
Students were scheduled on all different shifts, with no more than one student per attending physician per shift.
After each shift, students anonymously evaluated their supervising EM attending physician on 10 characteristics of clinical teaching using 6-point Likert scales.
Students who evaluated more than one shift with the same attending physician had each evaluation counted separately.
Attending physicians were unaware that they were being evaluated. Each attending physician’s clinical productivity was measured by calculating his or her total relative value units per hour (RVUs/hr) during the 9-month study interval. The authors compared the total RVUs/hr for each attending physician to the medians of their teaching evaluation scores at each ED using a Spearman rank correlation test.
Quality:
The correlation coefficient between the attending physicians’ RVUs/hr and their teaching evaluation scores was -0.08 (p = 0.44). The correlation coefficient is close to zero and the p-value is greater than 0.05, showing that there is no statistically significant relationship between clinical productivity and medical student teaching evaluations. In fact, they found that a subset of their more productive attending physicians were also the most highly rated teachers.
Evidently, it is possible to find a balance between efficient patient care and highly rated teaching.
While many EM attending physicians perceive patient care responsibilities to be too time consuming to allow them to be good teachers, the authors found that a subset of our more productive attending physicians are also highly rated teachers. Determining what characteristics distinguish faculty who are both clinically productive and highly rated teachers should help drive objectives for faculty development programmes.
Limitations: As surveys were anonymous and voluntary, only 76% of students submitted evaluation forms, and many failed to evaluate all their shifts.
RVUs/hr is an imperfect way to measure how busy attending physicians are during their shifts, and it does not directly reflect actual patient volume, patient satisfaction, or time spent performing nonclinical tasks.
Berger TJ et al. 2004. The impact of the demand for clinical productivity on student teaching in academic emergency departments. Academic Emergency Medicine, 11:1364–1367.
USA
General Medicine, Emory University School of Medicine
Hospitalists, general medicine and sub-specialist teachers
To compare evaluations of teaching effectiveness among hospitalist, general medicine, and sub-specialist attendings on general medicine wards.
3-groups comparison
Cross-sectional questionnaire survey
A total of 423 participants (206 3rd- and 4th-year medical students, 96 residents and 121 interns) evaluate 63 attending physicians (12 hospitalist, 24 general medicine and 27 sub-specialists) who supervised Emory medical ward teams
All medical students and house staff who worked on Emory medical ward teams between Aug. 1998 and Jul. 1999 were distributed equally among the 3 attending types by trainee level and gender.
At the end of each ward month, a research assistant approached potential subjects, asking students to complete a questionnaire about
Quality:
On a 150-point composite measure, hospitalists' mean score (134.5 [95% confidence interval (CI), 130.2 to 138.8]) exceeded that of sub-specialists (126.3 [95% CI, 120.4 to 132.1]), P = .03. General medicine
Some of this effect may be due to spending more time with team members, forming stronger personal bonds with trainees, and modelling characteristics highly valued by learners. Given the increasing demands placed on traditional ward attendings, as well as the continued specialization of medical knowledge and practice,
Kripalani S et al. 2004. Hospitalists as teachers. Journal of General Internal Medicine, 19:8–15.
during the 12-month period. their experience of working on the ward and evaluation of their clinical tutor.
Teaching effectiveness data were collected through a self-administered questionnaire of the McGill Clinical Tutor Evaluation (CTE), a validated 25-item survey with a 6-point Likert response scale, and a review of additional written comments.
Hospitalists supervised medical ward teams for 6–8 months per year. In addition, they spent approximately a third of their professional time in outpatient clinics. General medicine attendings spent most of their time in the outpatient setting and only 1–2 months working on the inpatient wards. Sub-specialists had varied clinical duties and generally spent 1 month per year as a ward attending. Many worked as sub-specialty consultants, and also conducted laboratory or clinical research.
attendings (135.0 [95% CI, 131.2 to 138.8]) were also rated higher than sub-specialists, P = .01.
Physicians who graduated from medical school in the 1990s received higher scores (136.0 [95% CI, 133.0 to 139.1]) than those who graduated earlier (129.1 [95% CI, 125.1 to 133.1]), P = .006. These trends persisted after adjusting for covariates, but only year of graduation remained statistically significant, P = .05.
Qualitative analysis of written remarks revealed that many young hospitalists and general internists received specific positive comments about their enthusiasm for teaching, ability to create a good learning climate, use of evidence-based medicine, and rapport with patients and other team members. These favourable characteristics, combined with a greater emphasis on current medical literature and evidence-based medicine, could have led to the better evaluations.
Trainees also appreciated hospitalists’ greater presence on the wards and their level of involvement in patient care.
hospitalists appear well suited to serve as clinician educators on the inpatient wards. Their presence as educators and role models may continue to drive the recent enthusiasm for hospital medicine as a career option for medical students and residents.
Limitations:
This study took place at a single institution. Since hospitalist faculty served a greater number of ward months, they each received more evaluations than the other attendings (introduced bias).
CTE scores may not reflect all the dimensions of teaching effectiveness and clinical importance.
USA
University of Kansas School of Medicine, Wichita
Medical faculty (academic full-time faculty)
To compare the knowledge and attitudes between academic full-time faculty and community faculty concerning EBM and their use of EBM in patient care and teaching.
Community-based faculty
Cross-sectional comparative survey
22 full-time academic faculty and 177 volunteer community-based faculty responded to the questionnaire
They obtained mailing lists of all full-time and community-based volunteer teaching faculty affiliated with the Departments of lnternal Medicine, Pediatrics, and Family Medicine.
The e-mail questionnaire survey was administered from January
Quality/relevance:
The respondents divided into 3 groups: volunteer primary care community faculty, volunteer sub-specialty community faculty, and full-time academic faculty, both primary
They identified which EBM concepts were not disseminated well into the collective knowledge base of community faculty. They found a few characteristics that were independently associated with having a higher knowledge of EBM concepts, including at
Beasley BW, Woolley DC. 2002. Evidence-based medicine knowledge, attitudes, and skills of community faculty. Journal of General Internal Medicine, 17:632–639.
through March of 2000.
They designed a questionnaire with 4 main sections, which was composed of "their personal and professional characteristics", "rating the importance of different EBM concepts and terms in their daily practice (5-point scale ranging)", "the respondents’ incorporation of EBM into their continuing medical education (CME) and teaching activities", and "7 test questions used to evaluate and stratify the baseline knowledge of EBM content areas". X2 tests were used to compare categorical variables.
Student's t tests, analysis of variance testing, and correlation coefficients were used for continuous variables.
They also used multivariate analyses to identify variables that were independently associated with the EBM test score.
care and sub-specialists.
Community faculty considered EBM skills to be less important for daily practice than did full-time faculty (3.1 vs. 4.0; P < .01).
Primary care community faculty were less confident of their EBM knowledge than the sub-specialty community or full-time faculty (2.9 vs. 3.3 vs. 3.6; P < .01). Objective measures of EBM knowledge showed primary care and sub-specialty community faculty about equal and significantly below full-time faculty (P < .01). 33% of community faculty versus 5% of full-time faculty do not incorporate EBM principles into their teaching (P < .01).
Community faculty are not as equipped or motivated as full-time faculty to incorporate EBM into their clinical teaching. Faculty development programmes for community faculty should feature how to use and teach basic EBM concepts.
least some research background, specializing in Family Practice, and the number of years since residency (a negative predictor).
Limitations:
This study took place in only 1 city.
This study was a questionnaire survey and is subject to response bias, as well as to the respondents' ability for self-evaluation, and EBM skills were not assessed in this study.
Not all respondents completed the entire EBM test and far fewer attempted to complete the final 2 short-answer questions.
Taiwan
School of Nursing, National Yang-Ming University
Effective clinical nursing faculty
To understand 4 categories of qualities (professional competence, interpersonal relationship, personality characteristics, and teaching ability), which, taken together, was the main contributor to effectiveness differences among clinical nursing faculty.
Ineffective clinical nursing faculty
Cross-sectional questionnaire survey
214 students (public school: n=52, private school: n=162) from two nursing schools completed the questionnaire.
A constructive questionnaire was distributed to 2 nursing schools in Taiwan (1 public, 1 private), with confidential return.
The questionnaire items were divided into 4 main categories: professional competence, interpersonal relationship, personality characteristics, and teaching ability.
A 5-point Likert-type scale was used for the quantity estimate.
The questionnaire was tested in 2 pilot studies (Tang, 1993; Tang & Su, 1999), and they arrived at the questionnaire that was used in this study, composed of 40 behaviours in 4 categories (professional competence: 6 items, interpersonal
Quality:
The results showed that effective teachers possessed significantly higher scores (>4) in all of these four qualities. While the scores of ineffective teacher were lower (<3) in all categories, except professional competence.
Larger differences in scores between effective and ineffective teachers were found in the interpersonal relationship category, followed by the category of personality
This research also indicates that students from different nursing schools have similar opinions regarding this concern.
Based on these findings, they highly recommend that teachers strive to improve their attitudes towards students as the best way to achieve the goals of clinical teaching.
Tang FI, Chou SM, Chiang HH. 2005. Students' perceptions of effective and ineffective clinical instructors. Journal of Nursing Education, 44:187–192.
relationship: 9 items, personality characteristics: 10 items, teaching ability: 15 items).
Students completing the questionnaire were asked to think about 2 teachers from their own experience (1 liked, the other disliked) and then use the same questionnaire to evaluate the 2 teachers' behaviours.
characteristics. Smaller differences in scores between effective and ineffective teachers were in the professional competence category, followed by the teaching ability category.
From these results, these results suggest that teachers' attitudes towards students, rather than their professional abilities, are the crucial difference between effective and ineffective teachers.
Recommendation 4: Health professionals’ education and training institutions should consider adapting curricula to the evolving health-care needs of their communities.
Country Institution Population Intervention Comparison
Study design/sample
size
Methodological quality issues
Reported results (Outcomes) Additional comments Reference
USA Arizona School of Dentistry and Oral Health (ASDOH), Mesa, AZ
Dental students
Development and implementation of a new dental school that incorporates several transformative elements (first class enrolled in 2003):
3-year course of study on the role of dentistry in the community, designed to provide specific skills and experiences to meet the needs of various population groups;
1st-year content presented in a systems review format using a modular delivery, rather than a typical approach of separate courses for anatomy, biochemistry, physiology, and the other core basic science courses;
earlier clinical experiences, increased clinical experience in the 3rd year, and half of the 4th year spent in external clinical rotation sites;
incorporation of current technology (e.g. majority of student participation in the placement and restoration of at least two implants, requirement for laser certification).
To retain continuity and communication, all faculty members are contracted to remain available to ASDOH students for 1 year following their module/course. Faculty members are also required to attend an annual 2-day faculty retreat to coordinate content integration across modules. The ASDOH administrative structure was purposely designed in a horizontal rather than vertical orientation, utilizing fewer full-time faculty members and administrators than in a traditional model. ASDOH administrators serve in multiple roles and often share administrative responsibilities. In place of separate departments, directors or co-directors, utilizing mostly part-time adjunct faculty members to manage the bulk of the teaching duties, lead disciplines. Further, the ASDOH Curriculum Committee is made up of a cross section of administrators and faculty members and uses a top-down approach to curriculum management (minimizes discipline-specific curriculum ownership issues).
National averages (implicit; not specifically referenced)
Descriptive case report No control/ comparison group
Quantity/quality:
Nearly 100% of all ASDOH graduates (2007–2009) have successfully completed the National Board Dental Examination Parts I and II, as well as the Western Regional Examination Board examination within 1 year of first attempting the examinations.
19% (2007), 32% (2008), and 30% (2009) have been accepted into dental residency/specialty programmes.
Relevance: At least 32% of 2007–2009 graduates have chosen to enter practice in community-based/public health settings (53%, 32% and 32%, respectively).
Advantages:
Financial model has remained sound even in challenging economic times: "The Arizona Model is designed to be cost-efficient with a curriculum design that minimizes the number of faculty members needed for content delivery, creates a horizontally lean administrative structure, provides offsite clinical experiences to maximize student proficiency, and provides a clinical training environment that creates the best opportunity for the clinical programme to be revenue-generating".
The entire basic science curriculum can be delivered for approximately the salary and benefits of 2–3 full-time equivalent faculty members. Travel, lodging, food, honoraria, and administrative costs make up the bulk of the expenses. Since there is only 1 faculty member on campus teaching basic science content at any one time, additional savings are realized in facilities as a single office is provided for all visiting faculty members.
A sample of ASDOH students returning to work in the school's dental clinic following external clinical rotations produced an average of US$ 3362/month, compared to an average student monthly gross clinic revenue of US$ 1000 reported by Formicola.
The Arizona Model curriculum is driven by a faculty-centred curriculum committee that directs structure and sequence through a top-down approach, which allows for maximum flexibility related to content and integration. With no departments and relatively few full-time faculty members, flexibility is enhanced, and curricula changes can be made on an as-needed basis.
Extremely low turnover of faculty and administrators, with nearly all faculty positions currently filled.
Disadvantages:
Sustainability remains a challenge, especially in securing the commitment of the visiting faculty. Competing priorities, time away from their home institution, institutional policies that limit outside participation, and increased workload at their home institution all factor into the visiting faculty member's decision to teach/continue to teach at ASDOH. (Still, the basic science faculty has remained very consistent for over 7 years now, and innovative contractual
Smith KP et al. 2011. The Arizona Model: a new paradigm for dental schools. Journal of Dental Education, 75:3–12.
relationships have started to develop across dental schools, which could lead to regionalization of faculties.)
Lean structure of the model also poses a challenge, with the limited number of full-time administrators and faculty members at risk of experiencing burnout due to the heavy workload in managing multiple areas and responsibilities.
Future plans: Plans currently being considered for incorporation of audiovisual content and self-paced, interactive web-based instruction into the basic science and preclinical curricula.
China, People’s Republic of
Sichuan University, Chengdu
Nursing students
Design and implementation of a training course titled “Introduction to Disaster Nursing”, based on the International Council of Nurses (ICN) Framework of Disaster Nursing Competencies and Global Standards for the Initial Education of Professional Nurses and Midwives.
The training course was developed by integrating an array of action learning activities with local relevance to engage students in acquiring the ICN disaster nursing competencies. It was implemented at the University, 20–31 July 2009. The course was offered to 150 students from 44 member schools of the Chinese Consortium for Higher Nursing Education.
A disaster nursing task force composed of faculty members from both The Hong Kong Polytechnic University and Sichuan University Schools of Nursing was formed after the 2008 Wenchuan earthquake. Out of this task force, “Introduction to Disaster Nursing” was structured as a 2-week intensive course targeting senior year nursing students and graduate nurses.
Two documents were used as a basis of the curriculum design – the ICN Framework of disaster Nursing Competencies (WHO and ICN, 2009) and the Global Standards for the Initial Education of Professional Nurses and Midwives (WHO, 2009). Structured according to the disaster management continuum, the ICN disaster nursing competencies were developed after an analysis of existing competency frameworks in the areas of public health, mental health, emergency management and disaster nursing. They are articulated in 4 categories (Mitigation-prevention competencies, Preparedness competencies, Response competencies, and Recovery-rehabilitation competencies) with 10 domains (Risk reduction, disease prevention, and health promotion; Policy development and planning; Ethical practice, legal practice, and accountability; Communication and information sharing; Education and preparedness; Care of the community; Care of individuals and families; Psychological care; Care of vulnerable
Pre-intervention
Pre-post survey Sample size:
150 students (88.2% female, 7.2% senior year, 77.1% from the Chinese mainland).
A total of 138 completed the ICN Disaster Nursing Competencies Questionnaire before and after the training course, and 144 completed the Course Evaluation Questionnaire (response rates of 92% and 96%, respectively).
Teaching materials used in the course were based entirely on natural disasters and did not address man-made disasters (more relevant to the region).
Scenarios used in this course were relatively benign and straightforward; students were not exposed to extreme or potentially jarring situations. Might have been helpful to include simulated disaster exercises or drills so as to allow students to gain first-hand experience, better understand what rapid responses are called for in disaster situations, and realize their own stress thresholds.
The training course involved only participants from the nursing discipline, though literature suggests that it is preferable to involve different health disciplines in disaster training programmes so as to prepare health professionals in collaborative practice in disaster situations.
Limitations in the methodology of using self-report questionnaires; the data collected are subjective, with no validation undertaken.
Quality/relevance:
All participants passed the assessments and examination with an average score of 70%.
Pre- and post-training self-ratings of the disaster nursing competencies increased from 2.09 to 3.71 (p< .001) on a Likert scale of 1 to 5, and the effect size was large, with Cohen’s d higher than 0.8.
No significant difference in both examination results (60% group assignments; 40% written examination) and self-rated competencies was noted between the senior year students and graduate nurse participants by Mann-Whitney U test (p = .90).
The majority of participants indicated their willingness to participate as a helper in disaster relief and saw themselves competent to work under supervision.
Many of the participants expressed that they had developed an interest and would continue to update their knowledge in the field of disaster nursing.
“This introductory training course could be incorporated into undergraduate nursing education programs as well as serve as a continuing education program for graduate nurses.”
Chan SSS et al. 2010. Development and evaluation of an undergraduate training course for developing International Council of Nurses disaster nursing competencies in China. Journal of Nursing Scholarship, 42: 405–413.
populations; and Long-term recovery of individuals, families, and communities).
The 3 principles of curriculum design promulgated in the Global Standards for the Initial Education of Professional Nurses and Midwives were followed in aligning the course contents, learning and teaching activities, and assessment methods with the expected disaster nursing competencies: (1) the curriculum has to build on established competencies; (2) the interaction between the nursing students and the client is the primary focus of quality education and care; and (3), an interprofessional approach to education and practice is critical. The course blended an array of learning and teaching strategies in simulated and real-life contexts, including PBL, role-play, lectures, action learning, group work, and disaster site and hospital visits.
USA Stanford Hospital and Clinics, Stanford University School of Medicine
Medical residents (postgraduate paediatric)
A medical leadership curriculum informed by military education - an adaptive use of a pre-existing leadership curriculum in US military education, 'Leadership Education and Development Program' (LEAD). Responding to a strong desire for more leadership opportunity within the training programme expressed by paediatric anaesthesia residents, a modified version of the LEAD curriculum was developed, in collaboration with the US Naval Academy, to introduce daily and graduated leadership opportunities. The programme (a 1-year fellowship) started with low-risk decision-making tasks and progressed to independent professional decision-making and leadership. Each resident who opted into the programme had a 3-month role as team leader and spent 9 months as a team member. The LEAD curriculum is based on three key elements: developmentally based experiences, graduated leadership opportunities, and self-evaluation. The new curriculum introduced leadership expectations at orientation, with an emphasis on practice management skills and improvement in team performance; a copy of the US army leadership manual for reserved officer training corps (ROTC) was placed in the policy and procedures manual, and leadership-focused goals and objectives were developed. (One of the residents in the initial cohort was a former career military doctor (in the US Navy) who had knowledge of the US Naval Academy's LEAD programme.)
Pre-intervention data
Descriptive case report Quantitative faculty evaluations of resident performance were collected, including assessment of 'leadership in the medical community and clinical decision making', rated on a 1-5 Likert-type scale. Aggregated scores in this leadership question were collected for the Year 1 and Year 2 cohorts, with pre- and post-score analysis compared using a 2-way unpaired Student's t-test (P<0.05).
No control/comparison group; outcomes assessed merely a proxy for those of interest (quality of health professional students --> quality of health professionals).
Quality (proxy measure):
At the end of the first year of the curriculum, both quantitative assessment and qualitative reflection from residents and faculty members noted significantly improved clinical and administrative decision-making. The second-year residents' performance showed further improvement (P<0.05).
In evaluations from year 2, there was only one reported concern of a lack of autonomy, as compared with a greater than 50% rating in the past years.
In year 2, the two trainee evaluations of clinical judgement and leadership ranked highest in the aggregated resident performance (4.62 + 0.11 and 4.60 + 0.16, respectively).
Residents have now taken over the scheduling of upcoming difficult surgical cases, based on their perceived educational needs and the relative needs of other residents. They have continued to expand their leadership roles in designing new elective rotations, including anatomy for medical acupuncture and theories of medical education. They have also revised the rotation schedules in accordance with curriculum needs, moving some rotations to earlier in the year, and have asked for the opportunity to participate in clinical scheduling. Comments for resident interviews and self-evaluations included 'being an administrative resident taught me how to solve conflicts', 'I am happy I had the chance to think about and plan my education, and help the other residents.' Limitations:
The leadership skills were not equal among all participants, and the faculty director needed at times to step in.
Unwillingness of some faculty members to relinquish their administrative roles in the programme, e.g. making the vacation schedule.
Edler A et al. 2010. Leadership lessons from military education for postgraduate medical curricular improvement. Clinical Teaching, 7: 26–31.
USA
School of Nursing, Adelphi University, Garden City, NY
School of nursing/nursing students
A baccalaureate curricular revision at the College of Nursing of Adelphi University that used the Institute of Medicine (IOM) competencies as part of an innovative framework to create a new curriculum.
Impetus for change at Adelphi University
No comparison group
Descriptive case report No outcomes yet reported – evaluation still ongoing
Evaluation still ongoing... Measures of programme’s overall success such as the NCLEX-RN scores, national standardized test scores, exit surveys of graduates, and feedback from
Lessons learned:
Factors such as the amount of time required, the voluntary nature of the commitment, and faculty teaching and other responsibilities were major obstacles in maintaining a consistent membership. Negotiating workload release time for the chairs of the task force was challenging
Hickey MT, Forbes M, Greenfield S. 2010. Integrating the Institute of Medicine Competencies in a Baccalaureate curricular revision:
came from the updated IOM recommendations as well as other factors. The existing curriculum followed a traditional curricular model that had not been changed significantly for around 10 years. A recent drop in NCLEX-RN pass rates for graduates, combined with feedback from several agencies indicating that students were not integrating knowledge as new graduates, provided additional impetus. A faculty curriculum task force was convened with representation from each of the specialty areas as well as those with experience and educational preparation in curriculum development. For transparency, a "Curriculum Task Force" repository was created on the university Intranet, whereby all nursing faculty had access to review minutes, reports, literature reviews and Web links. To maintain communication, all meetings were open, and reports were presented at monthly undergraduate and faculty meetings.
An extensive literature review was conducted by the task force at the outset of the process and focused on recent literature in four areas: curriculum reform in nursing education, strategies for NCLEX-RN success, new pedagogies, and trends in patient care settings. Innovative curricula from other schools of nursing in the US were also reviewed, and the curricular designs of "Schools of Excellent" as identified by the National League for Nursing were examined. The literature review identified four main themes: incorporating quality and safety in nursing education, redesigning conceptual frameworks, the content-laden curriculum, and teaching using alternative pedagogies.
To guide the revision, the task force identified 6 essential components of curriculum planning: - be grounded in key-central
concepts/framework - reflect the current and future practice
environment - fulfill and address all accreditation
requirements and recent recommendations
- adequately prepare students for competent generalist practice
- be developed specifically for our student population
- be congruent with the overarching goals and mission of the University at large.
The committee developed its own organizing framework to guide the curriculum revision, with IOM competencies and the nursing process at the centre. Surrounding these central components were 4 areas that are the focus of the new curriculum: core competencies, core knowledge, professional role development, and professional values.
community agencies will continue to be indicators of student success toward meeting the programme’s outcomes. Ongoing evaluation and revision of the programme will come from surveying the nursing education and workforce literature and from recommendations from the accrediting bodies.
and difficult. Hence, the authors recommend that options for workload compensation be explored prior to beginning the curriculum revision process.
Faculty workload responsibilities compounded resistance with the curriculum revision. Implementing new course sequencing and new models of clinical experiences presented additional challenges in light of the faculty shortage and limited clinical placement sites.
Open communication, perseverance, and the willingness to compromise were essential components in the process. "Substantial curricular change can only occur if faculty dialogue about the process and explore possible strategies for implementation."
Faculty "buy-in" was a key component to successful curriculum revision.
The challenge for nursing faculty is to incorporate the new recommendations into the curriculum while preventing a "content burden".
process and strategies. Journal of Professional Nursing, 26:214–222.
The entire process spanned 3 years from conception to implementation, with implementation commencing in the autumn of 2009. A detailed phase in/phase out plan was developed in collaboration with the administration and registrar of the university to achieve an orderly and smooth transition to the new curriculum.
Sudan
Faculty of Medicine, University of Gezira (FMUG) – second oldest medical school in Sudan; one of the founders of community-oriented medical education in Eastern Mediterranean Region. Most medical schools in the country have now adopted Gezira’s community-based curriculum model.
Medical students
Introduction of the Integrated Management of Childhood Illness (IMCI) strategy into the curriculum.
In 2001, the FMUG was one of 6 Sudanese universities that started the process of introducing the IMCI strategy into their medical curricula. The emphasis was on pre-service training that addresses standard case management and the IMCI community component. Implementation of the training package developed was facilitated by a committee that coordinated the role of the Gezira State Ministry of Health (MoH) in the implementation of community-based courses of the FMUG.
The Committee is headed by the dean of the faculty and includes staff from the Department of Community Medicine of FMUG, managers of IMCI and other primary health-care programmes, and directors of the preventive medicine and pharmacy directorates of the Gezira State MoH.
The role of Gezira State MoH includes the provision of information, education and communication (IEC) material (e.g. mother cards), IMCI wall charts and chart booklets.
Staff of the Gezira State MoH exclusively provide student training in primary health- care facilities and rural hospitals.
The curriculum is community-oriented, 5 years in duration, and with community-based issues constituting 25% of all studies, with 25% of the community courses conducted at field sites. Students are posted at clinical training sites from their first year.
6 main strategies adopted to help the school and students to achieve the curriculum objectives: community orientation; community-based education (CBE); integration of basic, clinical, and socio-behavioural sciences; problem-based learning (PBL), team work; early exposure to clinical and community training.
1.
Families not visited by students from FMUG
Descriptive case report + cross-sectional study Sample size: 240 students
Limited usefulness of comparison group
Quality:
Students within the community-based education programme contributed to the target of improving IMCI family and community practices:
58.0% of families visited by students reported that children under 5 years and pregnant women slept under an insecticide-treated bed net, compared to 26.3% among families not visited by students (p=0.002).
54.2% of families visited by students reported that mothers practiced exclusive breastfeeding, compared to 35.7% among families not visited by students (p=0.01).
69.1% of families visited by students reported following correct nutritional practices for children under 5 years, compared to 40.2% among families not visited by students (p<0.0001).
87.0% of families visited by students reported children under 5 years completing appropriate immunizations, compared to 68.3% among families not visited by students (p=0.003).
69.1% of families visited by students reported children under 5 years receiving timely vitamin A supplementation, compared to 27.6% among families not visited by students (p<0.0001).
The presence of large numbers of FMUG graduates on faculty and in key MoH positions suggests the impact of the undergraduate experience on leadership careers, but also points to desirability of a more formal tracking system to explore the long-term impact of FMUG graduates on the health system of Sudan and, possibly, other countries.
Incorporation of the new package did not result in an extra academic load on the students, nor did it create additional educational activities in the already congested faculty programme. Moreover, assessment of the students on the content related to the IMCI community component made use of the same methods and tools that are routinely used in all the courses.
No extra human resources were needed through all stages of the implementation of the programme. However, training in IMCI case management skills in the health centres and rural hospitals was handicapped by the fact that some doctors and medical assistants working in those facilities did not routinely implement the IMCI algorithm, even if trained in IMCI standard case management.
Rapid turnover of trained staff was another major impediment to both service delivery and pre-service training. Moreover, the increased demand on their time related to training students on the IMCI approach was a constraint, especially in maintaining quality. Training materials were always available on time because of the assistance of the federal and Gezira state ministries of health, but FMUG faced a considerable financial burden for the repeated photocopying of mother cards and other IEC material. The programme also used IMCI-trained part-time staff from the MoH, which added additional costs.
"The community based curriculum is very expensive, but due to the commitment of the school's leadership, FMUG has risen to the challenge of fulfilling the budgetary needs of the various aspects of the program, by setting aside some of the money that is generated from enrolling private students."
"An unusual degree of decentralization exists in the teaching, service, and research programs of the FMUG. This enables creativity and partnerships at all levels to the considerable benefit of the academic enterprise. This is the result of decisions at the federal level (Ministry of Health and Ministry of Higher Education) as well as at the university itself."
"Absorption problems for graduates suggest a mismatch between investments in the educational and the health service system - There is evidence that 3,500 annual graduates of Gezira and Sudan's other 28 medical schools greatly exceeds the government's capacity to hire new medical officers - despite in-country need. While many Sudanese graduates eventually migrate to the Persian
Mullan F et al. 2010. SAMSS Site Visit Report. NP, The Sub-Saharan African Medical Schools Study (SAMSS). Abdelrahman SH, Alfadil SM. 2008. Introducing the IMCI community component into the curriculum of the Faculty of Medicine, University of Gezira. Eastern Mediterranean Health Journal, 14: 731–741.
Gulf and elsewhere, there is a reasonable question about the long-term sustainability and cost-benefit rationale of this level of support for medical education."
USA
University of Texas Southwestern Medical Center
Medical students
An integrated cognitive and proficiency-based skills curriculum based on American College of Surgeons Graduate Medical Education Committee (ACGME) competencies to prepare students for surgery internships.
In 2008, at University of Texas Southwestern Medical Center, a new fourth-year medical student elective, Preparation for Surgical Internship, was initiated. 9 students, all entering general surgery or a surgical sub-specialty career, were enrolled for the 4-week course in February 2008. The overall objective was to prepare students to enter a surgical internship.
The curricula in similar courses in other medical schools, the expectations determined by the American College of Surgeons (ACS) for entering postgraduate year 1 (PGY-1) residents, and needs expressed by our own faculty provided the basis for course planning. Objectives and sessions were designed according to the 6 ACGME competencies: patient care; medical knowledge; practice-based learning; communication; professionalism; and systems-based practice. The curriculum comprised didactic sessions and seminars, intensive technical skills training, experience with various clinical skills, simulation-based team training, cadaver dissections, and independent study of a case-based core curriculum in general surgery.
Pre-intervention students
Sample size: 9 trainees (7 men, 2 women)
Lack of more complete follow-up into the internship year. Incomplete evaluation of trainees according to core competencies – PBL and communications not addressed in evaluation of the trainees, although included in the curriculum.
Quality: Trainees achieved proficiency on open tasks and FLS tasks 2–5. The mean confidence self-rating on 51 skills increased on a 5-point Likert scale from 2.4 + .6 to 4.0 + .6 (p< .001).
"In conclusion, this study demonstrates that the integrated cognitive and skills curriculum is effective in improving confidence levels before surgical internship."
The positive response of the participants was evident both in their attendance (97%) and in their overall positive evaluation of the course (mean 4.5 + .6 on a 5-point Likert scale).
The main cost of the course was the investment of time required for its planning and administration, for teaching, and for assisting and proctoring in the skills laboratory. The use of faculty from many departments diffused the required teaching time for each person, but this remained a major commitment for many. Monetary costs were those of the cadaver and the use of the anatomy laboratory, with skills laboratory supplies donated.
Future studies:
Following up to get feedback from former course participants, their residency programme directors, and perhaps peers.
Designing and implementing appropriate assessments to demonstrate improved competence in PBL and communications.
Naylor RA et al. 2010. Preparing medical students to enter surgery residencies. American Journal of Surgery, 199:105–109.
USA
Oregon Health and Science University School of Nursing
Psychiatric mental health nurse practitioner students
Redesign of an objective-based curriculum to a competency-based curriculum, based on the 2003 National Organization of Nurse Practitioner Faculties (NONPF) PMHNP competencies, in the psychiatric mental health nurse practitioner (PMHNP) program at Oregon Health and Science University School of Nursing (OHSU SON).
The NONPF released the first set of nationally recognized PMHNP competencies in the autumn of 2003. The competencies were the result of work by the Psychiatric Mental Health Special Interest Group
No comparison group
Descriptive report No evaluation of outcomes beyond student/faculty satisfaction
No relevant outcomes reported Working definition of competency: "…the highest level of description of what students will learn and demonstrate (Lenburg, 1999, The Framework, Concepts and Methods of the Competency Outcomes and Performance Assessment (COPA) Model and Schlick, 2002 ); a 'must be able to do in practice' set of behaviors and skills rather than those behaviors required at the levels of beginner, intermediate, or advanced student." At the same time of the curriculum conversion, the 2004 Oregon Governor's Mental Health Task Force recommended the development of core competencies for graduate-level mental health
LeCuyer E et al. 2009. From objectives to competencies: operationalizing the NONPF PMHNP competencies for use in a graduate curriculum. Archives of Psychiatric Nursing, 23:185–199.
(PMHSIG) formed at a NONPF conference in 2002 and the subsequent validation by a national panel of experts. The work of the PMHSIG was modelled after a project completed by NONPF in 2002 and funded by the Division of Nursing, Health Resources and Services Administration (HRSA), U.S. Dept. of Health and Human Services.
At the OHSU SON, the decision to transition to a competency-based curriculum was first discussed in 2003 when the PMHNP programme obtained funding from the US HRSA to deliver its graduate programme to 3 distant/rural campuses in Oregon, which was deemed an opportune time to examine the courses and curriculum for needed changes. Another factor that contributed to the decision to move to a competency-based curriculum was the wide scope of practice for NPs in the state of Oregon, as preparation for this degree of professional autonomy requires students to synthesize large quantities of complex information and to master practice-level skills in a relatively short item.
The competency work group consisted of 4 OHSU SON faculty members – 2 PhD-level PMHNPs, 1 master's-prepared PMHNP, and 1 master's-prepared community-nursing specialist who also practiced as a psychiatric nurse at the baccalaureate level. An integral member of the team was a master's-prepared instructional designer. This group of 5 met every other week, 2 hours a week, for approximately 12 months.
training programmes to meet current needs of clients, including those with substance abuse and co-occurring disorders, and chronic and persistent medical disorders, in accordance with an evidence base. Impact on students: Statements by students were largely positive. The impact on student outcomes, however, will need to be assessed further as more graduate cohorts and results are compiled from standardized exit surveys, alumni surveys, and certification exams. "Although this approach may benefit the student in the long run by providing a road map to important knowledge and skills, it may result in increased anxiety in the short run. Taking on more active-learning roles may also facilitate increased student self-awareness of the limits of their own abilities…. Attempts to improve procedures rarely resulted in decreased students' anxiety levels, and generally other issues arose in their place." "Rather than seek to completely diminish students' anxiety, however, our position was that a reasonable amount of anxiety is a real and constructive part of practice-level competency. In this context, strategies included encouraging students to channel their anxiety constructively into reflective processing of clinical cases, seeking out evidence-based sources of information, obtaining additional clinical supervision, and having clear communication with faculty and preceptors." "We also found that many students rarely engaged in practice learning activities that were not graded…One successful approach was to supplement online practice discussion of case studies with live in-person (videoconferenced) practice discussions. These were in response to students' requests for access to seeing and hearing how a faculty member, as an experienced PMHNP, would systematically analyze a clinical scenario to arrive at a decision about client diagnosis. Another approach was to provide an initial graded rather than an ungraded assignment, but graded more flexibly." Impact on faculty: Older faculty less familiar with competency-based education expressed concerns about the conversion. One concern was the lack of specific content addressed within the competency statements. To address this concern, the authors relied on the competency curriculum scaffolding structure, specifically, related components. Essential content was also delineated in course descriptions and course content outlines. Benefits of the conversion: Provided specialty faculty with an opportunity for intense and sustained collaborative effort, which resulted for many of the group in a shared sense of ownership and commitment toward the programme and students. It also seemed to result in an increased sense of coherence between academic coursework and actual practice across the PMHNP curriculum for both faculty and
students. Clinical preceptors reported increased satisfaction with the new competency-based clinical evaluation form. ("Presenting our curriculum in terms of practice-related competencies and providing them with a concise list of competencies as the basis for clinical evaluation may serve to build more trust with preceptors somewhat skeptical of "academic" nursing education.") "…in conclusion, the NONPF competencies provided an excellent basis for our advanced practice PMHNP curriculum development as we sought to improve our capacity to produce sound practitioners as well as scholars and advocates for our profession." "Descriptive articles may be an informative first step toward the diffusion of innovations, in this case, the integration of competencies by an educational community, and it is hoped that other PMHNP programs will present their ideas and experiences in this way as well. We hope that further dialogue will ensue, resulting in the development of best curriculum practices and research about the outcomes of our efforts, to further inform our educational processes and development as an advanced practice profession."
Denmark National level
76 contact-persons chairing the curriculum development process within the specialties
A national reform of the postgraduate medical education in Denmark introducing (1) Outcome-based education, (2) The CanMEDS framework of competence related to seven roles of the doctor, and (3) In-training assessment. Representatives from key stakeholders participated in a specialist commission that published a report containing various recommendations regarding postgraduate education in Denmark. As a result, the Danish National Board of Health (NBH) issued Guidelines for writing curricula, according to which all of the 38 medical specialties should revise their curriculum indicating learning outcome, teaching strategies, and in-training assessment strategies related to each of the 7 CanMEDS roles. Each specialty was to appoint 2 contact-persons to be responsible for the task of developing a new curriculum for the specialty. Each specialty was assigned an adviser from NBH responsible for supporting the work in the specialty. For political reasons, the process the subject to tight deadlines.
No comparison group
Descriptive report; triangulation of quantitative and qualitative data from a questionnaire survey (n=63, 83% response rate) and elaborating telephone interviews (n=26).
No evaluation of outcomes beyond process-related factors
No relevant outcomes reported "The main results of the study show that the contact-persons were positive towards the concepts introduced by the reform, that they found the task of developing new curricula according to these concepts to be quite difficult and that they did not get the necessary support in the process, especially regarding pedagogical problems." "It is possible that the pedagogical assistants themselves had problems with the new paradigm. A collision between their sociologic-pedagogical traditions and the structured, rational approach to education in the paradigm of outcome-based education and in-training assessment according to the seven roles of the doctor is likely." "The results demonstrate the importance of involving and motivating faculty in reform processes." Challenges: Although the contact-persons were motivated to undertake the task of developing the curricula, it was clearly a challenge. Contact-persons indicated problems in defining an appropriate number of learning goals and specifying an appropriate level of detail for each learning goal. Formulating strategies for learning and in-training assessment was also found challenging. Promoting factors: positive attitude and motivation in faculty, support from written guidelines, seminars. Impeding factors: insufficient pedagogical support, poor introduction to the task, changing and inconsistent information from authorities, replacement of advisers, stressful deadlines.
Lillevang G et al. 2009. Evaluation of a national process of reforming curricula in postgraduate medical education. Medical Teacher, 31:e260–e266.
USA
Southern Connecticut State University (a public university in the Northeast USA)
4th-year BSN students
Implementation of an end-of-programme integrative capstone course developed in the autumn of 2005 at a 4-year public university "in response to the need to prepare graduates to practice in an increasingly complex healthcare delivery system".
Necessary components of undergraduate baccalaureate nursing (BSN) graduates have been described in the newly revised American Association of Colleges of Nursing (AACN) (2008) "Essentials of Baccalaureate Education for Professional Nursing Practice".
The overall purpose of the course was to provide an in-depth, integrative clinical and seminar experience in the last semester of the programme.
Based on many of the competencies identified in the AACN (2008) document, which served as a framework for the undergraduate curriculum, this 4-credit course included 2 hours of seminar each week, in addition to 16 hours of clinical experience per week for 7 weeks.
Pre-capstone students
Multi-method study design - AACN/EBI Exit student satisfaction survey results, Mosby Access NCLEX-RN readiness scores, and first-time NCLEX pass rates from generic and accelerated students groups (pre-capstone) were compared.
Students' perceptions of their experiences in capstone clinical within the framework of the course objectives were explored through a focus group interview.
Finally, in the instructor-designed post-graduate survey, students were asked to identify their post-graduation employment site and specialty.
Sample size: 73 students (in the pre-capstone comparison group); 71 students (in the post-capstone comparison group); 8 students (in the focus group interview).
Differences in standardized assessment measures might have been significant if larger sample sizes were available for the study.
The employment survey data only indicate students who had secured employment prior to graduation and do not reflect the employment choice of students after graduation.
Students volunteering for participation in the focus group interview could have been more enthusiastic about the capstone experience than those who did not participate.
Quality:
The only significant quantitative finding was the increase in Mosby Assess scores in the accelerated group (post-capstone), and when the accelerated group and generic group were combined (post-capstone). It is speculated that this may be due to their participation in the capstone course. ("However, post-capstone students also had significantly higher GPAs than the pre-capstone group (p= .037), which may have also partially explained the higher knowledge test scores.")
There were no differences between AACN/EBI Exit Surveys results or NCLEX-RN pass rates between the generic or accelerated groups (pre-capstone), and the generic or accelerated groups (post-capstone), or when these groups were combined. ("This might be accounted for by the pre-capstone scores which were very high, hence a small increase in the pass rates or satisfaction scores might not have been statistically significant. Further research with larger sample sizes could result in a significant difference.")
Other:
47 students (accelerated and generic) of those responding to the post-graduation survey in 2006 indicated they had secured a nursing position.
67% of students in the 2006 class, and 100% of students in the 2007 class who were contacted during the follow-up telephone survey were still employed at their capstone institution.
Qualitative content analysis from the student interviews revealed the following themes.
Integration: Students responded about the value of the capstone course as increasing their ability to "tie everything together and make the connections". They also noted that they were able to share the knowledge they learned in class, including information on best practices and evidence-based interventions, with patients, families, and the nursing staff.
Autonomy: Students reported that their capstone experience was very different than previous clinical rotations since they were now in charge of total patient care. Furthermore, the preceptors were invaluable in helping students manage a multiple patient assignment and making them feel as if they were a part of the team. This socialization into the unit culture allowed students to feel more comfortable in the role of the nurse, and also to prepare for the real world of nursing practice.
Confidence: Extended time on the units allowed students more practice with technical and assessment skills, but the real benefit seemed to occur when they were able to build their knowledge base and comfort level in communicating with others. The students also remarked that realistically evaluating their strengths and weaknesses allowed them to practice more efficiently and confidently.
Authority: The students indicated that the experience of the capstone clinical helped them "step up to the role" of graduate nurse. They stated they often though of themselves as equal to the patient care technicians during their previous clinical experiences and were often treated as such on the units. "Having the authority, as a student, to be placed in charge of total patient care and delegate care responsibilities to others, could potentially decrease orientation time and ease the transition from student to graduate nurse."
Advocacy: Several students talked about bringing the patient's perspective to members of the health-care team, making use of their position as "outsiders". "These capstone students' unique perspective might result in improved patient care and satisfaction."
Rebeschi L, Aronson B. 2009. Assessment of nursing student's learning outcomes and employment choice after the implementation of a senior capstone course. International Journal of Nursing Education Scholarship, 6:Art.21.
USA (multiple pilot sites)
(1) Audrain Medical Center (Mexico, MO) (2) California University of Pennsylvania (California, PA) (3) University of Pittsburgh Medical
Medical students
The Cancer Core Competency Initiative.
As part of an effort to address shortages in the cancer workforce, C-Change (a not-for profit organization whose mission is to eliminate cancer as a public health problem) developed competency standards and logic model-driven implementation tools for strengthening the cancer knowledge and skills of non-oncology health professionals.
The first phase of the Cancer Core Competency Initiative included the rationale for a competency-based approach, the
No comparison group
Multi-site pilot/case studies
Descriptive data only Quality: Each site demonstrated measurable improvements in the knowledge, skills, and attitudes of participants. The percentage improvement in participant knowledge between pre-tests and post-tests ranged from 20% to 177%.
The results from the C-Chance Cancer Core Competency Pilot Project evaluation support the following conclusions.
The implementation of the Cancer Core Competency methods and tools in 4 pilot sites improved participant knowledge of their respective cancer topics and resulted in strong cancer skills and attitudes.
The methods and tools developed to support programme planning, implementation, and evaluation were useful and flexible. All site leaders found the tools useful and supportive of
Smith AP et al. 2009. A competency-based approach to expanding the cancer care workforce: proof of concept. MEDSURG Nursing, 18:38–49. Smith AP, Lichtveld MY. 2007. A competency-based
Center (Pittsburg, PA) (4) Marshall University School of Medicine (Huntington, WV)
definition of the targeted professional populations, and a complete inventory of the competency statements. The cancer competency statements were written to address the learning needs of any health professional who has general knowledge of cancer and can initiate the cancer care continuum from prevention and screening through palliative care. The statements were also written so that they could be interpreted at basic, intermediate, or advanced levels of expertise. Similarly, they can be interpreted within a particular profession's scope of practice, or in the context of an individual's years of experience or current role and responsibilities.
The C-Change Cancer Core Competency initiative focuses on Tier 2 health-care professionals, who, by virtue of their numbers and distribution, provide the greatest opportunity to reach the general population as well as patients and families with cancer. Tier 2 includes licensed, registered, or certified members of health professions who have not specialized in cancer and whose scope of practice includes face-to-face contact with patients and their families.
In 2008, four organizations pilot-tested the Cancer Competency Initiative tools and standards. Based on needs defined by the host organization, the initiative's goal was to improve the ability of the general health workforce to meet the needs of patients with cancer by increasing their basic cancer knowledge, skills, and attitudes.
their efforts. All sites utilize the methods and tools in a variety of settings and educational formats and with different disciplines, demonstrating their flexibility.
Each pilot site derived benefits from the programme investment beyond the educational gains demonstrated by their program participants. The sites leveraged the competency initiative to include faculty professional development, institutional value, and community value.
approach to expanding the cancer care workforce. Nursing Economics, 16:109–116.
USA
College of Human Medicine (CHM), Michigan State University - a community-based school with approx. 100 in each class.
Medical students
The "Contract for Social Commitment" – a 4-year process of curriculum development and implementation, designed to prepare medical students to care for populations who have Medicaid or low socioeconomic status.
CHM modified 25% of pre-clinical courses, 5 core clerkships of year three, and 2 clerkships (Senior Surgery and Senior Internal Medicine) from 4th year. The first cohort of students to experience all aspects of the curriculum graduated in 2006.
Through the programme, new curricular material was added, and expansions were made to the discussions of values and ethics already present across all 4 years of the curriculum. The project directors mapped students’ learning objectives on grid across courses and years, and evaluated the treatment of each objective in terms of teaching strategies, assessment of student performance, and faculty development. They worked with course directors to identify topics needing more coverage and to suggest where in the curriculum they could best cover these topics. Course directors worked together in committees to tie assignments in individual courses with those
Previous class/cohort of students (and other students nationally)
Descriptive case report + longitudinal cohort study Sample size: 101 students
More historical data or a concurrent control group needed to claim strongly that the revised curriculum was responsible for any effects observed in students.
Quality/relevance:
Students who experienced the revised curriculum performed slightly better than students in the previous class on key skills related to the project (e.g. ability to elicit patient's personal social context) and on the interview overall, but the differences were not statistically significant. Performance did not decline, though new material was added.
The pass rate for this cohort on the USMLE Step 2 Clinical Skills Exam was 98%, compared with 95% for the previous year. In addition, the CHM student scores on the Communication and Interpersonal Skills component rose from 98% for the 2005 class to 100% in the 2006 class.
Regarding student self-assessment of skills, 7 of the
The impetus to launch the project came from both internal and external sources. Faculty and administrators of the college were becoming increasingly concerned about the disparities in health and health care reported in the literature, including the IOM report.
In particular, the new assistant dean for governmental affairs at CHM had previous experience as bureau chief within the Medicaid Program, and the new assistant dean of the preclinical curriculum brought to a job a long-standing interest in health-care equity. In addition, clinical faculty experienced difficulty in finding specialists to see their patients on Medicaid.
Students demonstrated their interest in addressing inequities by offering midday electives, organizing an annual health-care rally, and serving in a free clinic. Finally, individuals in the Michigan Department of Community Health expressed interest in collaborating with medical educators and researchers to improve services to individuals and populations served by Michigan Medicaid. The Michigan Department of Community Health funded the Contract for Social Commitment, helping to support the salaries of faculty and
Turner JL, Farquhar L. 2008. One medical school's effort to ready the workforce for the future: preparing medical students to care for populations who are publicly ensured. Academic Medicine, 83:632–638.
in other courses for horizontal and vertical integration.
Student learning objectives were also linked to the core competencies as identified by the Accreditation Council for Graduate Medical Education.
New curriculum components were developed beginning in 2002 and integrated into the curriculum for the matriculating class of that year. New units were then rolled out as the class moved through the curriculum, adding content either as stand-alone curriculum units or as modifications of existing lectures, activities, or small-group discussion topics.
Faculty development was accomplished through course orientation sessions and additions to the discussion guide. In addition, faculty members receive a preceptors' guide highlighting new and significant themes to be addressed.
An inventory of project objectives was taken periodically throughout the implementation of the revised curriculum. A robust system of evaluation was also established to provide feedback to course directors to guide implementation and assess the impact of the curriculum changes on student attitudes and skills.
18 items assessed were rated significantly higher at the end of year 4 of the curricular change process: - "I have the skills to work
with patients who don't speak English." (p<0.000)
- "I have the skills to work with recent immigrants and refugees." (p<.001)
- "I know what constitutes appropriate interpreter services." (p<.001)
- "I know what public health system services can assist low-income patients." (p<.005)
- "I know the roles of other health professionals." (p<.000)
- "I know what health conditions are prevalent among the poor." (p<.01)
- "I know what community-based services are available for low-income patients." (p<.000).”
Attitudes of the students who experienced the modified curriculum showed greater agreement with Association of American Medical Colleges (AAMC) Graduation Questionnaire items than the previous class at CHM and than their classmates across the country: - "Access to medical care
continues to be a major problem for the United States." (92% vs. 87.5% vs. 88.8%)
- "Everyone is entitled to receive adequate medical care regardless of his or her ability to pay." (90.7% vs. 78.2% vs. 84.8%)
- "I am prepared to care for individuals from racial and ethnic backgrounds different from my own." (98.7% vs. 94.5% vs. 95.8%)
- "I was appropriately trained to care for individuals from racial and ethnic backgrounds different from my own." (100% vs. 100% vs. 92.6%).”
Of 72 surveyed residency programme directors, a majority rated CHM graduates as more skilled than their
administrators so they could dedicate a portion of their time to project activities. Faculty salaries were the most expensive part of the project. Factors contributing to success:
Central leadership in the dean's office allowed developers to see the curriculum as a whole and to coordinate across courses and across years to minimize redundancies and fill gaps.
Recognizing that the curriculum was already full, no new materials were added without eliminating existing material; instead replaced or "tweaked" existing material to address programme objectives.
Attention to fundamentals of curriculum design and implementation.
Using grids to track objectives across courses and years and to tie them to teaching strategies, performance assessment and faculty development.
Taking care to expose students to fundamentals before challenging with higher-order skills.
Providing salary support for course directors (through external funding from the Michigan Dept. of Community Health), which helped to gain and keep their attention when competing demands for their time drew them away. External funding also allowed course directors to purchase educational aids, which enriched the courses and saved faculty the time and effort needed to develop educational aids de novo.
peers in applying cultural competence (85%), working with patients who have Medicaid or a low SES (82%), and using community resources (79%).
USA
Division of Health Sciences (DHS), East Tennessee State University
Medical students
Development and implementation of the Community Partnerships Program (CPP) at East Tennessee State University schools of medicine, nursing, and public and allied health, sponsored by the W.K. Kellogg Foundation (1 of 7 institutions selected as part of the W.K. Kellogg Foundation's Community Partnerships Initiative [CPI]).
Prior to the development of the DHS (encompassing the colleges of medicine, nursing, and public and allied health) there was little interdisciplinary teaching or collaborative research, as each college and department competed for limited resources. This changed with the coming of the CPI and the resulting CPP, which stimulated the DHS and the entire East Tennessee State University to emphasize a health professions education model that was rural, primary-care focused, interdisciplinary, and community based.
The institutional change process that ensued focused on a transition competition to collaboration, the development of an interdisciplinary curriculum, and the incorporation of an inquiry-based learning approach. Innovations also included developing shared governance with community partners and ensuring a service-learning focus for all curricular endeavours.
A series of meetings between the respective academic deans, community members, and representatives from the W.K. Kellogg Foundation occurred over a 1-year period, 1990–1991. The result was a set of division-wide goals and objectives that acknowledged the need for the university to have a greater community focus.
Collaboration among those involved in the different health professions included joint curricular design, team teaching, and establishing division-wide support for innovative approaches and concepts. Three retreats were held to provide a forum to identify and resolve issues, based on a principle of consensus reaching.
To advance curricular transformation, an interdisciplinary, interprofessional curriculum committee was established to serve as an interface between department chairs and faculty whose programs would be affected by the new model. The first year was committed to developing essential core content from these curricula into an integrated program of study. The interdisciplinary curriculum committee wrote objectives based on standards defined by each profession
Students enrolled in traditional programmes at the same university
Descriptive case report + cross-sectional study Sample size: 41 students (who participated in the CPP for 2 or more years.
Not a compulsory curricular change. The programme may have attracted students who would have been inclined to work in the field of population and community health regardless of the impact of the intervention
Quantity/quality:
The programme’s students performed as well on professional licensing examinations as did their peers enrolled in traditional programmes.
A review of the programmes developed and implemented since 1992 revealed that over 9450 residents have been directly assisted from services offered. Improved access to primary care and the development of prevention programmes have been associated with a decrease in subsequent mortality and morbidity rates.
Relevance:
Programme graduates have been much more likely to select primary care careers and to practice in rural locations than have their non-program peers. Of 41 medical students who participated in the CPP for 2 years or more, 34 (83%) selected primary care residency training, compared with 67.1% of traditional-curriculum students in their classes at the same school.
Among the first 6 cohorts of nursing and public and allied health students graduated from the programme, 54% of the nursing students, and 73% of the public and allied health students have secured employment in rural or underserved communities.
“Opposition was present from the initial period of proposal development, since schedules, university calendars, and course syllabi required modification. A series of division-wide retreats was used to address faculty and accreditation issues that affected the new program." "Allowing community needs to determine specific curricular activities was a challenge. The philosophy of the program emphasized learning through service and moved away from the traditional linear model of education. It was difficult for many faculty members to understand and internalize this philosophy. However, the curriculum matured as both the needs of the community became clearer and the expertise of faculty and students evolved." "Effective faculty members were essential to the success of the program. At its inception, the university identified senior faculty members with past experiences working with communities to begin curriculum development. The university also recruited full-time interdisciplinary faculty members who would live and work in each community." "Issues of tenure and promotion have not been a deterrent to faculty participation, as the university administration has supported the innovative nature of the program and the faculty who make is possible. Early logistic problems such as communication with campus-based academic units and excessive travel were resolved with electronic communication technology." Some medical students left the programme because they were dissatisfied with the curricular content and concluded it did not warrant the extra time demanded of the programme. These students usually left before the end of the 2nd year. Some students also left because of concern over their academic performance. Students who questioned the value of course content relative to the extra time requirements believed they were at a competitive disadvantage to students studying a traditional curriculum, who have more time to prepare for basic science classes and block examinations.
Goodrow B et al. 2001. The Community Partnerships Experience: a report of institutional transition at East Tennessee State University. Academic Medicine, 76:134–141. Florence J, Goodrow B. 1996. Indicators of health in rural northeast Tennessee: the picture from two community partnerships for health professions education counties. Community partnerships annual report. Rogersville, TN, East Tennessee State University.
involved. The curriculum development process produced 13 new courses, to be offered over 5 consecutive semesters.
Recommendation 5: Health professionals’ education and training institutions should use simulation methods of contextually appropriate fidelity levels in the education of health
professionals
ID Country Health
professional group
Population Intervention Comparison Study design and methods
Descriptive Reported results Outcomes Benefits /limitations Other findings
1 USA (7) UK (1)
Nursing undergraduate students
n=830 range 13 to 403 Mean 104
High fidelity human patient simulation manikins (HPSMs)
Usual nursing course without HPSMs (5) Usual nursing course + HPSMs (1) Different fidelity levels (1) Written case study (1)
Systematic Review (1999–2009) 20 studies →8 quasi Convenience (8) Randomized (8) Pre & Post (7) Control (7) No blinding No meta-analysis due to heterogeneity
Sim MAN TM (4) Various HPSM
Competence: ↑ p<0.05 (2) ↑ p<0.002 ↑ p<0.037 ↑ p<0.0001 (2) Critical thinking: ↔ p=0.051 ↑ p<0.002 Confidence: ↔ (2) Satisfaction ↑ significant
Quality Clinical reasoning and satisfaction Knowledge Psychomotor Confidence
Benefits: JBI methodology Limitations: Low to moderate quasi-experimental studies Inconsistent outcome measurement
Inconclusive ~effectiveness of HPSMs clinical reasoning skills Evidence of HPSMs significantly improves 3 outcomes integral to clinical reasoning: knowledge acquisition (4), critical thinking (3) and ability to identify deteriorating patients (1 study). High self-reported levels of learner satisfaction with HPSMs.
2 Australia (2) USA (18) UK (6) Canada (1) Israel (3)
Post-qualifying medical practitioners (15) Nursing practitioners (3) Multidisciplinary teams (12)
N=18 to 132 Divided into 2–3 groups per study
Simulation (10)
Lectures/ normal course Self-directed learning Lectures + half sim. Lectures and patient actor No training
Systematic review (1998–2009) 38 studies →30 quasi pre-post → (10)** Randomized (12) Pre- and Post- (13) Post Control (8) Survey (1) Evaluation (2) No blinding No meta-analysis due to heterogeneity.
Recreation of patient centred scenario in realistic context (excluded partial task trainers) Trauma (2) Disaster (2) Obst. (9) ED (6) Others (9)
**Only reported results from studies using relevant interventions and randomization and control groups (10) Knowledge ↑ p=<0.086 sustained ↑p=0.001 ↑p=0<0001 ↑p=0.024 ↑p=0.01 ↔ Performance ↑p=0.047 & p=0.012 ↑ p<0.001 & p=0.002 ↑ p<0.0001 ↑ p<0.001 ↔ Confidence ↑ & ↔ Sustainability ↑ sustained (2) p=0.05 (1) ↓ sustained P<0.006 Communication ↑ p=0.001 ↓ p=0.035 Safety ↓ p=0.048 Teamwork ↔ p=0.07 Patient Outcome ↔
Quality Knowledge (14) Application & Increase Safety Psychomotor Confidence Communication Improved patient outcome
Benefits: JBI methodology Limitations: Qualitative and quantitative Low study quality and inclusion of survey descriptive studies Heterogeneity of outcome +++ unable to determine if all studies address infrastructure Primary studies included–small samples Not all randomized Not all control groups.
Considerable evidence for increased knowledge, increased performance Reports on sustainability of performance inconsistent Reasonable evidence for improvements in confidence & mixed evidence for communication No significant differences between simulator groups and non simulator groups for teamwork and patient outcomes
3 Unable to determine
Nursing (16) Medicine (6) Interdisciplinary (1)
N=1–12 High fidelity simulation
Other educational training methods such as standardized patients, use of psychomotor task
Systematic review (2003– 2007) 61 ~ 23 studies included Pre- and post-
High Fidelity Simulators - computerized human patient Simulator manikins
Clinical skills competence: ↑ p<0.05 (11) ↑ p>0.05 (9) Confidence ↑ p<0.05 (21)
Quality: Clinical skills Competence Confidence Perceived competence Combination scores
Benefits: Calculate effect sizes Focused intervention Limitations: Extremely small sample
“The use of simulation, as opposed to other education and training methods, increased the students’ clinical skills and confidence in the majority of the studies.”
trainers, computer programmes and lectures.
(10) OSCE (7) Pre- and post- OSCE (2) Other (4)
sizes of primary evaluation studies. Evaluation studies NOT clear as to type of studies. No tables of findings of individual primary studies. No explicit rating of studies No grey literature search. Not confident of extent of search.
4 Unable to determine
Nursing Unable to determine
Unable to determine
Unable to determine
Integrative review (1998–2008) +++++~ 24
High fidelity patient simulation in undergraduate nursing education.
In narrative format not providing individual study data.
Unable to determine Limitations Not a systematic review No details on individual studies.
This review found that HFPS benefits nursing students in terms of knowledge, value, realism, and learner satisfaction. Findings were mixed in the areas of student confidence, knowledge transfer, and stress. Further research into these and other areas will determine whether its increased use is warranted.
5 US (11) Australia (1)
Nursing – undergraduate, RN and muli-professional groups of nursing and medical staff (1)
Sample sizes ranged from 23 to 140 for the individual studies (mean n=67) and 798 students in the one multi-site study.
Medium- to high-fidelity simulation in Nursing Education
Other educational strategies Usual (9) Self-Directed Learning (1)
Systematic review (1999–2009) 32 ~ 11 studies Experimental (11) 1 RCT 1 Quasi experimental
Medium- to high-fidelity simulation in Nursing Education ranging from post-operative care to core patient assessment skills.
Knowledge ↑ p< 0.001 (2) ↑ p< 0.002 ↑ p< 0.051 ↑p< 0.000 ↔ (6) but sustained (1) Skill ↑ Confidence ↔ (4) ↓ ↑ Satisfaction ↑
Assessment measures varied Quality: OSCES Satisfaction Knowledge Critical thinking Confidence
Benefits Good clear SR Details of individual included studies provided Included grey literature Limitations Though studies were evaluated for quality and details provided, text referred to levels of evidence not identified per study.
All included studies reported simulation as a valid teaching/learning strategy, with additional gains in knowledge, critical thinking ability, satisfaction or confidence compared with a control group. Simulation may have some advantage over other teaching/learning methods.
6 Unable to determine
Medical, dental, nursing, chiropractics, veterinary and other
Knowledge (8595)
Technology enhanced simulation
No intervention Systematic review & meta-analysis 635–609 studies included Post-test 2 groups (110) Pre post – 2 groups (94) Pre post 1 groups (405)
Surgical simulation in surgical, emergency, obstetrics, anesthetics and dentistry
Pooled effect sizes Knowledge (n=118), OR 1.20 (95% CI, 1.04-1.35) Time kills n=210) OR 1.14 (95% CI, 1.03- 1.25) Process skills (n=426), OR 1.09 (95% CI, 1.03-1.16 Product skills (n=54), OR 1.18 (95% CI, 0.98-1.37) Time behaviours (n=20), OR 0.79 (95% CI, 0.47-1.1 Other behaviours (n=50), OR 0.81 (95% CI, 0.66-0.96) Direct effects on patients (n=32). OR 0.50 (95%CI, 0.34-0.66)
Quality Based on Kirkpatrick’s Classification Knowledge Time skills (time to do procedures) Process (Efficiency) Product (quality of finished product) Time beh (time to evaluate beh while caring) Process beh (time to evaluate processes while caring). Patient effects
Benefits Meta-analysis reported Methodology of studies graded using MERSQI and NOS Limitations Heterogeneity was large (I2_50%) in all main analyses.
“In comparison with no intervention, technology-enhanced simulation training in health professions education is consistently associated with large effects for outcomes of knowledge, skills, and behaviours and moderate effects for patient related outcomes.”
7 Western countries (assumed) Unable to
Medical (any) 389 internal medicine, surgical and emergency
SBME with DP Traditional clinical education or pre-intervention based learning
Meta-analytic comparative review (1990–2010)
Simulation Based Medical Education – varying fidelity design with deliberate practice Simulators
The overall effect size for the 14 studies evaluating the comparative effectiveness of SBME
Quality Skills acquisition – not knowledge and attitudes
Benefits Meta-analysis MOOSE (Meta-analysis Of Observational
SBME with DP is superior to traditional clinical medical education in achieving specific clinical skill acquisition goals
determine medicine residents; 226 medical students; and 18 internal medicine fellows.
328~ 14 studies included RCTs (6) Cohort (3) Case-control (1) Pre post (4).
Computer-based Laparoscopic simulation and suturing ACLS scenarios CVC insertions.
compared with traditional clinical medical education was 0.71 (95% confidence interval, 0.65–0.76; P < .001).
Studies in Epidemiology) statement 18 and the QUOROM statement 19 for reports of meta-analyses of randomized controlled trials. Limitation number of reports analysed in this meta-analysis is small, meta-analysis only on medical procedural skills.
“SBME is a complex educational intervention that should be introduced thoughtfully and evaluated rigorously at training sites. “ Further research needed.
8 USA (7) Australia (1) UK (3) Canada (7) Germany (2) Ireland (1) NZ (1) Singapore (1)
Nursing (6) Medical school (15) Nursing and medical (1) Rehabilitation (1)
348 Simulators with and without computer support
Traditional CD-ROM
Systematic JBI review (1995– 2006) 41~ 23 ~ 11** Experimental or quasi-experimental studies only included RCTs (109) Time series (1)
Human physical anatomical models, including whole and part body simulators – varied across studies with and without Baby comp (1) Partial trainers (5) Life size adults.
Knowledge ↓ (comp sim) ↔ (2) ↑ (1) (p<0.05) (1) Performance ↑ (4) ↔ (4) ↓ (comp sim) Satisfaction ↔ (2) Confidence ↑ ↔ (4) ↓ (comp sim) Sustainability Knowledge< skill Confidence (4 and 8 months) ↔ ↑ with practice and feedback.
Quality Knowledge Performance Satisfaction Confidence
Benefits JBI systematic review methodology Limitation Interventions very heterogeneous SR included studies of all quality and did not identify level of evidence in recommendation Poor quality studies Significance not always reported Inconclusive results.
23 studies were selected Results indicate that there is high learner satisfaction with using simulators to learn clinical skills. The studies demonstrated that human patient simulators, which are used for teaching higher level skills, such as airway management, and physiological concepts are useful. While there are short-term gains in knowledge and skill performance, it is evident that performance of skills over time after initial training decline.
9. Western, unable to determine
Surgeons 8–45 Simulation in addition to normal training
No simulator training (5) No training Patient-based training (1)
Systematic review (-2006) ~ 11 RCT (10) Comparative (1) Evidence assigned using NHMRC AUS II (10) III (1) No meta-analysis
Endoscopy/sigmoidoscopy/ laparoscopic simulators
Performance (2) ↑ p<0.0004 ↓ (1 – compared to patient training) Performance time (6) ↑ (p=0.008- 0.01) ↔ (3) (1 – compared to patient training) Completion (7) Laparascopic ↑ (2/3) (p=0.007 & 0.05) ↑ completion vs no training (< 0.0011;13 and P< 0.027 and 0.007 Errors (3) ↓ P < 0.003;8 P< 0.006;9 P < 0.01 after 5 hours training and P <0.01 after 10 hours of training Patient discomfort (6) ↓3/43 (P < 0.02;13 P < 0.019;15 P < 0.0114) ↔ (2) 1 – compared to patient training).
Quality Task performance Accuracy Skill/technique Time to complete Efficiency of movement Error rates.
Benefits Evidence assigned using NHMRC AUS Limitations Variable quality Heterogeneity: Comparable simulation-based Rraining methodologies Small sample sizes Outcomes ill defined.
Skills acquired by simulation-based training seem to be transferable to the operative setting.
10 Unable to determine
Surgeons 12–49
Surgical simulation
Other surgical training No training Standard training
Systematic review (– 2005) ~ 30 RCTs
Simulation types Computer Video Model
↔ Computer simulation better than no results but not superior to standard
Quality Surgical performance
Benefits Detailed good systematic review including mainly RCTs
Surgical simulation may be just as good as other forms of surgical training – can reduce reliance on cadavers and patients for surgical
Comparing methods of simulation.
Cadaver or video simulation Video simulation, no consistent results with no training Models better than standard training.
Limitations Heterogeneity in all ICO in terms of interventions ranging from computer video cadaver Small sample sizes Multiple and confounding comparisons Disparate intervention No standardized Poor quality RCTs .
training none of the methods of simulated training has been shown to be better Simulation cost US$ 5000– $200 000 Cost of training a surgical resident in the operating room for 4 years was nearly US$ 50 000.
11. Unable to determine
Medical education Unable to determine
High fidelity simulators for education
Unable to determine
Systematic review (1969 – 2003) 670–109 studies included.
High fidelity simulators for education
The research evidence is clear that high-fidelity medical simulations facilitate learning among trainees when used under the right conditions. - Feedback - Repetitive practice - Dose response practice - Integrated into curriculum - Adapted to learning strategies - Clinical variation - Controlled environment - Individualized learning- Outcomes and benchmarks - Validity.
Quality Clinical skills; practical procedures; patient investigation; patient management; health promotion; communication; information skills; integrating basic sciences; attitudes and decision-making.
Benefits Level of evidence classifications Limitations Few published journal articles on the effectiveness of high-fidelity simulations in medical education have been performed with enough quality and rigour to yield useful results. Only 5% of research publications in this field (31 ⁄ 670) meet or exceed the minimum quality standards used for this study’.
“The evidence is clear … that repetitive practice involving medical simulations is associated with improved learner outcomes. Simulation-based practice in medical education appears to approximate a dose–response relationship in terms of achieving desired outcomes: more practice yields better results”.
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g. Gilbart M, Hutchison C, Cusimano M, Regehr G. A computer-based trauma simulator for teaching trauma management skills. Am J Surg 2000; 79: 223–8.
h. Mueller M, Christ T, Dobrev D et al. Teaching antiarrhythmic therapy and ECG in simulator-based interdisciplinary undergraduate medical education. Br J Anaesth 2005; 95: 300–4.
i. Madden C. Undergraduate nursing students' acquisition and retention of CPR knowledge and skills. Nurse Educ Today 2006; 26: 218–27.
j. Bathalon S, Dorion D, Darveau S, Martin M. Cognitive skills analysis, kinesiology, and mental imagery in the acquisition of surgical skills. J Otolaryngol 2005; 34: 328–32.
k. Kovacs G, Bullock G, Ackroyd-Stolarz S, Cain E, Petrie D. A randomized controlled trial on the effect of educational interventions in promoting airway management skill maintenance. Ann Emerg Med 2000; 36: 301–9.
9. Sturm, L. etal (2008). A Systematic Review of Skills Transfer After Surgical Simulation Training. Annals of Surgery Issue: Volume 248(2), August 2008, pp 166-179
10. Sutherland, L. M., P. F. Middleton, et al. (2006). "Surgical simulation: a systematic review." Annals Of Surgery 243(3): 291-300.
11. Issenberg, S. B., W. C. McGaghie, et al. (2005). "Features and uses of high-fidelity medical simulations that lead to effective learning: a BEME systematic review." Med Teach 27(1): 10-28.
Recommendation 6: Health professionals’ education and training institutions should consider direct entry of graduates from relevant undergraduate, postgraduate or other
educational programmes into different or other levels of professional studies.
General nursing graduates
ID Country Year Population Intervention Comparison Outcome Study design and
methods Reported results
Strengths/ weaknesses
Findings
Evidence level
1 USA 2011 Nursing managers at a national conference N=200
Second Degree Nursing Program (SD) N=93 (All accelerated groups: BN, MN and PhD).
Traditional Program (TP) N=107
Leadership Critical Care Teaching Planning Interpersonal Professional
Two group single data collection survey Convenience sampling Six-D-Scalei
Leadership: SD↔TP Critical Care: SD↔TP Teaching: SD↔TP Planning: SD↔TP Interpersonal: SD↔TP Professional: SD↔TP
Strengths: Standard Tool Weaknesses: Selection bias Convenience sample Self-report Survey and weak study design Evaluation of 1 graduate No comparison of 2 groups Sample loss Recall bias
“Evidence that accelerated programs produce graduates who are comparable to their traditional BSN peers in clinical competencies.”
Level IIIc evidence Grade B recommendation of moderate support
2 US 2010 Nursing students Capella University graduates (3 weeks’ experience) N=142
Accelerated BN (AB) N=29
Traditional (TB) N=113
Clinical decision- making CDMNSii
Comparative descriptive cross-sectional study Convenience sample Survey
Clinical decision-making: AB↑ TB* *No significance data provided
Strengths: Standard Tools Weaknesses: Selection bias Convenience sample Self-report Survey and weak study design Generalizability
“Accelerated nurses have a higher perceived decision-making utility.”
Level IIIc evidence Grade B recommendation of moderate support
3 USA 2010 Graduates of accelerated program working in major medical centre in the south east (1 year of experience) N=124 (47, 37.9%)
Accelerated BN (AB) N=11
Traditional (TB) N=28 Associate Degree (RN) N=7
Job satisfaction Performance Transition into RN role
Comparative descriptive cross-sectional study Self-developed tool Survey orientation and 1 year in practice
Performance: Assessment AB↔ TB Planning AB↔ TB Implementation AB↔ TB Evaluation AB↔ TB Leadership AB↔ TB Research AB↔ TB Education AB↔ TB Satisfaction and transition into RN role: Satisfaction AB↔ TB Transition AB↔ TB
Strengths: No differences between survey sample and actual population. Weaknesses: No standard tools Selection bias Low response rate Self-report Survey and weak study design Generalizability Recall bias.
“Mean ratings for graduates_ self-assessment of performance improved significantly from the beginning of their orientation to year 1, except for competencies in research. There were no differences between accelerated and traditional baccalaureate program graduates.”
Level IIIc evidence Grade B recommendation of moderate support
4 USA 2009 Graduates from New Jersey University between 1991–2006 N=230 (73, 32%)
Accelerated BN (AB) N=40
Traditional program graduates (TB) N=33
Passing rates Transitioning to the professional role Employment Professional development
Survey Self-designed tool Random Sample
First attempt pass rates: AB↔ TB, p= .252 Serves on committees: AB↔ TB, p= .414 Professional certification: AB↔ TB, p= .127 Role transition:
Strengths: Comparison of 2 groups Random sample Weaknesses: Comparison not tested for significance nor
“There were no statistically significant differences between the two groups on these variables.”
Level IIIc evidence Grade B recommendation of moderate support
Certifications AB↔ TB, p= .503 GPAiii (full group): AB↑TB, p= .01
compared to sample No Standard Tools Response Bias Low response rate Self-report Survey and weak study design Generalizability Recall bias
5 USA 2009 Newly registered nurses from 650 geographical regions from 35 states (licensed 5–18 months), working in hospitals N=3391 N=953 (58%)
Second Degree Graduates (SD) 89.7% worked in hospitals
Traditional degree graduates (TD) 94% worked in hospitals
Work characteristics Attitudes Intent to stay Price’s (2001) model of turnover
Cross-sectional design Mailed survey (Dillman Taylored design method) Part of longitudinal study
Attitudes: Family-work conflict: SD ↑ TB, p= .02 Job satisfaction: SD ↔ TB, p= .11 Job opportunities: SD ↔ TB, p= .72-.80 Search jobs: SD ↔ TB, p= .72 Length of time stay in job (retention): SD ↑ TB, p= .02 Intent to stay: SD ↔ TB, p= .35 Income annually: SD ↑ TB, p= .04 Hours worked: SD ↓ TB, p= .01
Strengths: Big samples Follow up of non-respondents Good response rates Tested for differences between demographics Weaknesses: No Standard tools Self-report Generalizability Significant differences between 2 groups for demographics
“TDs worked slightly more hours per week and were more likely to provide direct care. SDs were more likely to plan to stay in job.” “Full-time SDs earn over $ 2,700 more income per year.”
Level IIIb evidence Grade B recommendation of moderate support
6 USA 2008 Graduate nursing students from two Universities in northeastern USA N=99
Second Degree Advance Practice Nursing Program 2 years’ RN experience (RNAP) N=69
Accelerated Second Degree APN graduates Non-nursing prior experience (AAP) N=30
Clinical competence WGCTAiv NPDTv Leadership competence LPIvi
Quantitative Cross-sectional, descriptive, correlational
Critical thinking: AAP↑RNAP, p< .001 Leadership competence: AAP(masters)↑AAP(BDeg), p= .026
Strengths: Standard Tools Weaknesses: Self-report Survey and weak study design Generalizability Recall bias
Age was a strong predictor of leadership skills and advanced educational degrees was a strong indicator of critical thinking in APN graduate nursing students, regardless of prior RN clinical experience.
Level IIIc evidence Grade B recommendation of moderate support
7 USA 2007 BN Nursing Graduates at the University of Louiseville N=326 (84.9% response rate)
Accelerated BN graduates (AB)
Traditional BN graduates (TB)
Job satisfaction Job stress Burnout Intent to leave (Lake’s model of turnover)
Comparative descriptive study IWSvii NSSviii MBIix
Work satisfaction: AB↔ TB Work stress: AB↑ TB Satisfaction being a nurse: AB↑ TB Burnout: AB↔ TB Autonomy: AB↔ TB Intent to leave: AB↔ TB
Strengths: Standard tools Good response rate Weaknesses: Self-report Survey and weak study design Generalizability
The study support findings that accelerated graduates are strikingly similar to traditional graduates in what they do in nursing and their future plans.
Level IIIc evidence Grade B recommendation of moderate support
8 USA 2003 John Hopkins School of Nursing graduates from 1989–2003
Accelerated BN graduates (AB) N=226
Traditional BN graduates (TB) N=204
Pass rates Course performance Attrition and Graduation Employment
Performance scores Pass rates: AB↔ TB Course performance: AB↔ TB Attrition and graduation: AB <3%↔? TB 6-7% No significance reported
Strengths: Total population used Weaknesses: Survey and weak study design Generalizability No p values reported No actual data reported
Study provides a model on how to conduct the accelerated programme
Level IIIc
Papers included:
1. Rafferty M, Lindell D. How Nurse Managers Rate the Clinical Competencies of Accelerated (Second-Degree) Nursing Graduates. Journal of Nursing Education 2011;50(6):355-58.
2. Krumwiede KA. An examination of accelerated and basic baccalaureate nursing students' perceptions of clinical decision making. Capella University, 2010.
3. Oermann MH, Alvarez MT, O'Sullivan R, Foster BB. Performance, satisfaction, and transition into practice of graduates of accelerated nursing programs. Journal for Nurses in Staff Development 2010;26(5):192-99.
4. Aktan NM, Bareford CG, Bliss JB, Connolly K, DeYoung S, Sullivan KL, et al. Comparison of outcomes in a traditional versus accelerated nursing curriculum. International Journal Of Nursing Education Scholarship 2009;6(1):1p.
5. Brewer CS, Kovner CT, Poornima S, Fairchild S, Kim H, Djukic M. A comparison of second-degree baccalaureate and traditional-baccalaureate new graduate RNs: implications for the workforce. Journal of professional nursing :
official journal of the American Association of Colleges of Nursing 2009;25(1):5-14.
6. Ferrara LR. Relationship of work experience to clinical and leadership competence of advanced practice nursing students. ProQuest Information & Learning, 2008.
7. Masters JC. Job satisfaction, job stress, burnout, and intent to leave among accelerated and traditional baccalaureate in science in nursing graduates. University of Louisville, 2007.
8. Shiber SM. A Nursing Education Model for Second-Degree Students. Nursing Education Perspectives 2003;24(3):135-38.
9. Dike P. Direct entry: equipped for competence? RCM Midwives 2007;10(5):228-31.
10. Fleming V, Poat A, Curzio J, Douglas V, Cheyne H. Competencies of midwives with single or dual qualifications at the point of registration in Scotland. Midwifery 2001;17(4):295-301.
11. New Zealand Ministry of Health. Evaluation of direct entry midwifery programs.2nd Interim Report. Wellington, 1995.
Excluded papers
1. Fullerton, J. T., M. A. Shah, et al. (2000). "Prototypes in midwifery education. Integrating qualified nurses and non-nurses in midwifery education: the two-year experience of an ACNM DOA accredited program." Journal Of
Midwifery & Women's Health 45(1): 45-54.
2. Karlinski, J., A. British Columbia Council on, et al. (2007). BC University Outcomes for Direct Entry and Transfer Students: Comparison of the Class of 2000 and Class of 1996 Five Years after Graduation. Research Results,
British Columbia Council on Admissions and Transfer.
3. Oermann, M. H., K. Poole-Dawkins, et al. (2010). "Managers' perspectives of new graduates of accelerated nursing programs: How do they compare with other graduates?" The Journal of Continuing Education in Nursing 41(9):
394-400.
4. Ouellet, L. L., J. MacIntosh, et al. (2008). "Evaluation of selected outcomes of an accelerated nursing degree program." Nurse Education Today 28(2): 194-201.
5. Rambur, B., B. McIntosh, et al. (2005). "Education as a determinant of career retention and job satisfaction among registered nurses." Journal of Nursing Scholarship 37(2): 185-192.
6. White, K. R., W. A. Wax, et al. (2000). "Accelerated second degree advanced practice nurses: how do they fare in the job market?" Nursing Outlook 48(5): 218-222.
7. Ziehm, S. R., I. C. Uibel, et al. (2011). "Success Indicators for an Accelerated Masters Entry Nursing Program: Staff RN Performance." Journal of Nursing Education 50(7): 395-403.
Tools used in studies
Medical
ID Country Year Population Intervention Comparison Outcome Study design and
methods Reported results
Strengths/ weaknesses
Findings Evidence level
1 UK 2010 Medical Students University of Newcastle – 5 cohorts since 2001
Graduate entry programme (GE), n=140 4-year programme. Problem- based learning – 1st year separate from SE course and then joined for last 3 years. GEA=GE + Arts (n=16) GES = GE + Science (n=49) GEB= GE+ Biomed (n=56) GEP=GE + Health prof (n=19).
Standard entry programme (SE), n=1254. 5-year programme SEPD = SE + previous degree (n=55).
Knowledge– measured with MCQs and final written exams in years 3–5.
Retrospective quasi-experimental
Knowledge Stage 3: GE↑SE (F=28.6, p< .01) Stage 4: GE↑SE (F=10.2, p< .01) Stage 5: GE↑SE (F=5.9, p< .05) Stage 3: GE↑SEPD (F=18.3, p<. 01) Stage 4: GE↑SEPD (F=9.2, p< .01) Stage 5: GE↑SEPD (F=5.1, p= .011) GE↔GEA↔GEB↔GES Critical thought
Strengths: Assessed for different educational backgrounds. Assessed different groups. No differences Tested for homogeneity Addressed unequal sample sizes. Weaknesses: Low numbers Classification of previous degree Generalizability.
There is no significant difference in these assessment scores between GEP students from different previous educational backgrounds.
Level IIIa evidence Grade B recommendation of moderate support
2 Australia 2010 Medical education students n=704 in 4 cohorts 2002–2004 n=181 2003-2005 n=166 2004–2006 n=177 2005–2007 n=180
Graduate entrants (GE), n=240 Entrance: GPA (Grade point average) and GAMSAT (Graduate Australian medical school admissions test). 2002–2004 n=61 2003-2005 n=57 2004–2006 n=59 2005–2007 n=63
UG entrants (UG), n=464 Entrance: UMAT and school results 2002-2004 n=120 2003–2005 n=109 2004–2006 n=177 2005–2007 n=180
Bioscience knowledge – final mark for assessment in 4 bioscience subjects by MCQ and short answer examinations. Clinical skills performance –final mark for OSCEs at end of each semester.
Retrospective quasi-experimental design across 2 years for 4 cohorts of medical students Sample included all students, excluding: international students and missing consecutive assessments. NB: Only assessing academic performance while a student.
Supplementary examinations: GE↓UG (1.2% vs. 7.9% X2-13.6, p< .001) Bioscience knowledge: GE↑UG (F=6.47, p< .001, Effect size small 0.04) Cohort effect (F=11.34, p< .001, Effect size med 0.06) Clinical skills: GE↑UG (F=10.0, p< .001, Effect size med 0.06) Cohort effect (F=20.5, p< .001 Effect size large 0.11)
Strengths:
3 groups and differences tested
Reasonable sample size
Sampling showed
Addressed repeated dependent interaction effect
Standard outcome measurement
Identical curriculum
Strong quasi-experimental design
Separate measurement of knowledge and skills
Weaknesses:
Non-randomization
Generalizability
GE students had a marginal academic performance advantage during the early years of this medical course. Recommended that results may be due to completed rather than partial prior tertiary studies.
Level IIIa evidence Grade B recommendation of moderate support
3 UK 2009 Medical students at the University of Birmingham N=1547 students
Graduate Entry (GE) 4-year programme (n=161). First degree in life sciences. A-level chemistry Top 20% graduates. Problem-based course).
Standard 5-year mainstream course (SM) N=1547
Examination marks for final 3 years of the programme (n=19263 examination results Honour’s degrees.
Retrospective cohort study from 2003 – 2007. Standard examination method with proven reliability with cut-off scores determined by Angoff method. NB: Only assessing academic performance while a student.
Clinical examination results: GE↑SM (1.7 points [95%CI 0.7-2.7], p< .0001) Honour’s degrees GE↑SM (31% vs. 11%), p< .01) 2007 (23.8% vs. 9.4%), p= .01)2008
Strengths:
2 groups
Reasonable sample size
Addressed repeated dependent interaction effect
Standard outcome measurement
Weaknesses:
Non-randomization
Differences 2 groups (not statistically tested)
PBL confounder
Generalizability.
“Academic performance of Graduate Entry medical students is better than mainstream medical students.”
Level IIIc evidence Grade B recommendation of moderate support
4 UK 2009 Medical students University of Nottingham 2 cohorts graduating in 2007 (n=320) and 2008 (n=325) 2.5 years of clinical training.
Graduate entry (GE), n=171 4-year programme
Undergraduate entry (UG), n=450 5-year programme
Completion rates Failures at first attempt Clinical Assessments N=14 assessments
Retrospective cohorts Marks standardized to Z-scores to address cohort variation NB: Only assessing academic performance while a student.
Completion rates: GE 94%↑UG90%, p= .04 Performance on tests: ↓↑ (F=5.5, p< .001) Exam 1(Knowledge): GE ↑UG Exam 4 & 5 (Knowledge): GE ↓UG Failures at first attempt: Overall GE↔UG, p= 0.26 Clinical OSLER GE↑UG, p= .04) Skills and attitudes: GE↔UG Interaction with graduation year in clinical phase (F=4.2, p< .001)
Strengths:
2 groups
Reasonable sample size
Addressed cohort effect
Standard outcome measurement
Same programme Weaknesses:
Non-randomization
Differences 2 groups (not statistically tested)
Mixture of results
Generalizability
All confounders not addressed
High completion rates are encouraging. Lower performance in knowledge-based exams may reflect lower prior educational attainment, different profile or an artefact of programme.
Level IIIb evidence Grade B recommendation of moderate support
5 Australian 2003 Medical students from University of Sydney
Graduate entry course (GE) 4-year programme (n=108 – 70% response rate) Problem-based course (PBL). 2000 graduates Sydney University
Standard 5-year mainstream course (SM) N=? Standard 5-year PBL course (PBL) N=? 1995 graduates Sydney and Universities of NSW and Newcastle (PBL).
Preparedness for practice using the PHPQ PHPQ valid reliable 41 questions on 8 scales of practice.
Quasi-experimental Self-reported survey of 2000 graduates compared with published data from 1995 using same questionnaire NB: Only assessing hospital preparedness as a student.
Interpersonal GE↑PBL↑SM, p< .05
Confidence GE ↑ PBL↑SM, p< .05
Collaboration GE ↑ PBL↑SM, p< .05
Patient Management GE ↔ PBL↔ SM
Understanding science GE ↔ PBL↔ SM
Prevention GE ↔ PBL↑SM, p< .05
Holistic care GE ↑ PBL↑SM, p< .05
Self-directed learning GE ↑ PBL↑SM, p< .05.
Strengths:
3 groups
Reasonable sample size
Addressed repeated Dependent
Interaction effect
Standard outcome measurement
PBL confounder addressed
Weaknesses:
Non-randomization
Differences 3 groups (not statistically tested) an ‘n’ not stated
Generalizability
Time difference between comparisons.
Graduates from the graduate-entry, problem-based programme are at least as well prepared for their intern year as graduates from traditional and undergraduate.
Level IIIc evidence Grade B recommendation of moderate support
Articles included:
1. Price R, Wright SR. Comparisons of examination performance between ‘conventional’ and Graduate Entry Programme students; the Newcastle experience. Medical Teacher 2010;32(1):80-82.
2. Dodds AE, Reid KJ, Conn JJ, Elliott SL, McColl GJ. Comparing the academic performance of graduate- and undergraduate-entry medical students. Medical Education 2010;44(2):197-204.
3. Calvert MJ, Ross NM, Freemantle N, Xu Y, Zvauya R, Parle JV. Examination performance of graduate entry medical students compared with mainstream students. Journal of the Royal Society of Medicine 2009;102(10):425-30.
4. Manning G, Garrud P. Comparative attainment of 5-year undergraduate and 4-year graduate entry medical students moving into foundation training. BMC Med Educ 2009;9:76.
5. Dean SJ, Barratt AL, Hendry GD, Lyon PMA. Preparedness for hospital practice among graduates of a problem-based, graduate-entry medical program. The Medical Journal Of Australia 2003;178(4):163-66.
Papers excluded:
1. Chang, L. L., M. S. Grayson, et al. (2004). "Incorporating the fourth year of medical school into an internal medicine residency: effect of an accelerated program on performance outcomes and career choice." Teaching And
Learning In Medicine 16(4): 361-364.
2. Cohen-Schotanus, J., J. Schönrock-Adema, et al. (2008). "One-year transitional programme increases knowledge to level sufficient for entry into the fourth year of the medical curriculum." Medical Teacher 30(1): 62-66.
3. Craig, P. L., J. J. Gordon, et al. (2004). "Prior academic background and student performance in assessment in a graduate entry programme." Medical Education 38(11): 1164-1168.
4. Daly, M.-L. (2004). "Accelerated graduate entry programmes: a student's perspective." Medical Education 38(11): 1134-1136.
5. Dickson, J. M., R. Harrington, et al. (2011). "Teaching clinical examination using peer-assisted learning amongst graduate-entry students." Clinical Teacher 8(1): 8-12.
6. Elzubeir, M. A. (2009). "Graduate-entry medical students' self-directed learning capabilities in a problem-based curriculum." Saudi Medical Journal 30(9): 1219-1224.
7. Groves, M., P. O'Rourke, et al. (2003). "The association between student characteristics and the development of clinical reasoning in a graduate-entry, PBL medical programme." Medical Teacher 25(6): 626-631.
8. Groves, M. A., J. Gordon, et al. (2007). "Entry tests for graduate medical programs: is it time to re-think." Medical Journal of Australia 186(3): 120-123.
9. Hayes, K., A. Feather, et al. (2004). "Anxiety in medical students: is preparation for full-time clinical attachments more dependent upon differences in maturity or on educational programmes for undergraduate and graduate entry
students?" Medical Education 38(11): 1154-1163.
10. Kennedy, F. S. and J. C. Austin (1988). "Comparison of performances of students in programs at LSU Medical School in Shreveport." Journal Of Medical Education 63(1): 1-6.
11. Kronqvist, P., J. Mäkinen, et al. (2007). "Study orientations of graduate entry medical students." Medical Teacher 29(8): 836-838.
12. Lewis, M. (2010). "The Faculty of Medical Sciences, St Augustine, and its contribution to human resource development in the Caribbean." West Indian Med J 59(6): 709-714.
13. Mathers, J. M., A. Sitch, et al. (2011). "Widening access to medical education for under- represented socioeconomic groups: population based cross sectional analysis of UK data, 2002-6." BMJ: British Medical Journal
(Overseas & Retired Doctors Edition) 342(7796): 539-539.
14. Nestel, D., A. Ivkovic, et al. (2012). "Benefits and Challenges of Focus Groups in the Evaluation of a New Graduate Entry Medical Programme." Assessment & Evaluation in Higher Education 37(1): 1-17.
15. Noor, S., S. Batra, et al. (2011). "Learning opportunities in the clinical setting (LOCS) for medical students: A novel approach." Medical Teacher 33(4): e193-e198.
16. Oermann, M. H., M. T. Alvarez, et al. (2010). "Performance, satisfaction, and transition into practice of graduates of accelerated nursing programs." Journal for Nurses in Staff Development 26(5): 192-199.
17. Petrany, S. M. and R. Crespo (2002). "The accelerated residency program: the Marshall University family practice 9-year experience." Family Medicine 34(9): 669-672.
18. Price, M. and B. Smuts (2002). "Prospective students? and parents? attitudes towards a graduate-entry medical degree." South African Medical Journal 92(8): 632-633.
19. Rapport, F., G. F. Jones, et al. (2009). "What influences student experience of Graduate Entry Medicine? Qualitative findings from Swansea School of Medicine." Medical Teacher 31(12): e580-e585.
20. Roberts, C., M. Walton, et al. (2008). "Factors affecting the utility of the multiple mini-interview in selecting candidates for graduate-entry medical school." Medical Education 42(4): 396-404.
21. Roberts, C., N. Zoanetti, et al. (2009). "Validating a multiple mini-interview question bank assessing entry-level reasoning skills in candidates for graduate-entry medicine and dentistry programmes." Medical Education 43(4):
350-359.
22. Weintraub, W., S. M. Plaut, et al. (1996). "Medical school electives and recruitment into psychiatry: A 20-year experience." Academic Psychiatry 20(4): 220-225.
23. Yeh, Y.-C., C.-F. Yen, et al. (2007). "Correlations between academic achievement and anxiety and depression in medical students experiencing integrated curriculum reform." The Kaohsiung Journal Of Medical Sciences 23(8):
379-386.
Midwives
Country Population Intervention Comparison
Study design/sample size
Methodological quality issues Reported results (Outcomes) Additional comments Reference
UK
Midwives Compare the perceptions of midwives trained on DE-programmes and those trained on 18-month PR-programmes, in order to better inform the debate on whether DE training equips midwives for competent practice.
PR-trained midwives
Cross-sectional questionnaire survey. The sample consisted of 3 groups. Group 1 comprised 18 midwives newly qualified from a direct-entry (DE) programme. Group 2 comprised 13 post-registration (PR)-trained midwives, and group 3 was composed of 27 midwives (14 were DE-trained and 13 PR-trained) working in one setting.
A qualitative survey questionnaire was used, which has the advantage of saving time and avoiding interview bias.
It measured 29 variables, which had been formulated in relation to the Nursing and Midwifery Council (NMC)-stipulated competencies regarding midwifery training and registration for part 10 of the professional register.
A Likert scale was used to measure participants’ level of agreement or disagreement with statements. There is a risk that the pre-coded nature of the questionnaire may have fostered inappropriately coded answers from respondents with less certain opinions and surveys are open to memory or viewpoint bias.
This study found no clear differences between DE- and PR-trained midwives’ perceptions of their respective training programmes’ effectiveness – both evaluated their own training positively.
Despite differing perceptions of levels of confidence and/or competence, the achievement of NMC competencies represents the endorsement of DE-programmes as effective in preparing midwives for practice.
PR-trained midwives tended to take a more disparaging stance in evaluating levels of competence among DE-trained colleagues.
Author recommends that PR-trained midwives need to re-examine their biases toward and misperceptions of DE-programmes and acknowledge their proven credibility in equipping midwives for practice.
Dike P. 2007. Direct entry: equipped for competence? RCM Midwives, 10:228-231.
UK
Midwives Examine the efficacy, from midwives’ perspectives, of pre-registration midwifery programmes in preparing them to be ‘fit for practice’, and to form a body of evidence that may inform both education and practice.
No comparison Qualitative study on 23 midwifery students in the final year of direct-entry programme followed by questionnaire survey.
A total of 31 variables was formulated from the questionnaire. Each of these variables formulated from the questionnaire represented important factors that might influence the effectiveness of the direct-entry midwifery programme.
Students were requested to state their level of agreement or disagreement with the statements regarding the effectiveness of their programme in aiding their achievement of the NMC competencies.
Likert-scale rating was adopted to enhance considered participants’ response as to the level of their agreement or disagreement with statements.
A majority of the sample perceived the direct-entry programme as effective in preparing them to fulfil most of the competencies stipulated by the NMC.
According to this group of students, achievement of NMC competencies represents an endorsement of the ‘fitness for award’, ‘fitness for purpose’ and ‘fitness for practice’, so long as they adhere to professional updating as an ongoing process as stipulated by the United Kingdom Central Council (UKCC).
This pilot study forms part of a main study (prospective) aimed at assessing the perception of midwives after a year of undertaking pre-registration midwifery programme.
Dike P. 2005. Student midwives: views of the direct-entry programme. RCM Midwives, 8:314–7.
USA
Midwives Assess the knowledge and skill equivalency of nursing students, at entry into the programme, with the non-nurse students, after completion of the basic health skills course.
Registered nurse students (no direct admission)
Case study, 5 direct entry (DE) and 5 registered nurse (RN) students admitted to the State University of New York Health Science Center at Brooklyn (SUNY HSCB) Midwifery Education Program in 1996–1997.
Research study designed for assessment of the Basic Health Skills course tested the assumption cited by the ACNM Division of Accreditation (DOA). Each of the individual skills on the short checklist was listed on a single slip of paper and placed in an envelope. Each student then picked 3 skills from the envelope, for a total of 15 different skills to be tested among them. Both groups of students were evaluated using the same instrument. As a means of internal consistency in the evaluation process, the same instructor evaluated both groups of students.
There was no significant difference in academic performance between the DE and nurse-midwifery students. DE students could acquire and demonstrate the basic health skills at a level equivalent to their RN students and affirmed the value of continued competency assessment across the professional lifespan.
None Fullerton JT et al. 1998. Direct entry midwifery education. Evaluation of program innovations. Journal of Nurse Midwifery, 43:102–105.
USA
Midwives Focusing on the profiles of the DE students, their achievements, and their experiences entering the workforce.
Registered nurse student (no direct admission)
Case study, 9 direct entry (DE) and 22 registered nurse (RN) students admitted to the State University of New York Health Science Center at Brooklyn (SUNY HSCB) Midwifery Education Program in 1996–1998.
This article presents SUNY HSCB’s 2-year experience with integrating RN and DE students in the certificate program of midwifery education. The SUNY HSCB Midwifery Education Program (MEP) faculty was deeply committed to a rigorous programme of formative (concurrent and progressive) and summative (outcome) comparative evaluation of both groups of students, the curriculum of study, and the impact of this DE programme on the profession and the community. To accomplish this, an external consultant was engaged during the period of programme planning to develop a prospective evaluation protocol.
DE students who enter with minimal or no nursing experience can achieve standards of academic excellence and clinical competency that are at least equivalent to those demonstrated by their RN students.
None Fullerton JT. 2000. Integrating qualified nurses and non-nurses in midwifery education: the two-year experience of an ACNM DOA Accredited Program. Journal of Midwifery and Women’s Health, 45:45–54.
Scotland Midwives Compare and contrast competencies of midwives with single or dual qualifications at the point of registration.
Shortened programme midwives (no direct admission)
Cross-sectional study. 157 midwives qualifying in Scotland in 1998, 130 completed the skills' Inventory (83%). 95 had undertaken the direct entry (DE) programme and 35 the shortened programme (SP). 166 supervisors of midwives.
This research has utilized a combination of qualitative and quantitative methods to compare the self-rated competencies of DE and SP midwives in Scotland at the point of registration and after one year of practice.
Self-completing survey using the Glasgow Royal Maternity Hospital's Skills' inventory by midwives at the point of registration and by supervisors of midwives analysed using non-parametric statistical tests. Content analysis of semi-structured interviews with experienced midwives and supervisors of midwives. Mann-Whitney and Kruskal Wallis analysis of skills of midwives at the point of registration in prenatal, labour, post-natal, neonatal areas and extended skills areas.
While support for the direct entry programmes has been clearly demonstrated, this is not unanimous, although as more direct entry midwives take up positions, attitudes are becoming more positive.
What has clearly been demonstrated throughout this study is the ability of all newly qualified midwives in Scotland, regardless of their educational preparation, to provide care for women and babies in normal midwifery situations.
Fleming V et al. 2001. Competencies of midwives with single or dual qualifications at the point of registration in Scotland. Midwifery, 17:295–301.
USA Midwives To evaluate the safety of home births in North America involving direct entry midwives, in jurisdictions where the practice is not well integrated into the health-care system.
None Prospective cohort study. All 5418 women planning to deliver at home when labour began in 2000 supported by midwives with a common certification. To collect the data, they contacted and sent detailed data forms and instructions for the study to the 409 practicing direct entry midwives who agreed to participate.
Their target population was all women who engaged the services of a certified professional direct entry midwife in Canada or the United States as their primary caregiver for a birth with an expected date of delivery in 2000. For each new client, the midwife listed identifying information on the registration log form, and filled out a detailed data form on the course of care. Every 3 months the midwife was required to send a copy of the updated registration log, consent forms for new clients, and completed data forms for women at least 6 weeks postpartum. To confirm that forms had been received for each registered client, author linked the entered data to the registration database.
Planned home birth for low risk women in North America using certified professional direct entry midwives was associated with lower rates of medical intervention but similar intrapartum and neonatal mortality to that of low-risk hospital births in the United States.
This study of certified professional midwives suggests that they achieve good outcomes among low-risk women without routine use of expensive hospital interventions. Their data also supports the American Public Health Association’s recommendation to increase access to out of hospital maternity care services with direct entry midwives in the United States.
Johnson KC, Davis BA. 2005. Outcomes of planned home births with certified professional midwives: large prospective study in North America. British Medical Journal, 330:1416.
Zambia Midwives (doctors, clinical officers and nurses)
Single variable and multiple variable scenario analyses of the supply of health workers in a model that uses health workforce to population ratios to understand minimum staffing requirements in Zambia.
None They developed a model to forecast the size of the public sector health workforce in Zambia over the next 10 years (2018) to identify a combination of interventions that would expand the workforce to meet staffing targets (doctors, clinical officers, nurses and midwives).
The key forecasting variables are training enrolment, graduation rates, public sector entry rates for graduates, and attrition of workforce staff. They model, using Excel (Office, Microsoft; 2007), the effects of changes in these variables on the projected number of doctors, clinical officers, nurses and midwives in the public sector workforce in 2018. Furthermore, they conducted what-if analyses to estimate the effects of changes in training, hiring, and attrition conditions on the supply of human resources for health over time. They assumed all changes would take effect by 2010.
The number of doctors is expected to decrease by 14 with no changes in current trends, while the number of clinical officers, nurses and midwives are expected to increase by 592, 921 and 2224, respectively, over the 10-year period.
New programmes for direct entry into midwifery training have just started, and removing prerequisites to advanced nursing degrees (by allowing direct entry) would increase training enrolment and reduce back-to-school attrition.
No combination of changes in staff retention, graduation rates, and public sector entry rates of graduates by 2010 is sufficient to meet staffing targets by 2018 for any cadre except midwives.
Tjoa A et al. 2010. Meeting human resources for health staffing goals by 2018: a quantitative analysis of policy options in Zambia. Human Resources for Health, 8:15.
New Zealand
Midwives Compare the employment rate, pass rate for an examination and course cost of midwives trained on direct entry-programmes and those trained on registered nurse-programmes.
Registered nurse midwives
Descriptive report The second interim report of the evaluation process was conducted as graduates emerged from the programmes.
95% of new direct entry graduates were employed in midwifery practice, comparing favourably with 1-year registered nurse diploma graduates, 78.5% of whom were employed in midwifery.
All direct entry students were successful at their first attempt in the midwifery State Final examination, comparing favourably with a registered nurse midwives 95% pass rate. Course costs per annum were lower for the direct entry programmes.
Graduates of the 3-year direct-entry programmes reported being confident in their midwifery knowledge and competent in their midwifery skills. The majority of consumers interviewed were most satisfied with the care and support they had received from direct entry students.
New Zealand Ministry of Health. 1995. Evaluation of direct entry midwifery programs. 2nd Interim Report. Wellington: New Zealand Ministry of Health.
Australia Midwives None None Descriptive report This paper, which is based on the preliminary findings of the Australian Midwifery Action Project (AMAP), outlines the issues around the midwifery labour force and education in Australia.
The current and projected shortage of midwives could be addressed more quickly through Direct Entry Midwifery programmes (3-year undergraduate programmes).
Government subsidized 1st degree programmes are a more viable proposition than the current expensive postgraduate (nursing) programmes (5-year programmes).
There are already overseas DEM educated midwives registering in Australia.
One of the most alarming features is the lack of comprehensive data on midwives. Where data are available, they demonstrate the shortage of midwives and the lack of consistency in educational programmes for midwives within states and nationally.
Tracy S, Barclay L, Brodie P. Contemporary issues in the workforce and education of Australian midwives. Aust Health Rev. 2000;23(4):78–88.
USA Midwives None None Descriptive report As part of this review, DORA staff interviewed division staff, reviewed division records including complaint and disciplinary actions, interviewed officials with state and national professional associations, interviewed health-care providers, reviewed Colorado statutes and director rules, and reviewed the laws of other states.
The laws that govern direct-entry midwives ensure competent and qualified practitioners. Complications that may arise during pregnancy, delivery, and childbirth are numerous, and include lifelong injury and death. Therefore, it is in the interest of the public to regulate direct-entry midwives.
A licensed nurse, who obtains the necessary skills and qualifications to be registered as a direct-entry midwife and maintains his or her licence in good standing, should be allowed to work as a direct-entry midwife without giving up his or her nursing licence in order to do so.
State of Colorado. Department of Regulatory Agencies (DORA). 2010. 2010 Sunset Review: Regulation of direct-entry midwives. Denver, CO. 61 pp.
Nursing students
ID Country Year Population Intervention Comparison Outcome Study design and
methods Reported results Strengths/ weaknesses Findings
Evidence level
1 USA 2011 2nd degree nursing students Second Degree Nursing Program (SD)
Traditional programme (TP)
Critical thinking Retrospective Missing PDF Missing PDF
2 USA 2010 All nursing Students University of Northern Colorado, n=96
Accelerated BN (AB) Traditional (TB) RN-BN
Professional development Leadership
Non-experimental cross-sectional design Convenience sample PDSAMx SALIxi
Professional development: RNBN↑AB ↔ TB Leadership AB↑ TB
Strengths: Standard Tools Weaknesses:
Selection bias
Convenience Sample
Self-report
Survey and weak study design
Generalizability
“PDSAM significant difference in professional development: Leadership capabilities of nursing students could not be attributed to their education in the nursing programs.”
Level IIIc evidence Grade B recommendation of moderate support
3 USA 2009 Baccalaureate Nursing Program University of Pittsburgh who completed NCLEX-RN xii between 2005 and 2008 N=120
Accelerated BN (AB) – holds a non-nursing degree Accelerated 18-month programme N=58
Traditional (TB) Holds no prior degree 4 year programme N=62
HESIxiii GPAxiv Passing rates
Retrospective study to investigate between subject comparison
Passing rates: AB 88%↑ TB 72.5%, p .036 HESI mean scores: AB ↑ TB, p< .01 (All except community exam) Course grades AB ↑ TB, 11/14 tests p < .01 GPA AB ↑ TB, 6/6 tests p< .01
Strengths:
Standard tools
Appropriate statistics
Compared 2 groups (p= .327)
Weaknesses: Generalizability
“Support for the continued recruitment and admission of the second-degree students into the nursing program”.
Level IIIb evidence Grade B recommendation of moderate support
4 USA 2009 Baccalaureate Nursing Program (no name of university) N=150
Accelerated BN (AB) – holds a non-nursing degree Accelerated 18-month programme N=35 (30)
Traditional (TB) Holds no prior degree 4-year programme N=115
Learning strategies using Exam scores (n=13v n=63) GPA (n=13v n=63)
Cross-sectional comparison 2 groups LASSIxv
Learning inventory Attitude: AB ↑ TB, p= .002 Selecting main ideas: AB ↑ TB, p= .029 Small mean differences – not clinically significant Other inventory: AB ↔ TB Exit exams: AB ↔ TB, p= .92 GPA: AB ↔ TB, p= .175
Strengths:
Standard tools
Appropriate statistics Weaknesses:
Did not compare 2 groups
Sample size small
Generalizability
“Findings showed little difference between AB and TB students on LASSI and no difference in exit examination scores and nursing GPA.” “Social and learning differences were apparent as a result of the focus group experience.”
Level IIIc evidence Grade B recommendation of moderate support
5 USA 2008 Foreign educated physicians in an accelerated nursing programme at Florida University 2002–2007 N=98 (76, 78%)
Accelerated BN programme for foreign educated physicians completing a 5- semester program AB(FEP) N=25
Traditional BN (TB) N=32 RN-BN N=19
Socialization Critical Thinking Pass rates
Survey of graduating community health nursing students SHCAIxvi CCTDxvii
Socialization: AB(FEP) ↔ TB↔ RNBN, p= .129 Critical thinking: AB(FEP) ↑ TB & RNBN, p< .0001 Pass rates: AB(FEP) ↑ TB & RNBN,
Strengths:
Standard tools
Appropriate statistics
Did compare 2 groups Weaknesses:
Sample size small
Groups different (p< .05) age and gender (p< .0001
Generalizability
“Model is cost effective with successful program outcomes.”
Level IIIc evidence Grade B recommendation of moderate support
6 USA 2008 Baccalaureate Nursing Program N=115
Accelerated BN (AB) – holds a non-nursing degree Accelerated 18-month programme
Traditional (TB) Holds no prior degree 4-year programme
GPA Pass rates
Cross-sectional comparison 2 groups using student information system
GPA prerequisite: AB ↔ TB GPA: AB↑ TB Pass rates: AB ↔ TB
Strengths:
Full target sample
Standard tools Weaknesses: Generalizability Missing PDF
“Nursing programs are meeting the established standards of traditional programs, accelerated students are performing better or as well.”
Level IIIc evidence Grade B recommendation of moderate support
7 USA 2008 Baccalaureate Nursing Program University of Oklahoma N=61
Accelerated BN (A) – Accelerated 18-month programme
Bachelor in non-nursing field
N=29
Traditional (TB)
Holds no prior degree
4-year programme
N=32
Pass rates
Laboratory skills
Summative Examinations
Formative Mark
Retrospective, quasi-experimental
Formative Mark AB↑ TB, p< .05 GPA AB↑ TB, p= .001
Strengths:
Full target sample
Standard tools
Tested for differences in 2 groups p= .18, except academic performance
Same course
Addressed age as a confounder
Weaknesses
Small study
Generalizability
“The accelerated students performed significantly higher on every measure than did the students in traditional program.”
Level IIIb evidence Grade B recommendation of moderate support
8 USA 2006 Baccalaureate Nursing Program of 3 Universities in Indiana, PA
Accelerated BN (AB) – holds a non-nursing degree
Accelerated 18-month programme
Traditional (TB) holds no prior degree, 4-year programme
Professional values NPVxviii
Cross-sectional comparison 2 groups using self-report data
Professional values AB ↔ TB
Strengths:
Standard tools
Tested differences in groups
Tested for confounding Weaknesses:
Convenient sample
Generalizability Missing PDF
“Affirm that the efforts instituted to fill the nursing shortage void have continued to produce competent nurses that uphold the professional values of the profession.”
Level IIIc evidence Grade B recommendation of moderate support
9 USA 2006 Baccalaureate nursing programme at one university between Dec 2000 and Dec 2004 N=224
Accelerated BN (AB) – holds a non-nursing degree
Accelerated 18-month programme
N=52
Traditional (TB) Holds no prior degree, 4-year programme N=172
Passing rates HESI
Comparative Groups Convenience sample
Pass rates: AB 92% ↔ TB89.5%, p= .388 Academic achievement: PsychHESI AB↑ TB, p= .010 Peads HESI AB↑ TB, p< .001 EXIT HESI AB↑ TB, p= .023
Strengths:
Standard tools
Full target population
Reasonable sample Weaknesses:
Main comparisons were within groups not between groups
Generalizability
“This study shows that the accelerated graduate is just as successful as, and more often more successful than, the traditional student.”
Level IIIc evidence Grade B recommendation of moderate support
10 USA 2001 Baccalaureate nursing programme at private comprehensive university in Indiana. N=123
Accelerated BN (AB) – holds a non-nursing degree
Accelerated 18-month programme
44 college credits N=43
Traditional (TB) Holds no prior degree, 4-year programme N=45 RN_BN group N=35
Critical thinking Comparative groups, pre- and post-test Convenience sample WGCTAxix
Critical thinking: AB pre ↔ AB post, p= .107 TB pre↓ TB post, p= .007 RN pre↓ RN post, p= .029
Strengths: Standard tools Weaknesses:
Differences in groups not tested for significance and confounding
Difference in PT and FT attendance
Main comparisons were within groups not between groups
Small sample
Convenience sample
Generalizability
The bias in not reporting the actual critical thinking scores makes this information difficult to interpret.
Level IIIc evidence
11 Australia 2001 Baccalaureate Nursing Program at LaTrobe university N=130
Accelerated BN (AB) – holds a non-nursing degree
Accelerated 18-month programme
N=34
Traditional (TB) 4-year programme N=96
Academic results
Exams
Clinical Assessment based on BONDY scale
Comparative Groups using academic results
Grades AB↔=TB, p> .05
Strengths: Standard tools Weaknesses:
Differences in groups not tested for significance and confounding?
Convenience sample
Generalizability
“From the evaluation data collected it seems that, as a concept, the two-year program has been successful in terms of academic results and employment opportunities.”
Level IIIc evidence Grade B recommendation of moderate support
12 Australia 2001 Baccalaureate nursing programme
Accelerated BN (AB) – holds a non-nursing degree
Accelerated 2-year pre-service degree
Traditional (TB) 4-year programme
GPA Comparative Groups using academic results
AP had a significantly higher grade point average at the point of divergence so by the end of the 2 programmes there was no significant difference. Missing PDF
Missing PDF The accelerated program resulted in academically equivalent graduates in a shorter time but graduates paid a price in terms of stress and under-achievements.
–
13 USA 1999 Baccalaureate nursing programme N=86
Accelerated BN (AB) – holds a non-nursing degree
Accelerated 18-month programme
44 college credits N=25
Traditional (TB) Holds no prior degree, 4-year programme N=24 Associate Degree RN_BN group N=37
Moral orientation Non-experimental Convenience MMOxx
Ethics of justice and care: AB↓ RN↓ TB, p<.01
Strengths:
Standard tool
Tested for confounding Weaknesses:
Convenience sample
Differences in groups not tested for significance and confounding
Small sample
Generalizability
“The findings of this study supported Gilligan's position that women have the propensity to make moral decisions from an ethics of care orientation.”
Level IIIc evidence Grade B recommendation of moderate support
14 USA 1998 Nursing students in 2 settings, a metropolitan university in Northern California & rural West Virginia (private Christian schools) over a period of 20 months N=464 (388)
Accelerated BN (AB) – holds a non-nursing degree
Accelerated 12–15–month programme in 2 settings and a 24-month degree programme
N=102
Traditional (TB) Holds no prior degree, 4-year programme N=268
Attitudes towards nursing
A one time ex-post facto design NAQxxi
Differences in NAQ AB↔TB, p> .05
Strengths:
Standard tool
Tested for confounding
Full sample
Reasonable sample Weaknesses:
Differences in groups not tested for significance.
Generalizability
“No difference was found regarding their attitude toward nursing: ~ choose nursing for the same reasons as do traditional students; ~ lend maturity to the profession.”
Level IIIc evidence Grade B recommendation of moderate support
15 USA 1997 BN students at a private liberal arts university located in the Midwest
Accelerated BN (AB)
Holds a non-nursing degree
Accelerated < 22 months
44 college credits N=43
Traditional (TB) 4-year programme N=45
Critical thinking Comparative group
Convenience sample WGCTA
Critical thinking Pre AB↑ TB, p=. 017 Post AB↔TB, p=. 107
Strengths Standard tools Weaknesses
Small sample
Convenience sample
Generalizability
Findings also revealed significant differences in pre-and post-curriculum test scores of traditional students but no difference for accelerated students .
Level IIIc evidence Grade B recommendation of moderate support
16 USA 1996 Undergraduate student at a private university in Washington from Fall 1991 to Fall 1993 N=102 (94)
Accelerated BN (AB)
Holds a non-nursing degree
Accelerated < 22 months
N=48
Traditional (TB) 4-year programme N=44
Critical thinking Stress Academic Performance GPA
Prospective study Voluntary convenient sample STAIxxii SJAxxiii
Stress
Pre AB↑ TB, p=.008
Post AB↔TB, p=.07 Grade Averages AB↑ TB GPA AB↑ TB, p=.002 Critical thinking Post AB↔TB, p=.06–98
Strengths Standard tools Compare 2 groups for demographic differences Adjusted for confounding Weaknesses
Small sample
Convenience sample
Generalizability
AB students showed consistently higher stress levels than those of the traditional and significantly higher grade averages in nursing courses than traditional students.
Level IIIc evidence Grade B recommendation of moderate support
17 USA 1995 Baccalaureate Nursing Program in Midwest in Sept 1989 N=56
Accelerated BN (AB)
Holds a non-nursing degree (Bachelor or Masters)
Accelerated 13-month programme
N=27
Traditional (TB)
Holds no prior degree
4-year programme
N=29
Performance S6DSxxiv Academic performance GPA
Quasi-experimental pre- test, post- test using self-report data collected at end of junior year (pre) and six months later
Nursing Performance
Pre AB ↑ TB p=.036
Post AB ↔TB p=.547 Preparation of Pgm
Pre AB ↑ TB p=.004
Post AB ↑ TB p=.05 GPA AB↔TB, p=.002 Passing rate Post AB ↑ TB Satifaction AB ↑ TB, p=.03 Difficulty AB ↓ TB, p=.05
Strengths
Standard tools
Tested differences in groups
Tested for confounding (GPA)
Weaknesses:
Convenient sample
Small Sample
Mix of nursing and non-nursing
Generalizability
Findings indicated significant differences between the groups.. The traditional group reported significantly more hours worked and less hours studied
Level IIIc evidence Grade B recommendation of moderate support
I=Intervention C=Control OR= Odds Ratio NNT=Numbers needed to treat CI=Confidence Intervals WMD=weighted mean difference ↓=lower ↑=higher ↔=no significant difference
I=Intervention C=Control OR= Odds Ratio NNT=Numbers needed to treat CI=Confidence Intervals WMD=weighted mean difference ↓=lower ↑=higher ↔=no significant difference
Articles included:
1. O'Reilly CM. A comparison of factors associated with critical thinking scores of second-degree versus traditional nursing students in an accelerated pre-licensure baccalaureate program. ProQuest Information & Learning, 2011.
2. Barbe TD. Professional development among registered nurse to bachelor of science in nursing, accelerated Bachelor of Science in Nursing, and traditional bachelor of science in nursing students. University of Northern Colorado, 2010.
3. Englert NC. The relationship between selected variables and the National Council Licensure Examination for Registered Nurses: A comparative analysis of pass/fail performance for traditional and second-degree baccalaureate students.
University of Pittsburgh, 2009.
4. Moe K, Brockopp DA, Walmsley LA, Davis J, Butler K, Diebold C, et al. A Pilot Project to Evaluate the Academic Performance, Abilities, and Satisfaction of Second-Degree Students. Nursing Education Perspectives 2009;30(4):226-28.
5. Grossman D, Jorda ML. Transitioning foreign-educated physicians to nurses: the New Americans in Nursing accelerated program. The Journal Of Nursing Education 2008;47(12):544-51.
6. Hallman PA. Accelerated and traditional baccalaureate nursing programs: A comparison of student academic outcomes. ProQuest Information & Learning, 2008.
7. Korvick LM, Wisener LK, Loftis LA, Williamson ML. Comparing the Academic Performance of Students in Traditional and Second-Degree Baccalaureate Programs. Journal of Nursing Education 2008;47(3):139-41.
8. Astorino TA. A survey of professional values in graduating student nurses of traditional and accelerated baccalaureate nursing programs. Indiana University of Pennsylvania, 2006.
9. Bentley R. Comparison of traditional and accelerated baccalaureate nursing graduates. Nurse Educator 2006;31(2):79-83.
10. Brown JM, Alverson EM, Pepa CA. The influence of a baccalaureate program on traditional, RN-BSN, and accelerated students' critical thinking abilities. Holistic Nursing Practice 2001;15(3):4-8.
11. Duke M. On the fast track. Collegian (Royal College Of Nursing, Australia) 2001;8(1):14-18.
12. Roberts K, Mason J, Wood P. A comparison of a traditional and an accelerated basic nursing education program. Contemporary Nurse: A Journal for the Australian Nursing Profession 2001;11(2/3):283-87.
13. Wilson FL. Measuring morality of justice and care among associate, baccalaureate and second career female nursing students. Journal of Social Behavior & Personality 1999;14(4):597-606.
14. Toth JC, Dobratz MA, Boni MS. Attitude toward nursing of students earning a second degree and traditional baccalaureate students: are they different? Nursing Outlook 1998;46(6):273-78.
15. Pepa CA, Brown JM, Alverson EM. A comparison of critical thinking abilities between accelerated and traditional baccalaureate nursing students. Journal of Nursing Education 1997;36:46-48.
16. Youssef FA, Goodrich N. Accelerated versus traditional nursing students: a comparison of stress, critical thinking ability and performance. International Journal of Nursing Studies 1996;33(1):76-82.
17. McDonald WK. Comparison of performance of students in an accelerated baccalaureate nursing program for college graduates and a traditional nursing program. Journal of Nursing Education 1995;34(3):123-27.
Excluded
1. Bentley, R. W. (2004). Examination of success rates of traditional nursing students and accelerated nursing students in a four-year nursing program. Ed.D., Auburn University.
2. Feldman, H. and C. Jordet (1989). "On the fast track." Nurs Health Care 10(9): 491-493.
3. Gutierrez, K. J. (1991). Accelerated nursing education: study patterns, behaviors and learner characteristics. PH.D., UNIVERSITY OF DENVER.
4. Hoffman, J. J. (2006). The relationships between critical thinking, program outcomes, and NCLEX-RN performance in traditional and accelerated nursing students. Ph.D., University of Maryland, Baltimore.
5. McDonald, W. K. (1995). "Comparison of performance of students in an accelerated baccalaureate nursing program for college graduates and a traditional nursing program." Journal of Nursing Education 34(3): 123-127.
6. Seldomridge, L. A. and M. C. DiBartolo (2007). "The changing face of accelerated second bachelor's degree students." Nurse Educ 32(6): 240-245.
Summary of additional searches
Search history
369 abstracts
Exclude irrelevant
301 abstracts
Add from Google & hand searching
309 abstracts
Exclude non-research studies
161 abstracts
Exclude non-outcome studies
52 abstracts
Exclude on final PICO check
5 medical papers
+
11 Graduate nursing papers (3 midwifery)
+
17 Student nursing papers
Definition/s
Direct admission: “An admission system which builds on previous learning experience and provides a way for individuals from relevant undergraduate, postgraduate, or other educational programmes to transition into higher levels of health professional studies.” (WHO Glossary of Intervention
Terms, Document 14). Additional descriptions can be found at the end of this document.
Search terms
Accelerated programmes, direct entry, second degree, graduate entry and masters entry
AND
Health professionals
Databases
Academic search complete: CINAHL, PUBMED, PSYCHINFO, PSYCHARTICLES, MEDLINE, NURSING ACADEMIC, ERIC, SCOPUS, EBSCOHOST, PROQUEST
Hand searching of references found in articles and literature reviews using Google Scholar
Issues
Issues log PICO
Issue Action
A few literature reviews were identified but they were not systematic
Literature review list attached
1. General low level of evidence due to poor study quality: a. No randomized controlled trials b. No well-designed quasi-experimental studies, problems
include: i. randomization ii. statistical comparison of differences in 2 group
demographics iii. addressing confounding of age iv. cross-sectional studies with surveys v. response rates
c. All studies in evidence tables included a 2-group comparison: i. no random selected groups with survey (1 study –
poor response rate) ii. convenience sample selection with naturally
occurring groups of students attending the same university. (This is the nature of how these courses are being offered and how students enroll in these programs)
iii. some studies were retrospective quasi-experimental, some cross-sectional surveys with historical or parallel group comparison (Level IIIc – see below)
iv. studies were called lots of different names v. only 2 studies had pre- and post-tests (critical
thinking in student group).
Papers included if they had a Traditional Program and
an Accelerated Program and if an attempt was made
to compare the 2 groups
Most studies were Level IIc (or lower) – classified as
per evidence levels below
Low quality of evidence
2. Heterogeneity of participants: a. health professional type:
i. medical students ii. graduate nurses iii. student nurses iv. midwives
b. different pre-entry criteria: i. non-nursing degree ii. prior degree with science specification iii. prior degree with entry points iv. college credits v. RN (diploma or associate degree) vi. foreign medical doctors doing the accelerated
Included all and provided separate tables for:
Medical
Graduate Nurses
Student Nurses
And Midwives
Information on pre-entry recorded if available
Issue Action
course.
3. Heterogeneity of intervention: a. educational programmess:
i. ranged from 13–32 months ii. same as Traditional Program from second year iii. different programme iv. different time periods.
4. Heterogeneity of outcomes: a. some standard outcomes:
i. GPA ii. passing rates on NCLEX RN examination
b. self-reported outcomes using an array of standard tools.
All the outcomes recorded were of quality – outcomes
for quantity and relevance were not found
5. Missing PDFs: The reviewers were unable to access the original theses when they were not published as papers
Data included as available – will be updated – missing
articles marked in red
Literature reviews
1. AltmannTK. 2011. Registered nurses returning to school for a bachelors degree in nursing: Issues emerging from a meta-analysis of the research. Contemporary Nurse, 39: 256–272.
2. Burggraf V. 2012. Overview and Summary: The New Millennium: Evolving and Emerging Nursing Roles. Online Journal of Issues in Nursing, 17.
3. Cangelosi PR, Whitt KJ. 2005. ACCELERATED Nursing Programs. Nursing Education Perspectives, 26:113–116.
4. DiBartolo MC, Seldomridge LA. 2005. A review of intervention studies to promote NCLEX-RN success of baccalaureate students. Nurse Education, 30:166–171.
5. DiBartolo MC, Seldomridge LA. 2008. A review of intervention studies to promote NCLEX-RN success of baccalaureate students. Computers, Informatics, Nursing, 26:78S–83S.
6. Dike P. 2005. Student midwives: views of the direct-entry programme. RCM Midwives, 8:314–317.
7. Farnworth LS et al. 2010. Occupational therapy entry-level education in Australia: which path[s] to take. Australian Occupational Therapy Journal, 57:233–238.
8. Neill MA. 2011. Graduate-entry nursing students' experiences of an accelerated nursing degree--a literature review. Nurse Education in Practice, 11:81–85.
9. Ouellet LL, MacIntosh J. 2007. Rise of accelerated baccalaureate programs. Canadian Nurse, 103:28–31.
10. Penprase B, Koczara S. 2009. Understanding the experiences of accelerated second-degree nursing students and graduates: a review of literature. Journal of Continuing Education in Nursing, 40:74–78.
11. Vinal DF, Whitman N. 1994. The second time around: nursing as a second degree. Journal of Nursing Education, 33:37–40.
Evidence assessment
Table 1. Adapted levels of evidence and grades of recommendations1
LOE Level of evidence (effectiveness) Grades of recommendations
I Systematic reviews or big Randomized Controlled Trial (RCT) A
II Well-designed RCT or experimental designs B (including extrapolations of level I studies)
III a Well-designed quasi-experimental studies B
III b Comparative studies (allocation not random or time series)
LOE Level of evidence (effectiveness) Grades of recommendations
III c Comparative studies (historical control, parallel group)
IV Case studies or series with post test reports C (including extrapolations of level II studies)
V Surveys D (including troubling or inconsistent studies at any level)
Term Definition Source
Graduate entry programme
Usually used in reference to medical education where mature candidates with a relevant undergraduate degree (and sometimes postgraduate) gain access to the traditional medical training programme that is not necessarily accelerated. Some may require prospective candidates to sit a graduate entry test; some require science in first degree while others accept full range of non-science undergraduate degrees. These candidates generally enter into the second year of the traditional programme, the length of which varies. GEP identified as an innovative mechanism by (one or more?) medical schools in SSA for reducing the barriers to increasing quality and quantity of medical education.
Calvert, 2010; Chen et al, 20012; Price, 2010
Accelerated programmes
Accelerated nursing degree programme means a programme of education in professional nursing offered by an accredited school of nursing in which an individual holding a bachelor’s degree in another discipline receives a BSN or MSN degree in an accelerated time frame as determined by the accredited school of nursing.
http://definitions.uslegal.com/a/accelerated-nursing-degree-program/
An accelerated nursing programme is usually an accelerated bachelor’s in nursing programme. Some schools may refer to it as the BSN express. This programme is for those individuals that currently hold a bachelor’s degree in another discipline and would like to obtain a second bachelor’s degree in nursing.
http://www.nurses-neighborhood.com/accelerated-nursing-program.html
Accelerated baccalaureate programmes offer the quickest route to licensure as a registered nurse (RN) for adults who have already completed a bachelor's or graduate degree in a non-nursing discipline.
http://www.aacn.nche.edu/media-relations/fact-sheets/accelerated-programs
RN to MSN RN to MSN programme ideal for nurses who intend to work in the nursing field for a decade or longer. Experienced nurses who hold their Registered Nurse license (and RNs who also hold bachelor’s degrees in other fields) can apply their associate degree toward the MSN without having to first earn a BSN.
http://www.americansentinel.edu/health-care/rn-to-b-s-nursing
Direct entry Direct-entry midwife: A midwife who has entered the profession of midwifery as an apprentice to a practicing midwife rather than by attending a formal school programme.
http://www.medterms.com/script/main/art.asp?articlekey=40489
Direct entry accelerated BN or MN programme: This direct-entry accelerated programme is designed for individuals who have a college degree but no nursing experience.
Recommendation 7: Health professionals’ education and training institutions should consider using targeted admissions policies should be adopted to increase the
socio-economic, ethnic and geographical diversity of students.
RURAL DOCTORS AND RURAL BACKGROUNDS: HOW STRONG IS THE EVIDENCE? A SYSTEMATIC REVIEW
Gillian Laven1,*,
David Wilkinson2
Laven, G. and Wilkinson, D. (2003), RURAL DOCTORS AND RURAL BACKGROUNDS: HOW STRONG IS THE EVIDENCE? A SYSTEMATIC REVIEW. Australian Journal
of Rural Health, 11: 277–284.
Author Information
1
Department of General Practice, The University of Adelaide and
2
Division of Health Sciences, University of South Australia, Adelaide, South Australia, Australia
*Gillian Laven, Department of General Practice, The University of Adelaide, Adelaide, South Australia 5005. E-mail: gillian.laven@adelaide.edu.au
Publication History
Issue published online: 19 FEB 2004
Article first published online: 19 FEB 2004
Accepted for publication June 2003.
Keywords: association; observational studies; practice location; rural; urban
Objective: We sought to summarise the evidence for an association between rural background and rural practice by systematically reviewing the national and
international published reports.
Design: A systematic review.
Setting: A search of the national and international published reports from 1973 to October 2001.
Subject: The search criteria included observational studies of a case-control or cohort design making a clear and quantitative comparison between current rural and
urban doctors, this resulted in the identification of 141 studies for potential inclusion.
Results: We systematically reviewed 12 studies. Rural background was associated with rural practice in 10 of the 12 studies, in which it was reported, with most odds
ratios (OR) approximately 2–2.5. Rural schooling was associated with rural practice in all 5 studies that reported on it, with most OR approximately 2.0. Having a rural
partner was associated with rural practice in 3 of the 4 studies reporting on it, with OR approximately 3.0. Rural undergraduate training was associated with rural
practice in 4 of 5 studies, with most OR approximately 2.0. Rural postgraduate training was associated with rural practice in 1 of 2 studies, with rural doctors reporting
rural training about 2.5 times more often.
Conclusions: There is consistent evidence that the likelihood of working in rural practice is approximately twice greater among doctors with a rural background.
There is a smaller body of evidence in support of the other rural factors studied, and the strength of association is similar to that for rural background.
What is already known on this subject?: It is widely perceived that doctors with a rural background are more likely to return to work in rural areas and major policy
initiatives in Australia rely on this assumption. It is recognised that other factors such as location of primary and secondary education, rural medical training and
spouse or partner background may also be influential. In order to determine the strength of the evidence for an association between rural background and rural
practice we did a systematic review of the published reports.
What does this study add?: This systematic review provides good evidence that doctors with a rural background are about twice as likely to work as rural doctors,
compared with those with an urban background. Rural background seems to be an important factor that can be employed in policy and practice, however, the problem
of increasing the number of rural doctors is multifactorial and so is the solution.
INTRODUCTION
Australia is not unique in having an inequitable distribution of doctors, with urban excess and rural deficit. The United States of America,1–6 United Kingdom,7,8
Sweden,7,8 Nigeria,9 New Zealand,10 Canada,11 Korea,12 Japan13 and others have also reported similar maldistribution.14
This maldistribution has generated substantial research into factors that influence a doctor's decision to practice in rural areas. It is widely perceived that doctors
with a rural background are more likely to return to work in rural areas and major policy initiatives in Australia rely on this assumption.15–24 It is recognised that
other factors such as location of primary and secondary education,18,25 rural medical training26,27 and spouse or partner background may also be influential.18,25
In order to determine the strength of the evidence for an association between rural background and rural practice we did a systematic review of the published reports.
There is no agreed definition of ‘rural background’ and various definitions are used in the published works. While the focus of our review was on ‘growing up in a rural
area’, we also considered the influence of rural undergraduate medical training; rural postgraduate education; and spouse or partner's rural background.
METHOD
Study inclusion and characteristics
We included observational studies of a case-control or cohort design that sought to make an explicit and quantitative comparison between doctors currently working
in rural and urban areas, or that followed medical students or doctors over time to determine employment patterns.
As such we required studies to comprise urban and rural groups to allow an explicit comparison and we focused on general practitioners and primary care
physicians. For studies with a case-control design the cases were defined as doctors currently in rural practice and controls were in urban practice. Exposure was
defined as a rural background (variably reported as being born, growing up and/or schooling in the country). Where reported in the studies included we also examined
the association between current practice location and rural schooling, partner's background, and rural undergraduate and postgraduate training.
Search strategy
We searched the major electronic databases including MEDLINE, Web of Science, CINAHL, the Cochrane Library and online medical journals. Search terms used
were: general practitioner; family physician; rural; background; origin; practice location; physician manpower; physician supply; geographical distribution; physician
maldistribution; physician distribution; decision-making. We also searched the reference lists of all identified studies. Searches were restricted to the English
language due to financial constraints. The publication period covered was from 1973 to October 2001.
Data extraction and synthesis
All studies identified in the search were initially reviewed by title and abstract by both authors. Those identified as potentially suitable based on our inclusion criteria
were further assessed using the full text. Each reviewer then independently extracted data from the papers onto a data capture form. We then summarised included
studies in text and table format, before providing a narrative synthesis of findings.
RESULTS
Profile
From our initial search that yielded several hundred references, we identified 141 for potential inclusion. These were assessed in full text and 20 were found to
comprise quantitative comparisons of urban and rural groups. These were assessed in further detail and 8 were excluded, leaving 12 studies to be included in the
review. Excluded studies included Cooper et al.,15 Piterman and Silagy,21 and Shannon and Gunnel, who all studied future intent rather than actual practice.28 Jarratt
et al.,29 Leonardson et al.30 and Rhodes and Day reported correlations rather than associations, which we were unable to analyse further.31 The study reported by
Makkai20 comprised data reported by Western.18 The population studied by Elam et al. did not meet our inclusion criteria.32
Description of included studies
Table 1 describes the included studies. Becker et al. compared 216 doctors who graduated in the 1950s and 202 doctors who graduated in the 1960s in Wisconsin,
USA, and were practicing in 1973.33 Rural doctors were more likely to have been born in a rural area (1950s; 35 vs. 13.8%) (1960s; 31.4 vs. 16.6%) and to have
attended a rural high school (1950s; 2.2 times; 26 vs. 12%) (1960s; 3.5 times; percentage not provided).
Table 1. Studies included in systematic review
Author Year Country Subjects Major variables studied Main findings
Becker et al. 1979 USA
418
(rural
only)
Doctor background and schooling
Rural doctors born in rural areas were 2–3 times more likely to be in rural
practice. Rural doctors who attended rural high schools were 2.2–3.5 times
more likely to be in rural practice.
Carter RG 1987 Canada 423 (135
rural)
Doctor and partner background,
gender, doctor schooling and
undergraduate training
Rural doctors were more likely to have graduated from a rural high school
(OR1 5.42) and to have had rural undergraduate training (OR 2.03). Rural
doctors were more likely to have rural partners (OR 3.84).
Easterbrook
et al. 1999 Canada
159 (45
rural)
Doctor background; gender,
undergraduate and
postgraduatetraining
Doctors with a rural hometown were more likely to be in rural practice (OR
2.48). There was no association between rural undergraduate or postgraduate
training and rural practice.
Fryer et al. 1997 USA 986 (266
rural) Doctor background and gender
Rural doctors were more likely to have grown up in a rural community (40.7
vs. 25.6%; OR 2.7).
Potter JM 1995 Alaska 156 (83
rural)
Doctor background, gender
undergraduate and postgraduate
training
There was no association between rural background and rural practice. Rural
doctors were more likely to have had longer undergraduate or postgraduate
rural training (average of 100.9 vs. 72.5 months).
Rabinowitz
et al. 2001 USA
3365 (187
rural)
Doctor background, gender,
undergraduate and postgraduate
training
Rural doctors were more likely to have a rural background (RR2 3.5). Rural
doctors were more likely to have had rural undergraduate training (OR 2.3).
Rabinowitz
et al. 1999 USA
1609 (206
rural)
Doctor background, gender, location
of undergraduate college
Rural doctors were more likely to have a rural background (OR 3.9) and to
have attended a rural undergraduate college (OR 2.4).
Table 1. Studies included in systematic review
Author Year Country Subjects Major variables studied Main findings
Rolfe et al. 1995 Australia 149 (36
rural)
Doctor background, gender and
undergraduate training
Rural doctors were more likely to have a rural background (RR 2.49) and to
have chosen a rural general practice attachment in their final year of medical
school (RR 3.02).
Stewart et al. 1980 USA 287 (136
rural)
Doctor and partner background and
gender Doctors and partners background was not associated with rural practice.
Strasser RP 1992 Australia 883 (609
rural)
Doctor background, gender, and
postgraduate rural training
Rural doctors were more likely to have a rural background (30.1 vs. 11%).
Rural practice was associated with rural postgraduate training (33.8 vs.
13.8%).
Western
et al. 2000 Australia
232 (39
rural)
Doctor and partner background and
gender
Rural doctors were more likely to have lived in a rural area as a child (24 vs.
16%), to have attended a rural secondary school (31 vs. 16%) and were more
likely to have a partner with a rural background (28 vs. 15%).
Wilkinson
et al. 2000 Australia
504 (268
rural)
Doctor and partner background and
gender
Rural doctors were more likely to have a rural background (37 vs. 27%) and
rural primary (33 vs. 19%) and secondary (25 vs. 13%) education. In
multivariate analysis, rural primary education (OR 2.4) and having a partner
with a rural background (OR 3.1) were significant.
1 Odds Ratio; 2 Relative Risk.
Carter studied 423 doctors, of whom 135 were rural, who graduated from the University of Manitoba, Canada.34 The year in which the study took place was not clearly
stated. Rural doctors were more likely to be male (P < 0.005), to have graduated from a rural high school (OR 5.42) and to have had rural undergraduate training (OR
2.03). Rural doctors were also more likely to have a partner with a rural background (OR 3.84).
Easterbrook et al. in 1993 studied 159 doctors, of whom 45 were rural, who graduated from the Family Medicine Program in Ontario, Canada between 1977 and 1999.26
Doctors with rural hometowns were more likely to be in rural practice (OR 2.48). There was no association between gender, rural undergraduate or postgraduate
training and rural practice.
Fryer et al. studied 986 doctors, of whom 266 were rural, in Colorado, USA in 1995.24 Rural doctors were more likely to be male (P < 0.01), to have grown up in a rural
community (OR 1.68) and a rural state (OR 2.7).
Potter studied 156 doctors, of whom 83 were rural, listed by the 1992 Alaska State Medical Association.27 While they found no association between rural background
and rural practice, rural doctors were more likely to have had longer rural undergraduate or postgraduate training (average of 100.9 vs. 72.5 months). Although Potter
found rural GPs were more likely to be male, a greater percentage of the female responders were working in a rural location (53 vs. 60%).
Rabinowitz et al. studied 3365 doctors, of whom 187 were rural, who graduated from Jefferson Medical College, USA between 1978 and 1993.35 Rural doctors were
more likely to be male (P < 0.04; relative risk [RR] 1.5, 95% confidence interval [CI] 1.0–2.1), to have a rural background (OR 3.5) and to have had rural undergraduate
training (OR 2.3).
Rabinowitz et al. studied 1609 doctors, of whom 202 were rural, who graduated between 1972 and 1991 and were practicing in Pennsylvania, USA, in 1996.36 Rural
doctors were more likely have a rural background (OR 3.9) and to have attended a rural undergraduate college (OR 2.4). No significance was found between gender
and rural practice.
Rolfe et al. studied 149 graduates, of whom 30 were rural, of the University of Newcastle medical school, New South Wales, Australia in 1990.19 Doctors with a rural
background were more likely to be working in a rural location (RR 2.5, 95% CI 1.4–4.4). Those who had chosen an undergraduate rural GP attachment in the final year
were also more likely to be rural doctors (RR 3.0; 95% CI 1.3–7.3), but those who had chosen a rural rotation in year 3 were not (RR 0.7; 95% CI 0.4–1.2). No
significance was found between gender and rural practice.
Stewart et al. studied a sample of physicians in Arizona and New Mexico, USA in 1975.37 The original sample size is unclear, but 287 (136 rural) physicians and
partners were analysed. No association between background and location of practice was demonstrated for doctors or partners.
Strasser studied 883 (609 rural) GPs in Victoria, Australia in 1991.3 Rural GPs were more likely to have a rural background (defined as ≥ 10 years childhood in the
country). Rural GPs working in towns with a population of < 20 000 people were also more likely to report a rural term during postgraduate training (P < 0.05). Rural
GPs were more likely to be male (P < 0.05) in rural towns of < 20 000 but not in towns with a population of > 20 000.
Western studied 232 GPs, of whom 39 were rural, who graduated from Melbourne, Monash and Queensland Universities in 1967.18 Rural doctors were more likely to
have lived in a rural area as a child (24 vs. 16%), to attend a rural secondary school (31 vs. 16%) and were more likely to have a partner with a rural background (28 vs.
15%).
Wilkinson et al. compared doctor and partner background among 236 urban and 268 rural general practitioners in South Australia in 1998 and 1999.25 Rural doctors
were more likely to be male (81 vs. 67%), to have a rural background including having grown up in the country (37 vs. 27%), having primary (33 vs. 19%) and
secondary (25 vs. 13%) education in the country and were more likely to have a partner with a rural background (49 vs. 24%). In multivariate analysis significant
variables included rural primary education (OR 2.43) and having a partner with a rural background (OR 3.14.
SYNTHESIS OF DATA
Rural background
Rural background was associated with rural practice in 10 of 12 studies. The strength of association ranged from an odds ratio of 1.68–3.9, but in most cases was
around 2–2.5.
Rural schooling
Rural schooling was associated with rural practice in all 5 studies in which it was reported. The association was not studied in the remaining seven. The strength of
association ranged from an odds ratio of 2.2–5.42, but in most cases was around 2.5.
Rural partner
Having a partner with a rural background was associated with rural practice in 3 of the 4 studies in which this association was studied. The strength of the association
was an odds ratio of approximately 3.
Rural undergraduate training
Rural undergraduate training was associated with rural practice in 4 of the 5 studies that reported on this. The typical odds ratio was approximately 2.0, but in one
study the relative risk was 3.0 for final rural year placements and 0.7 for year 3 rural placements.19
Rural postgraduate training
This factor was reported in only 2 studies and in 1 of these, doctors in rural practice reported rural postgraduate training about 2.5 times more often (approximately 14
vs 34%).
Gender
Nine out of the 12 studies looked at the association between gender and rural practice. Gender was not found to be significant in three of the nine studies. Five
studies found that rural GPs were more likely to be male. It is interesting to note that Strasser found rural GPs to be more likely to be male only in populations of
< 20 000.3 Potter, however, found that a greater percentage of female responders were working in a rural location (60 vs 53%).27
DISCUSSION
This systematic review of the published reports provides good evidence that doctors with a rural background are about twice as likely to work as rural doctors,
compared with those with an urban background. This association was observed in most, but not all studies, and was observed in studies from several different
settings, and over several decades.
Our review also provides evidence that rural schooling is associated with rural practice. However, there will inevitably be close correlation between rural residence
and rural schooling, and so, rather than supporting the evidence for rural background, the evidence for rural schooling should be seen more as replication. Our review
does, however, also provide support that rural undergraduate and rural postgraduate training, or having a partner with a rural background is associated with rural
practice, and the strength of association is similar to that for rural background itself. However, these factors were not included in our search strategy and therefore
conclusions cannot be drawn from this review.
Rural GPs have traditionally been more likely to be male but this may have reflected the proportions of male to females in medicine. This review shows that gender
has not always been found to be associated with the decision to work in a rural location.
There are some important limitations to this research that should be considered. First, the definition of rural background itself is problematic. In most studies it was
not clearly defined, but seems to include being born in a rural area, and/or having grown up in a rural area (for a variable period of time). This is hardly a desirable
situation for research, but at least there is a clear distinction between never and ever having lived in a rural area. It is also important to recognise that auto-correlation
occurs between rural background and rural schooling. Rural undergraduate and postgraduate training are essentially voluntary (or were at the times of the studies
included in our review) but may be correlated with rural background. Many of the rural doctors in these studies seem likely to have been ‘predisposed’ to being rural
doctors and elected to do rural under- and postgraduate training because they have a rural background.
This is of particular importance when reviewing studies such as Rabinowtiz et al., where a special admissions and educational program has been employed with the
intention of increasing the number of rural physicians.35,36 This predisposition or self selection of students to enter medical training programs with identified rural
aspects must be considered as intention to practice in a rural area. Also, some of the studies we examined did not include the amount of detail that would be expected
for modern peer reviewed publications, making assessment of their quality difficult at times. Finally, it is important to note that not all studies showed an association
between rural practice and rural background. It is possible that some studies with a negative association have never been published and so our findings may suffer
from publication bias; the evidence may in fact be weaker than our review suggests.
There are, however, important policy implications to our research. In Australia, the Commonwealth government has encouraged medical schools to increase the
enrolment of students with a rural background and many have done this.38 Our findings support this approach and it will be important to evaluate the impact of this
policy over time. The Commonwealth has also funded rural placements for all medical students, provided scholarships for rural students and established a network of
university departments of rural health and rural clinical schools, to train large numbers of medical students for long periods of time in the country. Our findings
support this policy.39
There remains, however, a need for more large scale and high quality studies that explore in quantitative and qualitative ways the factors that are associated with rural
practice. In particular we need to understand the apparently important role of partners and their background. We also need to know more about the influence of rural
background. For example, is it early childhood experience that counts, or is it later experience? What is it about rural background that really influences future career
choices? We also need to know whether rural background and rural under- and postgraduate experience are additive in influence, or whether they are multiplicative.
Rural background seems to be an important factor that we can employ in policy and practice that should lead to an increased number of rural doctors. However,
increasing the likelihood of this outcome approximately two-fold, while important, will not by itself end the shortage of rural doctors. The problem is multifactorial and
so is the solution..
This review was undertaken as part of the Rural Background Study funded through the Rural Health Support, Education and Training (RHSET) Program of the
Commonwealth Department of Health & Ageing
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Department of Health and Aged Care. The Australian Medical Workforce. Occasional Papers. New Series No 12. Canberra: Commonwealth Department of Health and
Aged Care; 2001.
“Full Text provided by your WHO Libraries”
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Humphreys JS, Lyle D, Wakerman J et al. Roles and activities of the Commonwealth Government University Departments of Rural Health. Australian Journal of Rural
Health 2000; 8: 120–133.
Recommendation 8: Health professionals’ education and training institutions should consider using streamlined educational pathways, or ladder programmes, for the
advancement of practising health professional
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PubMed
USA Tennessee is experiencing acute nursing shortages in the area hospital and medical centres Northeast Tennessee also has an unstable economic environment
Descriptive study design A report on a year-old project that assists LPNs to obtain a baccalaureate degree in nursing (BSN). To determine the level of interest of LPNs for an LPN to BSN programme prior to the start of the project, 1833 LPNs were surveyed in December 2000 (21% return rate).
– Licensed practical nurses (LPNs)
LPN to BSN Career Mobility Project Educational mobility for licensed practical nurses (LPNs) to obtain baccalaureate degree in nursing
The specific concerns of the LPNs about returning to school were noted and included as retention strategies in the project.
The LPN to BSN Career Mobility Project also partners with several health-care agencies and with an LPN programme at a local community vocational centre.
Due to the complexity of the project and agency policies, there is an advocate assigned in each agency who holds an administrative position.
The 6-year curricular plan allows an LPN to "earn and learn".
LPN students were fully supported by the available resources in the university
4 unique features of the project: (1) role transition seminars for each cohort entering during the same semester (2) cohorts per year); (3) a project faculty mentor for each LPN student throughout the curriculum; (4) a BSN clinical nurse mentor for clinical courses; (5) advanced practice nurse mentors (nurse practitioners or NPs) in nurse managed clinics for clinical experiences.
Invitations were sent to those who indicated an interest in the project.
– Quantity:
93% retention rate at the end of the first year
A total of 30 students were admitted in the first year of the project (23 in the fall semester and 7 in the spring)
Admission rate for the 2nd and 3rd year of the project was estimated to be at least 25 and 30, respectively Quality:
85% of the respondents wanted to pursue a BSN degree and 75% wanted to begin within the next 6 to 12 months from the survey Others:
The average number of semester credit hours was 8 (2–3 courses) with an average grade point average of 2.99
Resources needed:
The funds for this project come from the Division of Nursing (DN), Bureau of Health Professions (BHPr), HRSA, DHHS under the grant number 1-D11-HP-00224 for US$ 852 967.
Several health-care agencies and an LPN program at a local community vocational centre as partners.
An advocate assigned in each agency to perform administrative functions
Expertise of directors of the Center for Adult Programs and Services (CAPS) in support of project participants, which offers a variety of support programmes for project participants of all age groups.
Key staff, identified by the admission, bursar and financial aid offices, to work with the LPN students.
A support service like the Nursing Undergraduate Resource for Successful Education (NURSE) center offering peer mentoring and tutoring for those in the nursing major.
Project faculty mentor, BSN clinical nurse mentor and advanced practice nurse mentors
Tutors for students.
Pre-nursing assessment test and interactive interviews to identify students at risk
Advertisements of the programme such as in newspapers. Social acceptability:
Project LPN students expressed their satisfaction and benefits gained from the project.
Ramsey P et al. 2004. Community partnerships for an LPN to BSN career mobility project. Nurse Educator, 29:31–35. PubMed PMID: 14726797
PubMed
USA Inova Health System is an integrated, not-for-profit delivery system with 5 hospitals, home health agency, urgent care centres, and 2 long-
Evaluative study Pre-implementation survey (June 2000): 478 nurses; 19% response rate Post-implementation survey (June 2002): 310 nurses; 10% response
Low response rate in the second survey Pre-survey and post-survey respondents were not the same nurses
Nurses Inova Health System's clinical ladder programme also known as ADVANCE (Achievements Demonstrating Versatile Accomplishments of Nursing Clinical Excellence)
Designed by a team consisting of members from across the system
Absence of a clinical ladder program
Quantity:
5.2% turnover rate for the 268 clinical ladder promoted RNs with only 14 resigning compared to a general Inova wide turnover rate of 14.1%.
From the analysis of terminations in 0–3 year timeframe: o 66% had tenure of 3 years or less o 55% left within the first year of employment. o of those leaving within the first year of
Resources needed:
Nursing clinical ladder design team meeting biweekly for 1 year.
Nursing Clinical Ladder/ADVANCE Steering Committee that continually evaluates and improves the programme.
Benefits:
Streamlining of the clinical advancement process which is uniform and includes all operating units and all RN direct care providers.
Drenkard K, Swartwout E. 2005. Effectiveness of a clinical ladder program. Journal of Nursing Administration, 35:502–506. PubMed PMID: 16282828 Definition:
Database Country/ setting
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term-care facilities located in northern Virginia
rate Review of records for the analysis of terminations
and from various nursing specialty areas, which promoted system integration in nursing.
Based on Critical Care Synergy Model and Benner's model from Novice to Expert.
Provides professional autonomy over practice to bedside RNs.
4-step ladder.
4 domains that are skill and competency based: o clinical practice/case
management o quality o teamwork o professional development.
Each level of the ladder entails a 6% salary increase.
Promotion review is a peer-reviewed process.
3 main components of application: 360 degree performance evaluations, career portfolio, clinical narrative.
Promotion criteria: improved patient care outcomes and professionalism.
A steering committee is in place to continually evaluate and improve the programme.
Applicants must be employed in budgeted positions.
Criteria-based and competency-based programme.
employment, 58% were RN2s (experienced nurses at the time of hire). o 7% of terminations were RN1 or new graduates. Other:
The clinical advancement programme has a strong positive influence on nurse satisfaction with the ladder (application procedures, maintenance requirements, professional aspects).
Increase in satisfaction from 47% to 68%.
The improved satisfaction of nurses can lead to retention of nursing staff
268 nurses received clinical promotions for the first 2 years (210 RN3 promotions and 58 RN4 promotions); 27 of those were later promoted to advanced practice roles in management, education, and clinical specialty.
56.3% of the nurses promoted in the ladder for the first 2 years were from specialty areas of Emergency Department, Operating Room, Labor and Delivery, Post-Anesthesia Care Unit and adult critical care.
The 6% salary increase associated with advancement in the ladder is justifiable when compared to the costs associated with the recruitment and replacement of nurses.
Standardization of clinical excellence-based job description and performance appraisal system for RNs.
Improved level of clinical skill and competency of staff nurses.
Significant function for succession planning for nursing leadership positions.
Improved retention of RNs.
Cost-effective retention measure.
Career advancement programmes – introduced in the 1970s as a means to recognize, reward, recruit, and retain bedside nurses
PubMed
Norway; Norway has a history of nursing shortage in the 1990s.
Cross-sectional survey design This study was part of a larger study entitled “Job satisfaction and competence in nursing service” (Bjørk, 2004). There were 541 clinical nurses who participated in the study. All of them were participants in the clinical ladder programmes of four hospitals in Norway. An expert research team has refined the questionnaire. The questionnaires were optically scanned and data were entered into the Statistical Package for the Social Sciences version 12. Descriptive statistics and ANOVA were used to analyse data.
The study participants were from hospitals selected on the basis of those offering clinical ladder programmes since the late 1990s. Hospitals without a relatively long history of systematic professional development programmes may have provided different results.
Clinical nurses Clinical ladder programme
Since the 1990s, the design of clinical ladders in Norwegian hospitals shifted from recognition systems to systems for developing competence
5-year programme of continuing development in clinical nursing.
Awarded the title of clinical specialist to nurses fulfilling the specified criteria.
Voluntary.
Regulated by nursing leaders.
Criteria of the clinical ladder programme were: o 5 years of clinical practice within
one specific field of nursing o 150 hours of coursework: 50%
related to the specific field of nursing and the rest related to general aspects of nursing such as ethics, nursing theory, documentation, communication, quality assurance and health policy
o 120 hours of supervision equally divided with individual, group, and
– Quality:
It was reported that the intent to stay at the hospital for more than a year increased, as nurses moved up the ladder.
The valuation of organizational aspects increased as one moves up the ladder
There is an increase in the use of acquired competence (i.e. clinical work with patients and supervision of colleagues) as the nurses move up the ladder. Nurses in level 3 used their acquired competence much more in quality assurance work Other: Intrinsic motivational factors:
updating of nursing knowledge and skills
personal development
possibility of salary increase
development of the quality of nursing
development of clinical skill with own patient group were found to be of high importance when it comes to the reasons for joining the clinical ladder. External motivational factors such as those involving the influence of other people were ranked at the lowest level of importance.
Benefits from participating in the clinical ladder increased as nurses moved upward on the ladder system, with the largest increase between nurses in levels 2 and 3.
Lack of managerial involvement in nurses' professional development .
Benefits: Personal and professional benefit and the use of new competence were some of the perceived benefits from a clinical ladder programme.
Bjørk IT et al. 2007. Evaluation of clinical ladder participation in Norway. Journal of Nursing Scholarship, 39:88–94. PubMed PMID: 17393972 Definition: Career advancement programmes – clinical ladders which have shown to enhance professional development, improve staff relations, reward competency, and heighten nurses’ motivation in their work Clinical ladders – can be ladders that are primarily defined as systems for recognition and reward of skill in nursing practice or ladders that are defined as systems for development of new expertise
Database Country/ setting
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peer supervision; o 4000 pages of literature
(obligatory and self-elected in relation to patient group and theme of developmental work)
o a developmental work grounded in the field of nursing, decided in collaboration with the unit manager, and documented in a paper.
Nurses move to the next level upon completion of learning tasks specified at each level.
Nurses receive a financial incentive.
Leaders were reported as not giving as much encouragement and engagement to nurses in clinical ladders.
PubMed
Taiwan Cross-sectional study design A total of 1500 nurses were given the questionnaires to be filled out. However, only 431 were considered valid after eliminating indiscriminate and incomplete questionnaires. Literature review and in-depth interviews were conducted to develop a scale in measuring career needs at different stages and identify the suitable career development programmes. Regression analyses were also performed to explore the relationships between career needs and career development programmes gap, turnover intention and organizational commitment. Two-way repeated measures analysis of variance was utilized to determine if nurses have different career needs at different career stages.
Common method bias concerning the relationship between organizational commitment and turnover intention. Career stage measures concerning work experience were classified based only on the relevant studies and results from interviews with nurses.
Nurses Explores whether nurses have different career needs (career goal needs, career task needs and career challenge needs) in each career stage (exploration, establishment, maintenance and disengagement). Examines the gap between career needs and career development programmes and if the gap influences turnover intention and organizational commitment of nurses.
– Quality:
The gap between career needs and career development programmes influenced turnover intention caused by the decline in nurses’ commitment towards the hospital.
From the hierarchical analysis, the gap between career needs and career development programmes significantly increased turnover intention (β = 0.183, P <0.01).
The gap between career needs and development programmes was found to have significant contributions to organizational commitment (β = -0.209, P < 0.01). Others:
Nurses have different career needs at different career stages (F = 6.10, P < 0.001).
There is a significant difference (F = 3.51, P = 0.015) in career goal needs occurring at the establishment and maintenance career stages.
There are greater career goal needs among nurses in the maintenance stage compared to those in the establishment stage.
No significant differences (F = 2.52, P = 0.057) found between career task needs at each different stage. >When it comes to the career challenge needs, there was a significant difference (F = 5.07, P = 0.002) found between nurses in the establishment stage compared to those in the exploration or disengagement stage
Those in the establishment stage have less career challenge needs than those in the exploration or disengagement stages.
Organizational commitment was considered as the mediator and it was found to have significant negative contributions (β = -0.453, P < 0.01) to the outcome (turnover intention). When this mediator was controlled, the coefficients for the gap between career needs and career development programmes significantly decreased from β = 0.183, P < 0.01 to β = 0.093, P < 0.05. This shows that organizational commitment reconciles the gap between career needs and career development programmes, and turnover intention.
– Chang PL, Chou YC, Cheng FC. 2007. Career needs, career development programmes, organizational commitment and turnover intention of nurses in Taiwan. Journal of Nursing Management, 15:801–810. Epub 2007/10/20. PubMed PMID: 17944605.
PubMed
USA Miami Valley Hospital (MVH)
Evaluative study Annual surveys developed internally were conducted to evaluate participants’ and clinical nursing leaderships' perspectives. The evaluation team also utilized the findings from the longitudinal study conducted by the Administrative Research Interest Group for organizational evaluation.
Nurses Clinical ladder for nurses or PACE for Quality (Pathway for Advancement in Clinical Excellence)
Adapted Patricia Benner's Model ‘novice to exper’ as its foundation.
Exemplar questions were designed to reflect organizational strategies for quality patient care.
Core values of the programme: education, experience, citizenship, clinical practice, nurse/patient relations and collaboration.
The core values/6 domains identified
Absence of a clinical ladder for nurses
PARTICIPANT EVALUATION Quantity:
Overall participation rate increased from 5% in the old ladder to 17% in the new ladder.
In 1998, there were 171 participants: 13 in level 2; 91 in level 3; and 67 in level 4.
Increased participation from more clinical areas such as surgical services and ambulatory services. Quality: Within 3 years participants have expressed the value of the following: o hospital-based educational activities o 3 recognition programs were conducted o local and national workshops.
Resources needed:
Budget for programme revitalization and implementation of a communication plan.
A 25-member group to evaluate and redesign the old clinical ladder.
Information, support, resources and opportunities from the administration.
Task forces to perform different duties to be able to implement the programme: o theoretical framework o criteria o scoring tools o review o recognition o compensation
Gustin TJ et al. 1998. A clinical advancement program: creating an environment for professional growth. Journal of Nursing Administration, 28:33–39. PubMed PMID: 9787678 Definition: Clinical ladders - help maintain expert, motivated, and effective nurses in direct patient care roles – once a part of a professional practice model, it becomes a
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In 1998, there were 171 programme participants: 13 in level 2; 91 in level 3; and 67 in level 4.
were the basis for criteria development.
Voluntary and separate from the annual performance appraisal by managers.
The programme has annual recognition programme, education days, local and national workshops and a quarterly newsletter for participants.
There will be bonus dollars for levels 2, 3 and 4.
Nurses in a support role (per diem) are allowed to participate together with full-time and part-time nurses.
4 levels.
5 overall objectives for RNs providing direct patient care: o environment that promotes high-
quality patient care o recognition and reward
associated with the level of practice
o incentives for RNs to increase and widen their current experience levels
o attract and retain highly-skilled RNs
o vision for nursing.
Participation eligibility criteria: o provide direct patient care as
primary responsibility o RN for at least 2 years o 6 months continuous service as
RN at MVH o employed at MVH for >600
hrs/yr o received "achieve" or "exceed"
standards on last performance review
o support from nurse manager o no written corrective action
recorded in permanent personnel file in the last 12 months.
Nurses in clinical leadership are not eligible to participate but act as mentors for participants and they are surveyed annually as well.
Evaluation team that conducts annual surveys.
Participant responses give direction to the improvement of the programme.
Other:
From the survey of RNs in MVH, more than 50% believed that the current ladder programme needs to be updated.
Opportunity for professional growth was the top motivating factor for nurses. LEADERSHIP EVALUATION Quality: Those in clinical leadership or the mentors have a favourable attitude to the programme's impact on professional growth and to the way it is communicated. Other: PACE for Quality was found to possess an opportunity to increase participants' involvement in achieving unit goals. ORGANIZATIONAL EVALUATION Quality:
Participants considered the programme as more effective than did non-participants.
Participants were statistically more positive than non-participants regarding the excitement and interest in their work. Other:
Participants found more opportunities and resources available for their job.
Participants were more empowered by relationships within the organization
Participants were more satisfied with organizational policies.
Participants perceived greater professional autonomy in their practice.
o transition.
Work groups: o conference o communication o programme evaluation o consult/publish.
Standardized scoring tools and scoring method.
Literature review, research of other programmes and a consultation with Benner's partner on "novice to expert" concepts.
Evaluation team that conducts annual surveys.
Findings from the longitudinal study, “Organizational Dimensions in Hospital Nursing Practice”, conducted by the Administrative Research Interest Group for organizational evaluation.
Mentors for programme participants comprising nurses in clinical leadership (those in positions of management, education, case management and advanced practice).
Ardent empowerment = passion + knowledge + accountability + authority.
Social acceptability: The mentors of the participants believed that the programme was well communicated and that it provides an opportunity for professional growth.
structure for recognition and development of clinical experts.
PubMed
USA 257-bed acute care facility (St. Elizabeth) located in a Midwest
Descriptive longitudinal study design This article describes the experiences with a 20-year long
Did not compare outcomes and benefits of career ladder programmes with those other
Nurses Clinical ladder programme for nurses in a 257-bed facility
Patricia Benner’s Novice to Expert Model as a reference for the
No clinical ladder programme
Quantity:
54 to 70 nurses advanced in the ladder in each of the last 3 fiscal years.
Number of nurses in each RN track ladder and in the LPN2 level continued to increase over time.
Resources needed:
A team of staff nurses from a wide range of practice settings was commissioned to develop the programme .
Extensive literature review was conducted to be able to determine nurses’ recognition preferences.
Pierson MA, Liggett C, Moore KS. 2010. Twenty years of experience with a clinical ladder: a tool for professional growth, evidence-based practice, recruitment, and
Database Country/ setting
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metropolitan area clinical ladder programme in a 257-bed acute care facility located in a Midwest metropolitan area
nursing service without clinical ladder programme
conceptual framework of the clinical ladder programme.
Initially, there were 4 levels in the ladder. Over time, the programme shifted to a differentiated practice model, adding the licensed practical nurse (LPN) track. The RN track was also transformed into 5 levels.
The committee planned different advancement criteria on this programme. In order to advance in the clinical ladder, nurses would need to meet the minimum score for the level to which they desired to advance in each of the six major categories: education, experience, professional and leader, provider, teacher, and advocate.
An annual performance appraisal is done to validate the maintenance of one's clinical ladder status .
There is a quality/practice council in charge of maintaining a list of projects for those nurses who wish to advance in the ladder.
Clinical ladder advancement involves salary increases.
Annual policy review was also included in the programme.
Also, exemplars, which are rich stores of the relationships in which care is provided, are employed in the programme to validate the provider, teacher, and advocate roles of nurses
1998: 382 RNs and 42 LPNs who participated in the clinical ladder programme .
2008: 611 RNs and 23 LPNs participated in the clinical ladder programme. Quality:
It allowed nurses to reach out of their comfort zones.
The clinical ladder programme increased professional self-awareness in nurses. Relevance:
The clinical ladder programme for nurses became an integral to the facility’s recruitment and retention, professional development, and evidence-based practice initiatives.
Was also proven a useful tool in succession planning since there was a continuous movement of nurses in and out of the facility.
The programme promotes and supports professional development and has enabled the facility to recognize talents in nurses that were previously unidentified.
It makes ‘selling’ work at the institution easier to prospective employees.
Also assisted the hospital in being designated as a Magnet hospital in 2004 and in its re-designation in 2008.
The team also needed to benchmark with known successful programmes in the same geographical area.
An annual budget plan to include salary increases from advancements in the ladder.
Social acceptability:
There is a continued interest in clinical ladder advancement among nurses
retention. Journal of continuing education in nursing, 41:33–40. Epub 2010/01/28. doi: 10.3928/00220124 20091222-06. PubMed PMID: 20102141. Definition: Clinical ladder programme – has a potential to serve the following functions:
enhance recruitment and retention of competent experienced staff
foster professional development
establish an effective reward system for improved clinical performance
strengthen the quality of nursing practice
recognize staff nurses for excellence in patient care
identify excellent nurses as role models.
PubMed
USA Kaiser Permanente of Colorado (KPCO) is a large health maintenance organization with 595 RNs working in ambulatory care offices and regional support roles for ambulatory care
Descriptive study design
There were 68 nurses as participants in the study (45 career-ladder participants and 23 non-participants).
Participation in the study was voluntary and surveys were anonymously conducted through SurveyMonkey. The survey was sent to all current career ladder RNs at KPCO, and an equal number of non-career ladder RNs.
The non-career ladder sample was randomly selected from a list of RNs who were employed by KPCO for at least 1 year and to eliminate the confounding by job role, non-career ladder nurses were matched to career ladder nurses.
The average length of service was collected from the
A self-report format was used in measuring career ladder outcomes.
The survey used in this study was a new instrument and was not previously tested for reliability and validity.
Factor analysis should have been done with a larger sample size .
Some of the subscales interpreted in the factor analysis have fewer items.
Another limitation
Nurses RN Career Ladder
The RN Career Ladder at KPCO was started by a Labor Management Partnership Committee in 2003.
It gives financial incentives (5–7.5% salary differential) to RNs who show commitment to continuing education, leadership activities and program development on a local and regional level.
The career ladder was designed to enhance and reward role expansion, rather than performance.
Participation in interdisciplinary committees, task forces, and guidelines development teams are rewarded in the programme.
A nurse can participate in the career ladder if he/she has served for at least 1 year at KPCO and at least half-time work status.
Criteria for career ladder advancement:
Absence of an RN Career Ladder
Quality: Career ladder RNs were more involved in:
leadership (F (1, 57)=13.9, p<0.001)
quality improvement (F (1, 57)=5.90, p=0.02)
preceptorship (F (1, 57)=13.4, p=0.001). Activities than non-career ladder RNs in the same job role. Other:
No difference in job satisfaction (F (1, 57)=2.02, p=0.16) between career ladder RNs and non-career ladder RNs in the same job role.
Career ladder participation was correlated with: o knowledge of the career ladder (F (1, 57) = 67.0, p<0.001) o belief in the career ladder philosophy and perceived benefits of participation (F (1, 57)=49.1, p<0.001).
Career ladder participation was not correlated with nurse manager support.
– Nelson JM, Cook PF. 2008. Evaluation of a Career Ladder Program in an ambulatory care environment. Nursing Economics, 26:353–260. PubMed PMID: 19330969. Definition: Clinical ladders or career advancement systems - designed to enhance professional development, provide a reward system for quality clinical performance, promote quality nursing practice, and improve job satisfaction among nurses.
Database Country/ setting
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Population Intervention Comparison Reported results (outcomes) Additional comments Reference/definitions
participants and those having less than a year of service were eliminated from the sample.
Demographic data were also gathered and 2-way ANOVA was performed to analyse the results.
53% response rate.
was the way of survey distribution to nurses. The survey link was sent to them through a staff messaging function in the electronic medical record and this required them to cut-and-paste the link to a Web browser to access the survey form. Due to lack or absence of computer training, some respondents may have opted to not participate in the study. Also, age and computer literacy may be inversely correlated so participants may have been younger than non-participants. Also, computer experience may be associated with leadership and other interdisciplinary activities making the study participants possibly having higher levels of participation in these areas. Non-career ladder nurses were also deemed to be underrepresented in this study.
o educational level o participation in continuing
professional education o experience as an RN o professional nursing
certifications and memberships o engagement in leadership,
communication and research activities, and health care-related volunteer work.
The programme also requires nurses to articulate an organizational goal related to improving health care quality or cost, with measurable outcomes.
Applicants must reapply to the programme annually and applications are reviewed quarterly.
PubMed
USA Kaiser Permanente of Colorado (KPCO) is a large health maintenance organization with 595 RNs working in ambulatory care offices and regional support roles for ambulatory care
Descriptive study design Development and implementation of the career ladder in ambulatory care nursing was described. Barriers and key success factors were also discussed No sample size was mentioned.
– Nurses RN Career Ladder
The RN Career Ladder at KPCO was started by a Labor Management Partnership Committee in 2003.
It gives financial incentives (5–7.5% salary differential) to RNs who show commitment to continuing education, leadership activities and programme development on a local and regional level .
The career ladder was designed to enhance and reward role expansion, rather than performance.
Participation in interdisciplinary committees, task forces, and guidelines development teams are rewarded in the programme.
Absence of an RN Career Ladder
Relevance: In addition to acquiring points, specific, measurable, realistic, time-phased, and collaborative annual goals are required for career ladder RNs. As a result of the programme, there have been several successful goal-related projects completed such as the development of a post-surgical teaching tool and the mechanism of identification and reaching out to patients who had not received an HbA1C test in over a year. Other: The data from Nelson and Cook (2008) indicate that participation of nurses in the career ladder program enabled nurses to be involved in activities that were beneficial to their professional growth and to the priorities of KPCO. (Evaluation of a career ladder program in an ambulatory care environment. Nurs Econ. 2008 Nov-Dec;26(6):353-60)
Resources needed:
In partnership with United Food and Commercial Workers Local 7, a labour management partnership (LMP) committee created the RN career ladder programme to be able to define the roles and responsibilities of the RN in KPCO.
An interest-based problem solving committee was formed, which consisted of 5 management and 5 labor employees, to come up with multiple alternative solutions and eventually develop a shared resolution.
Consensus decision-making was also employed.
A volunteer career ladder committee was also formed, having representatives from both labor and management, to review applications to the career ladder .
A point tool was developed to be able to assess the eligibility of an applicant to advance in the career ladder.
Challenges encountered:
Communication about individual RN projects in order to manage collaboration with each other.
Nelson J, Sassaman B, Phillips A. Career ladder program for registered nurses in ambulatory care. Nursing Economics. 2008 26:393–398. PubMed PMID: 19330975
Database Country/ setting
Study design/sample size
Methodological quality issues
Population Intervention Comparison Reported results (outcomes) Additional comments Reference/definitions
A nurse can participate in the career ladder if he/she has served for at least 1 year at KPCO and at least half-time work status.
Criteria for career ladder advancement: o educational level o participation in continuing
professional education o experience as an RN o professional nursing
certifications and memberships o engagement in leadership,
communication and research activities, and health care-related volunteer work.
The programme also requires nurses to articulate an organizational goal related to improving health care quality or cost, with measurable outcomes.
Applicants must reapply to the programme annually and applications are reviewed quarterly.
Burdensome and time-consuming application review process.
Initial lack of administrative support.
There were times when nurses found it difficult to gather support for their projects.
PubMed
USA Akron Children's Hospital (ACH)
Descriptive study design/programme evaluation study
Sample population: 174 RNs in the Career Achievement and Recognition of Excellence (C.A.R.E.) Ladder programme.
Only 136 were able to complete the survey.
The University Hospital’s Focus on Nursing Excellence in Clinical Care, Education and Leadership (UEXCEL) evaluation questionnaire survey was utilized.
Voluntary participation in the online survey.
1-month data collection through the hospital’s intranet.
Participants were offered an incentive in the form of a gift certificate for the hospital’s coffee shop.
Anonymity was maintained and data were stored in a password-protected database.
Results were presented in aggregate form. Due to a small sample size in Levels 2 (n=6) and 5 (n=7), these were removed from some analysis or combined with Levels 3 or 4, respectively. Those with a doctor of philosophy degree
– Nurses Career Achievement and Recognition of Excellence (C.A.R.E.) Ladder programme
Based on Benner's theory and was articulated by a group of staff registered nurses, nurse educators, and nurse managers
5 levels of the ladder are: novice, advanced beginner, competent, proficient and expert
Education, leadership and research are integral in each level
Focuses on different nursing roles and has three tracks: clinical, education, and management
In each track and in each level within the track, there are specified capability statements, which will assess the eligibility of a nurse to advance based on his/her practice
Allows recognition and reward for any registered nurse
In each track, there is a focused set of criteria to show the advancement from the novice to the expert level
Advancement is voluntary and a nurse must apply to advance or maintain C.A.R.E. Ladder status
Validation of the nurse's level of expertise involves the creation of a portfolio of his/her professional activities
Professional growth and financial rewards such as paid education
– Other:
Mean overall satisfaction score for all respondents: 83.5 out of 100
Respondents agreed that advancement in C.A.R.E. Ladder provides a sense of accomplishment and professional satisfaction about their nursing career (M = 4.16 out of 5). Those in the education track reported the highest score on this item (M = 4.38)
Respondents agreed that participation in the career ladder is an effective way for nursing expertise to be recognized (education track (M = 4.10); clinical track (M = 3.94); management track (M = 3.80))
No significant difference in overall satisfaction scores related to nursing education degree and to the level on the C.A.R.E. Ladder was found
The mean satisfaction scores of those who advanced did not differ significantly by track (clinical = 83.23; education = 81.55; management = 79.00)
Among those who did not advance, a significant difference was observed (p = 0.03). Those in the education track who have not advanced reported to have the highest overall satisfaction score (90.70) while those in the management track had the lowest (77.10)
Results suggest that nurses participating in the C.A.R.E. Ladder view the program positively regardless of nursing education preparation, level of advancement, or selected track
Resources needed:
University Hospital’s Focus on Nursing Excellence in Clinical Care, Education and Leadership (UEXCEL) evaluation questionnaire survey
Professional development tool that assigns points for activities in education, leadership and research
Partial funding was provided by the Akron Children's Hospital, Pediatric Nursing Research Grant, and Delta Omega Chapter of Sigma Theta Tau International Honorary Society of Nursing
It was also mentioned that in 2007, the financial investment in C.A.R.E. Ladder benefits was approximately US$ 215 508 for the 295 C.A.R.E. Ladder participants (US$ 730 per participant per year, averaging all benefits of bonus, education days, and other)
The programme was considered to be cost-effective as a nurse retention strategy when compared with the estimated cost of replacing a registered nurse (US$ 82 000–US$ 88 000) (Jones, 2008).
Social acceptability:
Nurses participating in the C.A.R.E. Ladder view the programme positively regardless of nursing education preparation, level of advancement, or selected track
Korman C, Eliades AB. 2010. Evaluation through research of a three-track career ladder program for registered nurses. Journal for nurses in staff development. Journal of the National Nursing Staff Development Organization, 26:260–266. Epub 2010/12/02 PubMed PMID: 21119379 Definition: Clinical ladders - recruitment and retention tool that provide a framework for the bedside nurseto advance and gain professional recognition
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(n=2) were also combined with those with a master of science in nursing degree.
hours; lump sum initial and maintenance bonuses; reimbursement for a variety of professional practice items of the nurses; and paid education time to attend conferences (fully reimbursed registration fees) are the motivations for the nurses to participate in the programme.
PubMed
USA Medical College of Virginia Hospitals (MCVH)
Evaluative study design EVALUATION OF THE INITIAL DESIGN
Surveys regarding satisfaction were mailed to all nurses who had advanced to challenge levels (III, IV, V).
Focus groups with nurse managers to know their perception of the impact of the program on patient care, unit operations, and turnover.
Consultation with an expert to differentiate clinical nursing practice and design of clinical advancement programmes.
FEEDBACK ON THE NEW PROGRAM Focus groups with staff members and nurse managers.
– Nurses Nursing clinical ladder programme to professional advancement programme INITIAL DESIGN
Recognizes and rewards clinical practice.
6 levels (staff nurse to clinical nurse V).
Upper levels: advanced practice roles of clinical nurse specialist, case manager, and nurse practitioner.
Based on Benner's novice-to-expert research.
The 7 domains of practice from Benner's model were adopted
Behaviours for each level were formulated by a task force of clinical nurses and nurse managers.
For staff nurse through clinical nurse II, advancement depends on individual assessment and nurse manager recommendation.
To be considered for upper levels (III, IV, V), nurses must submit a portfolio describing their clinical practice, which will be reviewed at a departmental board and at nursing services board.
DESIGN AFTER EVALUATION
4 levels (clinical nurse I-clinical nurse IV).
Nurse practitioners, clinical nurse specialists and case managers cannot participate in the ladder anymore and were placed in advanced practice positions.
For the development, reward and recognition of the bedside clinical nurse.
Nurse manager as coach and partner for practice development.
Nurse prepares a self-assessment with practice examples reflecting the selected challenge level.
Nurse cannot challenge the ladder without the full support f the nurse manager.
Nurse prepares the portfolio
– EVALUATION OF INITIAL DESIGN Other:
The clinical ladder programme: o provided a framework that defined performance expectations of practice o gave a clearer understanding of the different levels of practice o did not provide the clinical nurse with a framework for professional development.
Advancement led the nurse into behaviours and activities more focused on management practice than clinical bedside nursing.
Many of the portfolio requirements were unnecessary to demonstrate professional practice.
The review process needed to be through peer review with a single review board for levels III, IV and V.
6 levels were excessive.
Nurse manager involvement in the process was not clearly defined and was not adequate. REVISED PROFESSIONAL ADVANCEMENT PROGRAM Quantity:
72 portfolios for review.
43 clinical nurse IIIs and 16 clinical nurse. IVs were advanced. Other:
Overall success rate for advancement increased in the revised programme (82%) compared to the old one (75%).
Possible reasons for increased success rate: 1) clearer definition of levels of practice 2) inclusion of nurse manager in the process 3) staff involvement in the identification of actual practice behaviours at MCVH.
Participants perceived that behaviours supported and defined their practice.
The portfolio was believed to be more reasonable and reflective of their clinical practice.
Both participants and nurse managers have favourable attitudes towards the involvement of the latter.
Resources needed:
Task force of clinical nurses and nurse managers to develop behaviours for each level of the ladder.
Departmental board and nursing services board (composed of co-chairs of departmental boards) to review portfolios of nurses who wish to advance to levels III, IV and V.
Each of the board consisted of clinical nurses at the upper 3 levels of the ladder, nurse managers and human resource personnel.
Expert who is knowledgeable in the differentiation of clinical nursing practice and design of clinical advancement programmes.
Task force including all levels of clinical nurses to review the results of the evaluation and make recommendations for improvement.
Two divisions of the task force: (1) qualitative group (for defining the domains and behaviours of nursing practice); and (2) operations group (focused on systems and issues within the programme).
Expert in qualitative methodology as consultant in conducting focus groups.
Handbook as a guide for application and challenge process.
Facilitator for each review board created for the new program design.
Handbook with the revised programme details.
Formal education sessions regarding the revised programme.
Ongoing evaluation and validation. Disadvantages of the initial design: Advancement led the nurses into behaviours and activities more focused on management practice than clinical bedside nursing.
Goodloe LR et al. 1996. Clinical ladder to professional advancement program. An evolutionary process. Journal of Nursing Administration, 26:58–64. PubMed PMID: 8648422 Definition: Clinical ladder programmes – method of defining, recognizing, and rewarding nursing practice since the 1970s.
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reflective of practice 12 months before challenging the ladder.
Revised portfolio requirements: o professional portrait o curriculum vitae o performance appraisal o nurse manager letter of
endorsement o peer letters of support o healthcare team or patient/family
member letters of support o exemplars o self-assessment.
Single level peer review (peers practicing at the level the candidate is challenging).
2 review boards with 15 members each (clinical nurses III and IV).
Review board membership requires a 2-year commitment and selection is through self-nomination.
Facilitator for each review board.
1-month review process.
A decision for advancement is not final until all members agree with each other.
Feedbacks (strengths and areas for growth) are given to the applicant.
PubMed USA Battle Creek VA Medical Center (VAMC) caters to an aging population with complex illnesses. It has experienced shortage of licensed practical nurses that meet the demands of its patients. Out of the 65 approved positions, 25–30 were vacant for 2 years, thus VAMC's resources decreased due to increased overtime costs or the use of RNs to meet scheduling needs.
Evaluative study At the time of evaluation, there were 7 students enrolled in the programme (5 in prerequisite classes and 2 in LPN classes)
– Nursing assistants Career ladder programmes for nursing assistants (NAs) becoming licensed practical nurses (LPNs)
Objectives: o Provide higher education for
seasoned NAs for the benefit of the veterans and the employer in a cost-effective manner
o Work collaboratively with community education resources
o Increase employee retention and professionalism with the ability to render greater level of care to those with complex needs.
Part-time programme designed by the nursing faculty.
Basic Skills Assessment for Reading, Writing, and Math (ASSET) placement test was conducted.
An academic counsellor helps students register for prerequisite courses depending on their placement exam information.
VAMC requirements: VA employee for at least 2 years; good record of employment; agree to serve a contractual service obligation; meet the requirements of the academic institution.
Academic institution requirements:
– Quantity:
7 students have been enrolled in the programme for 1 year (5 in prerequisite classes; 2 in LPN classes).
Additional students are being recruited from the VAMC and from the community. Quality: Several students already expressed their desire to further their education beyond the LPN level. Their attitude influences others to pursue further education. Other:
Students were excited and challenged to study in school once again.
The Program Coordinator considers the programme a rewarding experience.
Students appreciate the support of their employer who has invested in them financially and has given them flexible working schedule and emotional support thought the Program Coordinator.
The employer found that this partnership with the employee is beneficial.
The academic institution found the programme to be beneficial to the community and not just to the VAMC since students from the community have already enrolled in the programme.
Based from the evaluation, the faculty will shorten the programme from 6 to 5 semesters to accommodate more students and to make the clinical experiences more continuous.
After the 1st year, VAMC and the academic institution deem the programme a success.
Resources needed:
Communication between the VAMC and the academic institution.
Nursing faculty to design the part-time programme.
Basic Skills Assessment for Reading, Writing, and Math (ASSET) placement test
An academic counsellor to help students register for prerequisite courses.
Handbook that outlines the programme.
Selection Committee to interview students prior to selection.
Program Coordinator to perform the following duties: o review applications to be submitted to the Selection Committee o prepare Funding Request o process official programme contract o develop a mentoring programme o facilitate monthly meetings with the students o negotiate a workable scheduling plan o coordinate with Patient Care Services to get school supplies at a
lower price o monitor student progress and report to the Associate Director for
Patient Care Services o assist students finish tasks and provide support and encouragement.
Programme and local funds from the upper-level management.
Garcia RM et al. 2003. The Nursing Assistant to Licensed Practical Nurse Program: A collaborative career ladder experience. Journal of Nursing Staff Development, 19:234–237. PubMed PMID: 14581831
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American College Test (ACT) and ASSET testing; GPA of 2.0 or better; at least a grade of C on anatomy, physiology and algebra courses.
A Selection Committee interviews students prior to selection.
Program Coordinator who is a Nurse Manager with 20 years’ experience works directly with students.
Sharing of lessons learned is a part of the programme.
PubMed
Australia, New Zealand, UK, USA
Literature review Comprehensive review of available published literature and other documentation on the subject. Most of the literature reviewed was from the Australia, UK, New Zealand, and the USA. CINAHL, Medline and the library of the Royal College of Nursing were searched for relevant literature.
– Nursing staff Literature review on clinical ladders for nursing staff
A grading structure which facilitates career progression and associated differentiation of pay by defining different levels of clinical practice.
Progression up the ladder depends on the nurse meeting defined criteria of clinical excellence, skills and competence, professional expertise and educational attainment.
Absence of a clinical ladder for nursing staff
Most literature reviewed focused on describing the mechanisms of clinical ladders (most often based on a 3 or 4 level system) often referring to the works of Zimmer and Benner in highlighting the theoretical underpinnings of its use. The literature reviewed rarely reports on any evaluation of the effect of using clinical ladders. Descriptive studies mostly state that the rationales for designing and introducing clinical/career ladders normally include improving staff retention, improving quality of care/`productivity' and providing a mechanism for retaining qualified and experienced nurses in the clinical environment. From Australia, two studies evaluated the South Australian system of career structure. Dale (1987) reported improvements to patient care and quality of care. However, it was not possible to attribute these positive changes to the new career structure. On the other hand, Koch (1990) reported that job satisfaction increased for nurses at level II-V as well as the quality of care. Vacancies and overall absenteeism decreased. The study of Roedel and Nystrom (1987) showed that nurses on level III reported greater autonomy, motivation, "task identity" and job satisfaction. Malik (1991) also found out that there were statistically significant mean higher scores of job satisfaction in the critical care unit using a clinical ladder although this may also be explained by differences between nurses and organizational structures in each unit. However, this study is limited by the small sample sizes. Schultz (1993), in a comprehensive evaluation of a 4-level clinical ladder in a large university teaching hospital, found that that turnover rates were markedly lower for clinically advanced staff in a retrospective examination of data for 8 years of operation of the ladder. However, Schultz calculated a negative cost-benefit ratio for the clinical ladder. The cost of implementing the ladder for 8 years outweighed the reduction in turnover costs by approximately US$ 440 000. The study also showed that those who were not promoted were twice as likely to consider leaving their jobs, as were advanced respondents. Begle and Johnson (1991) described a formula for determining the cost/benefits of a clinical ladder system in order to achieve a good cost-benefit ratio. Strzelecki’s study (1989, unpublished ED.D; abstract only) aimed to design and test a research instrument for evaluating the effectiveness of clinical ladder programmes in acute hospital settings. There were 385 RNs surveyed from the 24 hospitals offering clinical ladder programmes. Majority of the nurses have favorable attitudes to the “essential outcomes” (i.e. differentiates levels of clinical competency, reinforces responsibility and accountability, etc.) of the clinical ladder. Also, majority reported improved job satisfaction. Bruce conducted a survey of 600 randomly drawn staff nurses in his unpublished study (1990). There were 238 responses (40% response rate). In order to determine which reward strategy (including clinical ladders), improve job satisfaction and retention of nurses, Stamps and Piedmonte Index of work satisfaction was used as the research instrument. Results show that “professional status” component provided most job satisfaction; nurses who worked in primary nursing settings and in those environments with a clinical ladder were more satisfied than non-clinical ladder nurses. Costa (1990, unpublished, abstract only) examined the effect of the implementation of a clinical ladder programme on patient care and nurses’ role orientation with 114 nurses included in the random sample.
Benefits:
Improved staff retention
Improved productivity
Improved job satisfaction
Differentiates levels of clinical competency
Reinforces responsibility and accountability
Serves as a guide for evaluation of clinical performance
Assures opportunities for professional growth
Provides for increased levels of autonomy and decision-making
Buchan J. 1999. Evaluating the benefits of a clinical ladder for nursing staff: An international review. International Journal of Nursing Studies, 36:137–44. PubMed PMID: 10376223 Buchan J, Thompson M. 1997. Chapter 3: Clinical ladders in nursing: A review of the Literature. In: Recruiting, retraining and motivating nursing staff The use of clinical ladders. Brighton, UK, The Institute for Employment Studies (Report No. IES-R-339). Definition: Clinical ladder: (1) Grading structure which facilitates career progression and associated differentiation of pay by defining different levels of clinical practice. The progression up the ladder depends on the nurse meeting defined criteria of clinical excellence, skills and competence, professional expertise and educational attainment; (2) 3 or 4 level system; (3) clinical performance, education and competence as common criteria for assessment.
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Nurses placed higher importance on professional values after implementation. However, there were no significant differences in patient satisfaction and job satisfaction among nurses after the implementation of the programme. Thornhill (1994) concluded that the clinical advancement programmes evaluated in the hospitals of Louisiana and Mississippi had limited impact or job enrichment. Goodloe et al. (1996) and Jones (1996) both evaluated the redesign (broadening the activities and simplifying the levels and portfolio requirements) of two different clinical ladders in the USA. After the overhaul, majority of the staff nurses were in favour of the clinical ladders.
PubMed
USA Tampa General Hospital implemented a career ladder programme in the 1980s with 4 levels across clinical practice, management and education. This programme failed due to reorganization, re-engineering and budgetary restrictions in the hospital
Descriptive study design – Nurses Clinical ladder programme based on Carper's Fundamental Patterns of Knowing in Nursing.
Carper's fundamental patterns of knowing in nursing (empirical, personal, aesthetic, ethical) were utilized as an organizing framework in programme development and implementation.
All members of the nursing staff were invited to participate in the development of the programme.
There were 2 developmental task forces: Criteria Task Force and Advancement Task Force.
Differentials were developed so as not to disrupt the existing salary and wage programme of the organization.
There were 4 levels in each of the 4 domains of knowledge.
Certain activities were mandatory to be submitted in each level for advancement.
Optional activities were also available for advancement giving flexibility to the programme.
EMPIRICAL KNOWLEDGE
Consists of factual knowledge that can be learned and taught.
Criteria include: formal education leading to a degree, continuing education, and the generation and utilization of nursing knowledge in practice.
There is also a substitution factor wherein experience is substituted for formal education.
PERSONAL KNOWLEDGE
This develops through interpersonal relationships.
Criteria: work experience in the registered nurse role, which is validated by existing payroll records in the organization and employment application from other organizations.
– Quantity: During the first year, 58 staff nurses advanced (10.6% of those eligible to participate in the programme). Some advanced during the subsequent advancement periods. Quality: The interest and participation in the programmr exceeded the initial expectations.
Resources needed:
Two developmental task forces: Criteria Task Force and Advancement Task Force.
Review Board to review applications for advancement.
Programme booklets were distributed to the workforce to introduce the programme.
Schmidt LA, Nelson D, Godfrey L. 2003. A clinical ladder program based on Carper's Fundamental Patterns of Knowing in Nursing. Journal of Nursing Administration, 33:146–52. PubMed PMID: 12629301 Definition: Clinical and career ladder programmes: (1) adjuncts to recruitment and retention during the nursing shortage of the 1980s. It also involves activities such as:
continuing education credit
committee participation
work experience
certifications
academic degrees
community service
performance appraisal scores as criteria for advancement;
(2) programmes of clinical progression that offered professional nurses a means of recognition while at the same time serving as a motivational mechanism and contributing to improved staff nurse retention (Zimmer, 1972); (3) Buchan found that ladder programmes commonly consisted of 3-4 levels.
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ESTHETIC KNOWLEDGE
It was noted that this dimension has been vaguely described in terms of the ‘art of nursing’ and has been associated with the manual and technical skills involved nursing care delivery.
Criteria: Submission of exemplars describing clinical judgement and use of nursing skills in patient care situations; precepting, charge nurse role, competency assessment.
ETHICAL KNOWLEDGE
It represents standards, codes and values of professional nursing
Criteria: completing legal/ethical continuing education of varying degrees, membership in professional organizations, certifications, and ethical problem solving and community service.
Each pattern of knowing has an overlap with each other.
The same activity could vary in complexity and commitment as one advances through the ladder.
A Review Board reviewed applications for advancement and if criteria were not met the materials submitted were evaluated for achievement of criteria at a lower level.
The Senior Vice President for Patient Care Services gives final approval.
Advancement ceremonies were planned to publicly recognize the accomplishments of the participants
Focus groups were held after 1 year of implementation to gain qualitative feedback.
Minor adjustments after the focus groups: candidates are required to provide less evidence of having attained the criteria to maintain their level in the ladder; instead of guest speakers during the advancement ceremonies, exemplars written by the candidates were read.
ERIC
USA Community College of Denver, Colorado
Case study Interviews with the Director of Workforce Initiatives and the Site-based Healthcare Program Manager
– Certified Nursing Assistants (CNAs) and other entry-level workers (clerical, dietary, laundry, and housekeeping staff)
CNA-to-LPN Program
Part-time, evening and weekend worksite programme for Certified Nursing Assistants and other entry-level workers.
Begins with a 9-hour Nursing Success Course (counseling on life skills, time management and study skills).
– Other:
At the start of the programme in 2002: 20 students; 13 have begun the programme and 4 of whom have graduated.
All participants: 6th grade reading level.
Many of the participants: 3rd–5th grade math level.
77% have either earned their LPN diploma or are still enrolled.
As of February 2005: o 230 had started the programme
Resources needed:
Community College of Denver partners with the City of Denver's Division of Workforce Development and local health care employers in developing the programme.
Employers of the programme participants to provide classroom space and computers and coordinate work schedules for employees.
Employers of participants to pay for the tuition fees.
10 health-care organizations as partners.
Case manager as a counsellor to students.
Programme manager.
Goldberger S. 2005. Community College of Denver CNA-to-LPN Program. In: From the entry level to licensed practical nurse: Four case studies of career ladders in health care. Boston (MA): Jobs for the Future.
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A Learning Lab is offered to provide 30 weeks of remedial instruction in math, reading, and writing to make students competent in college-level course work.
Health-care examples are used as the context for teaching to make the lessons more understandable.
There is additional tutoring support at the college campus.
Upon completion of the Learning Lab courses, students need to take prerequisite courses to enter the LPN programme.
Prerequisite courses: nutrition, medical terminology, English composition, anatomy and physiology.
Nursing classes required for licensure are taken after completing the prerequisite courses.
Participating employers provide classroom space and coordinate work schedules for employees.
Classes are 2 evenings per week.
Students are enrolled in one class at a time.
5 clinical rotations in 55 weeks; 1-2 days a week depending on the specialty.
Clinical rotations are scheduled on Saturdays and the first one is at the employee's workplace.
The employers have minimum criteria for programme participation concerning: o period of employment o exemplary performance
evaluations o recommendation of supervisors.
No minimum academic requirement.
Participants must test at an 11th–12th grade level in math, reading and writing to take prerequisite courses.
Participants: low-income employees working as CNAs and clerical, dietary, laundry, and housekeeping staff.
Students have access to all Community College of Denver support services
Entire programme: 2 1/2 years.
o 42 had graduated as LPNs o 136 were still enrolled o 52 left prior to programme completion.
Gatekeeper courses: the last module of the Learning Lab course and anatomy and physiology.
The programme helps employers to fill critical nursing positions and to retain the proven employees.
Employers are guaranteed that employee participants will stay with them for the duration of the programme.
The participants are of high calibre, are happy with their work and have favourable attitudes toward the programme.
Students appreciate peer support and employer's support and encouragement.
Peer support and tutoring/tutors during the Learning Lab.
Programme faculty.
Textbooks.
Funds for the Learning Lab.
Funds for the programme from: o U.S. Department of Labor (secured by the Division of Workforce
Development) o general city funds o WIA funds o employer.
College's budget for the case manager and the programme manager.
Continuous monitoring. Costs:
Student requring: o Full 30 weeks of Learning Lab courses: US$ 3044 o 20 weeks: US$ 2226 o 10 weeks: US$ 1500.
Total cost for students who need to take the full 30-week of Learning Lab courses, prerequisite courses, nursing courses and all other costs, except for required immunization and background checks: US$ 8252.
Benefits:
The programme helps employers to fill critical nursing positions and to retain the proven employees.
Employers are guaranteed that employee participants will stay with them for the duration of the programme.
The participants are of high calibre, are happy with their work and have favourable attitudes toward the programme.
Disadvantages: Employers may not be able to hire all LPNs at one time. Social acceptability:
The participants see the programme as a job-related benefit.
Students appreciate peer support and employer's support and encouragement.
ERIC
USA; Philadelphia, Pennsylvania
Case study Interview with the District Director of 1199C Training and Upgrading Fund
– Nursing assistants and other entry-level health-care workers
1199C Training and Upgrading Fund (LPN Career Ladder Program)
Operated by a union-employer training fund.
Part-time nursing programme held two evenings a week or every other
– Quantity:
Since 1999: o 396 individuals have entered the Practical Nurse (PN) programme o 185 (47%) completed the programme o 85 (21%) are still enrolled o 126 (32%) did not complete the programme
Resources needed:
Union-employer training fund.
Government funds including grants from Pennsylvania Department of Education and other state funding.
Employer fee-for-service agreements.
Adviser as counsellor for each student.
Individual and group tutoring services
Goldberger S. 2005. 1199C Training and Upgrading Fund LPN Career Ladder Program. In: From the entry level to licensed practical nurse: Four case studies of career ladders in health care. Boston, MA, Jobs for the Future.
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weekend for low-income health care workers in entry-level positions (i.e. nursing aides).
Operated by the District 1199C Training and Upgrading Fund.
Funds administered by District 1199C of the National Union of Hospital and Health Care Employees (part of the American Federation State, County and Municipal Employees) and representatives of approximately 50 health-care employers.
Supports for students include individual advisor, individual and group tutoring, counselling and adult literacy programmes.
Participants begin with a 3-week, 50-hour bridge programme, which includes mathematics, medical terminology, life skills and computer skills.
The bridge programme intends to prepare the participants and to identify those who are not in the position to commit for 18 months.
Applicant requirements: o high school diploma or GED o demonstrate sufficient academic
skills o must pass math, English and
scientific reasoning sections of the Nursing Entrance Test (NET).
Those who do not pass the NET could take free preparatory classes and reapply for the next session.
Must meet the state's standard of having a satisfactory criminal and child abuse check.
60 slots will be filled.
Enrolls 120 students per year (60 students per class).
The programme includes a 16-week Pre-Nursing Program for those who tested at an 8th grade level in math and a 9th grade level in reading.
Union and non-union or community members can join.
Preparatory classes are held at the central Training Fund facility and at workplaces of sponsoring employers.
Applicants who tested below the 8th-9th-grade level are offered basic education and ESL classes.
Tuition reimbursements for union members whose employers contribute 1.5% of gross payroll.
o 81% of graduates passed the LPN licensure examination on the first attempt o approximately 60% of those who entered the programme need to take preparatory classes.
Participants under the employer-sponsored workplace advancement programme had a higher-than-average PN completion rate (82% for NewCourtland's nursing aides and 83% for Golden Slippers).
Higher attendance and pass rates in the preparatory course. Quality:
Greater commitment of becoming a nurse for those people who already work as caregivers.
Program faculty.
Adult literacy programmes .
Bridge programmes and pre-nursing programme.
Central Training Fund facility and workplaces of sponsoring employers as venues of preparatory classes.
Basic education and ESL classes for individuals who tested below the 8th–9th grade level.
Costs:
2004–2005 tuition fee per student: US$ 8200.
16-week, 144-hour preparatory program: US$ 650 per student.
Tuition reimbursements for union members whose employers contribute to the fund: up to US$ 5000 a year.
ERIC
USA Workforce Alliance and
Case study Interviews with the Workforce and
– Low-income employees and other low-income
LPN Career Advancement Program
Developed by 3 Hospital Corporation
– Quantity:
January 2002: first class of 36 LPN trainees; 64% successfully finished the training.
Resources needed:
3 Hospital Corporation of America (HCA) facilities with the local Workforce Investment Board (The Workforce Alliance) to develop the
Goldberger S. 2005. Workforce Alliance and Hospital Corporation of America LPN Career
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Hospital Corporation of America West Palm Beach, Florida
Organizational Program Director of JFK Medical Center, with the former and the current Vice President of Resource Development of Workforce Alliance
residents of West Palm Beach, Florida
of America (HCA) facilities with the local Workforce Investment Board (The Workforce Alliance).
3 HCA facilities: JFK Medical Center, Columbia Hospital, Palms West Hospital).
For low-income employees and residents of West Palm Beach, Florida.
2-year programme to include preparatory classes for the state licensure exam, a required IV certification course, and a module in supervision and delegation.
Meets twice a week (1 day for classes and another day for clinical rotation) at the worksite for 9 hours a day; optional 3rd day for individual tutoring.
Participants can work part-time with employers assuring flexible work schedules.
Eligible participants: o employees and residents who
meet the TANF (Temporary Assistance for Needy Families) family income guidelines of <200% of the federal poverty level;
o must score at the 11th-grade level on TABE reading and math exams;
o must pass a critical thinking and writing exam administered by the Academy for Practical Nursing and Health Occupations (APNHO).
Programme participants are offered part-time jobs with participating employees.
Participants are required to commit to working at the facility of the sponsoring employer for 2 years after getting an LPN license in exchange for paid tuition fees.
Several non-profit vendors to deliver services: o Academy for Practical Nursing
and Health Occupations (APNHO) (LPN training programme);
o ACS State and Local Solutions (case management services);
o Palm Beach County Literacy Coalition (remedial reading, writing, ESL and math lessons).
The programme includes an intermediate credentialing where participants qualify as Certified Nursing Assistants and Patient Care Assistants within the first 6 months,
Two additional classes in December 2003 and December 2004: a total of 73 students; 77% are still enrolled at the time of the study and will graduate in December 2005 and December 2006.
At the time of the study: o 150 students have participated in skill enhancement classes o Approximately 30%: 9th grade reading level o 55%: 7th–8th-grade level o 15%: 5th-grade level or below o 30% of those students who have attended at least 25 hours of remedial sessions passed all TABE sections and qualified for admission to the LPN program; an additional 78 students were able to improve their reading and/or math levels.
As of July 2005: 21 graduates passed the state licensure exam on their first attempt. Other:
2003: The Workforce Alliance received the First Place “Best Practices” award given by Workforce Florida (state’s Workforce Board).
programme.
Morse Geriatric Center was added as a non-HCA hospital partner.
Florida's Career Advancement and Retention Challenge Initiative (CARC), which is state-sponsored, catalyzed the development of the LPN career advancement programme.
CARC was responsible for approximately 55% of the cash costs and 40% of the overall costs of the programme: o US$ 4500 per student o Cost of programme staff o Cost of the worksite remediation classes: US$ 700 per participant.
Other major sources of programme funding: employer tuition payments (US$ 3500 per student) and federal Pell Grants (US$ 3500 per student).
In-kind contributions (staffing and facilities) from employers and The Workforce Alliance.
APNHO faculty for academic tutoring.
A part-time career consultant at ACS to counsel and provide job-coaching support and assistance in connecting eligible students to transitional support services funded by TANF.
LPNs and RNs as mentors.
Senior human resources staff at JFK Medical Center as the lead in organizing HCA hospital involvement.
Costs:
Tuition, books, and fee costs for the 2-year LPN programme per student: US$ 11 500
Salary of a half-time coordinator and half-time career consultant: US$ 88 000 or US$ 2400 per student.
Nominal stipend of US$ 150 a year to each of the 20 LPN and RN employee volunteers acting as mentors.
Implementation limitation: Restriction of eligibility to only those who meet the TANF (Temporary Assistance for Needy Families) family income guidelines of <200% of the federal poverty level made it difficult for employers to offer educational opportunities to all entry-level staff.
Advancement Program. In: From the entry level to licensed practical nurse: Four case studies of career ladders in health care. Boston, MA, Jobs for the Future.
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which serves a good purpose to those who do not finish the programme and enables the participants to gain pay increases prior to reaching the LPN level.
LPNs and RNs as mentors.
Peer support through grouping employees from the same facilities together for classes.
ERIC
USA
Case study Interviews with the Vice President of Workforce Development, Manager of Training and Development, and with the President of WorkSource Partners
– Certified Nursing Assistants (CNAs)
CNA-to-LPN career ladder programme
Developed by WorkSource Partners (workforce development firm) in partnership with long-term care employers and community colleges
“grow your own” career advancement model: Regional Advancement Center (RAC).
Facilities involved: 5 owned by Genesis HealthCare and 11 independent non-profit facilities in Worcester that comprise Intercare Alliance.
Local community college partners offer a full sequence of preparatory educational courses and an evening LPN programme.
Genesis HealthCare partners with Holyoke Community College while Intercare Alliance partners with Quinsigamond.
Genesis HealthCare and Intercare Alliance sponsor CNA-to-LPN programmes and offer the following services: o career counseling o remediation o college preparatory classes o ongoing academic and “life”
coaching .
Intercare Alliance offers pre-college courses through Notre Dame Educational Bridge Center.
Sequence of the career ladder: o pre-college courses o (Upon passing the College
placement Test) Prerequisite college courses required for entry into the LPN programme:
Holyoke Community College: psychology, human development, human anatomy and physiology
Quinsigamond Community College: 2 psychology courses, biology and “Math for Meds”;
o LPN programme:
10-month evening and weekend programme
– Quantity: Reduced staff turnover and vacancy rates Outstanding retention and completion rate for CNA-to-LPN programs:
Alliance o 75% of Alliance employees in the 1st LPN class completed the programme o 17 out of 18 graduates passed the licensure exam on their first attempt o 23 out of 24 enrolled students in 2004-2005 passed the 1st semester.
Genesis o 13 out of 14 enrolled in the 1st class completed the program o 6 out of 8 enrolled in the 2nd class are still enrolled and near completion.
Since 2003: o 69 Genesis and Alliance workers entered the evening LPN training programme o 31 graduated o 29 will be graduating in the summer of 2005 o 13% failed to complete the programme.
Since 2001: o an additional 350 Genesis employees received career counselling and education services; 74 of those enrolled in pre-college classes.
2004–2005: 141 CNAs in Alliance nursing home facilities participated in a career ladder class through RAC.
Genesis HealthCare ended its use of agency nurses to fill LPN vacant positions at its 5 Agawam facilities saving US$ 500 000 per year over January 2001.
The programme reduced the turnover of nursing assistants in Genesis HealthCare.
The Alliance facilities have experienced similar benefits. CNA turnover rates dropped by 30–40% in the past 2 years. Quality: Improved patient care Other:
1st year of the programme: only 9 of 48 candidates passed the College Placement Test causing the programme start to be delayed for 6 months.
Genesis-Holyoke enrolls a mix of Genesis employees and community members.
Significant financial benefits to employers.
Resources needed:
WorkSource Partners (workforce development firm) in partnership with long-term care employers and community colleges to develop the CNA-to-LPN career ladder programmes.
Funds from the Extended Care Career Ladder Initiative (ECCLI) grants (US$ 100 000 a year at each of the sites) for programme development costs, career counselling and pre-college classes.
*ECCLI is an innovative state programme designed to help the long-term care industry in upgrading the skills of the entry-level workers.
Tuition benefit plans from employers covering their employees’ LPN tuition and fee costs.
Relevant state subsidies/FTE payments
Federal Pell Grants.
Classroom space, computers and salary of the director to manage the programme.
Notre Dame Educational Bridge Center owned and managed by Notre Dame Long Term Care Center (a member of the Alliance) to offer pre-college courses.
Staff from WorkSource Partners to provide employee outreach services.
WorkSource career development specialist to conduct one-on-one sessions to help each interested employee formulate a career plan.
Front-line managers to arrange work schedules accommodating the programme
Genesis RNs as adjunct faculty.
LPN instructors from the college partner. Costs:
Cost per person for the Alliance-Quinsigamond programme: o Pre-college classes including books: US$ 400–US$ 450 o 4 prerequisite courses including books: US$ 450–US$ 500 each o Tuition and fees for LPN programme excluding estimated US$ 775
book costs: US$5 896 o Counselling services given by WorkSource Partners staff: US$ 65 per
person.
Cost per person for the Genesis-Holyoke programme: o Pre-college classes including books: US$ 700 o 3 prerequisite courses: US$ 300 each o Tuition and fees for LPN programme: US$ 7997 o Counselling services given by WorkSource Partners staff: US$120
per person.
Benefits:
Reduced staff turnover and vacancy rates.
Improved patient care.
Significant financial benefits to employers
Genesis HealthCare ended the use of agency nurses to fill LPN vacancies at its 5 Agawam facilities saving US$ 500 000 per year over January 2001.
Goldberger S. 2005. Work source partners regional advancement centers. In: From the entry level to licensed practical nurse: Four case studies of career ladders in health care. Boston, MA, Jobs for the Future.
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Alliance-Quinsigamond: classes from 16:00–22:00 and additional clinical rotations every other weekend from 07:00–15:30; 24 students a year
Genesis-Holyoke: classes 2–3 days per week from 16:00–22:00 and clinical rotations twice a week from 16:00–23:00; no weekend instruction.
Flexible work schedules and reduced working hours are offered to students for this full-time education. Alliance employers still pay full medical and dental benefits.
The Genesis-Holyoke evening LPN programme is built on a community satellite model wherein courses are part of the college’s regular catalogue and open to the community. This is to split programme costs between community residents and employers.
Employers answer the bulk of programme costs in exchange for 2 years’ return of service by the employees after earning the LPN licence Genesis employees pay back the tuition benefit at a rate of 1 hr/dollar of tuition used.
Genesis offers a tuition assistance programme.
Employees can get assistance in applying for financial aid through Free Application for Financial Student Aid (FAFSA).
The programme reduced the turnover of nursing assistants in Genesis HealthCare.
The Alliance facilities have experienced similar benefits. CNA turnover rates dropped by 30–40% in the past 2 years.
SHS Book
Philippines The author discussed the story and development of the Philippines’ medical education and presented his own speculations based on the facts presented
– Doctors and the Philippine community
Discussion on the state of health and health practices in the Philippines from the pre-Spanish times to the Spanish and American era of colonization. Discussion of medical education and training irrelevant to the needs of the country.
– Quantity:
To respond to the growing need for more medical practitioners, the College of Medicine in the University of the Philippines, Manila, and the Philippine General Hospital were established under the American period of colonization. There came new medical schools as well.
The physician-population ratio improved from 1:21 000 to 1:3222.
However, there is a maldistribution of physicians in the country. Only 3% of the 15 000 physicians are in public health and only 27% of the population benefit from the physician-population ratio. The brain drain from the state medical school during the 1970 was 63%, which was higher than the national average of 50%. Relevance:
From the shamanistic nature of medicine in the Philippines, came the founding of hospitals, orphanages and asylums during the Spanish period of colonization.
The Spaniards established laws and systems attending to public health concerns (i.e. waste disposal, public markets and slaughter houses, food inspection, etc.).
The faculty of medicine in the University of Sto. Tomas was also established during this time.
– Estrada HR. 2011. The realities of Philippine medical education. In: Tayag JG, Clavel L, eds. Bringing health to rural communities, innovations of the U.P. Manila School of Health Sciences. Manila, University of the Philippines Manila, pp. 3–5.
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Other:
With all the advances in Philippine medical education, Filipinos of today have increased their life expectancy by a third compared to that of 1918.
No serious outbreaks of diseases were seen.
It also came to a point where academic excellence is measured in terms of how excellent the Philippine physicians comprehend and imitate the advances abroad no matter how irrelevant those are to the situation in the country.
It can be deduced that the medical education and training of physicians from the American period made the physicians irrelevant to the needs of their own people.
SHS Book
Philippines The author discussed the maldistribution of health manpower in the Philippines and the need to seriously address the training of other levels of health workers
– Doctors, nurses, midwives, barangay health workers Community in the rural areas
Discussion on the maldistribution of health manpower in the Philippines and the need to train other levels of health workers in addition to physicians
– Other:
In the 1970s, there was a rural service requirement being implemented to address the growing problem of brain drain and worsening health condition in the rural areas. However, this did not work for a long time because of some flaws in the system (i.e. being able to get assigned to fairly urbanized barrios with proper political connections and the students being underequipped in the rural areas).
Production of physicians will not be able to solve the problem of maldistribution
The need of primary health workers helping in the health service delivery is underscored
To be able to address both the condition of the body and the environment, a team composed of a mutually supporting group of people of various levels of expertise and interest is needed
There is a need to train other levels of health workers with competencies and attitudes other than those found among traditional physicians
Bonifacio AF. 2011. The maldistribution of health manpower. In: Tayag JG, Clavel L, eds. Bringing health to rural communities, innovations of the U.P. Manila School of Health Sciences. Manila, University of the Philippines, pp. 6–7.
SHS Book
Philippines Discussion in greater detail of the ladder type curriculum of the School of Health Sciences (SHS) including the service leaves in between the ladder and the requisites and expected competencies.
– Health professionals, health science students
Ladder type curriculum of the School of Health Sciences (SHS) for health science students
The Institute of Health Sciences established in Tacloban, Leyte, in 1976 is a different kind of medical school seeking to contribute to the development of various levels of health manpower.
Its programme is radically different from those found in standard medical schools with the objectives of: 1) Producing a broad range of health workers to serve the depressed and underserved communities in Region VIII (the islands comprising Samar and Leyte); 2) Designing and testing programme models for health manpower development that would be replicable in different parts of the country, and hopefully, in other countries with the same situation as in the Philippines.
Students nominated by his/her own community for admission to the programme come from depressed and underserved areas.
The client of the Institute is actually the community or the barangay, which can likewise recommend a student to not be readmitted.
The community and the student, with the consent of the parents, undergo a social contract with a pledge of the
Traditional curriculum for health science students
Relevance:
What makes the Institute of Health Sciences markedly different from other medical schools is that the curriculum's social context is a live Philippine rural community instead of an urban community.
Aside from this, the fact that the students' roots are in the rural areas provides more reason to believe that these students have greater chances of serving in rural communities.
Resources needed:
The community or barangay to give financial support to the student (i.e. transportation money) as well as support in the latter’s health programmes.
Bonifacio AF. 2011. The Institute of Health Sciences: A strategy for health manpower development. In: Tayag JG, Clavel L, eds. Bringing health to rural communities, innovations of the U.P. Manila School of Health Sciences. Manila, University of the Philippines, pp. 71–75.
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student returning and serving in the community as a health worker.
The community gives transportation money to the student and actively supports the latter in his/her health programmes.
The 5 levels in the ladder-type structure are: 1) Barangay Health Workers programme (which was later incorporated in the first quarter courses of the Community Health Workers program or midwifery course); 2) Community Health Workers programme; 3) nursing programme; 4) B.S. Community Medicine (Bachelor's degree on par with baccalaureate degrees awarded by the University); 5) M.D. programme.
The academic calendar is divided into 4 quarters with each consisting of 11 weeks of training.
Service leaves are observed between levels to be able to apply for 3 months the knowledge he/she has gained in a particular level of the programme.
During the service leaves, the Institute ensures a firm linkage between the student, the rural health unit and the barangay.
Upon performing his/her tasks satisfactorily, the student returns to the Institute to move up the ladder.
SHS Book
Philippines An account of a former faculty administrator and the present dean of the SHS, Jusie Lydia J. Siega-Sur
– Health professionals, health science students
Ladder type curriculum of the School of Health Sciences (SHS) for health science students
The community acts as the essential partner of the programme, from recruitment of SHS scholars to employment of SHS graduates
The programme has multiple levels of entry and exit depending on the need of the community.
The 5 major roles expected to be fulfilled by a student as he/she develops competencies in each level are: 1) health-care provider 2) community mobilizer and organizer 3) health-service manager 4) trainer/educator 5) researcher.
Service leave between ladders is an important component of the programme, providing an opportunity for the student to serve and learn at
– Quantity:
A number of UPM-SHS graduates, who after more than 10 years from graduation, stayed and served in depressed and remote areas in the Philippines.
Some positions occupied by those graduates are: municipal health officer, chief of a community hospital, medical officer in district and provincial hospitals, public health nurse, midwife and rural sanitary inspector.
About 85–90% of the UPM-SHS graduates are still serving in depressed and remote rural areas in the country despite the dangers of the kind of transportation in accessing these areas worsened by terrible weather conditions.
Less than 10% of the physicians who graduated from UPM-SHS have gone abroad.
In a step-ladder approach, there is less attrition and waste of resources as one may exit at any level and become a functional health provider in the health-care system. Quality:
Two of the graduates also topped the 2004 Physicians Licensure Examinations (5th and 10th place).
It also allows for the progressive, unified and continuous development of competencies of a health worker.
The step-ladder approach promotes team spirit and appreciation of the different levels of health workers and the community's contribution to health development.
It also promotes service to the country.
Resources needed: The community as the essential partner of the programme, from recruitment of SHS scholars to employment of SHS graduates
Siega-Sur JLJ. 2011. The UPM-SHS: Where the health workers are trained to stay and serve. In: Tayag JG, Clavel L, eds. Bringing health to rural communities, innovations of the U.P. Manila School of Health Sciences. Manila, University of the Philippines, pp. 113–117.
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the same time.
Relevance:
The University of the Philippines Manila School of Health Sciences was UP's answer to the brain drain and maldistribution of health manpower obtaining in the country in the 1970s.
The need to produce "basic physicians who are scientifically disciplined, medically competent, and more importantly, socially conscious, community-oriented, and firmly committed to serve the people" was identified by the 'Extraordinary Curriculum Committee of the U.P. College of Medicine'.
The school's research and development project in Carigara, Leyte, jointly carried out with the DOH and the WHO, influenced the restructuring of the health care delivery system in the Philippines.
The school also provided the principal field experience for the development of the 'Health for All' policy and the primary health care policy of the country and the WHO Western Pacific Region.
SHS Book
Philippines This article presents a discussion on research and development as a component of the Institute of Health Sciences
– Health professionals, health science students
Research and development (R&D) as a component of the IHS
Made for a highly flexible curricular structure.
Rationale: o necessary to validate some
assumptions and to continually develop the Institute’s programmes;
o important to ensure the continuous evolution of programmes relevant to the changing needs of the countryside.
It involves an information monitoring system that: o has internal and external
components to generate data where the changes in the program could be based;
o internal: admissions programme, teaching methods, course contents, alumni follow-up;
o external: perspectives, expectations, programmes, structures in the underserved communities of the region.
There is a constant review of different courses and emphasis is placed on data from: o MOH field personnel feedback o students’ information obtained
during service leaves.
A crucial function of R&D is monitoring of graduates to see whether they are serving the areas they are suppose to serve through: o correspondence o continuing educational programmes o regular, periodic visits by faculty o supervision of MOH.
Community health development projects as a means to collect data for the evolution of programme.
Guiding principles of health
– Quantity: At the time of writing this article, 45 out of 47 (96%) were serving the communities that recruited them to the IHS Other:
In 1976, data of admissions showed that: o the group admitted was quite heterogeneous when it comes to age, entering skills and socio-economic status o 80% are females o 40% were political choices instead of community choices.
The linkage between the programme and the R&D component is illustrated by the changes in the recruitment and admissions process: o information campaign, especially in the identified needy communities, 5-6 months before actual recruitment in partnership with Ministry of Public Information, Ministry of Local Government and Community Development, Ministry of Education and Culture, and Ministry of Health o age criteria: only high school graduates for the past 2 years were eligible; o socioeconomic criteria.
Results of the changes made (1977): o less heterogeneity: age and socio-economic status o <5% not actually selected by their communities.
However, more females were still observed and this has been related to the title ‘Midwife’ and ‘Nurse’ in the programme.
Heterogeneity in the entering skills of students were observed so teaching methods were adjusted to cope with this problem instead of prescribing academic criteria for admissions because such may disqualify those coming from the target areas of the Institute.
New teaching methods and tools: o tutorial system o faculty develop their own manuals syllabi and teaching aids o newly developed instructional modules for the nursing level.
Resources needed:
Faculty to conduct regular, periodic visits to monitor graduates.
Supervision teams consisting of IHS faculty members and personnel from the regional and provincial health offices to implement the Underboard Program.
IHS and MOH staff to conduct meetings, conferences and workshops with the underboard participants.
Romualdez AG Jr. 2011. Research and development as a component of the IHS. In: Tayag JG, Clavel L, eds. Bringing health to rural communities, innovations of the U.P. Manila School of Health Sciences. Manila, University of the Philippines, pp. 118–121.
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programme development: o involvement of community in
planning and decision-making; o communities and health system
(including IHS) as partners instead of recipients and providers of health care.
Stages of health programme development: o preliminary stage (6–12 mos.):
deals with existing health system in the area; social preparation and technical preparation;
deals with individual barangays or village-sized communities; social preparation and baseline data survey;
o implementation stage: allow for modifications and
provisions for expansion within each barangay and to other barangays;
o developmental stage: information system already set; continuous channelling of
information to the Institute and other interested agencies.
Study areas: o Gandara area in Samar located in
one of the most economically deprived areas in the country;
o Baybay area of Leyte with a fairly large general hospital and catchment area relatively progressive;
o Carigara in Leyte where R&D community activities were concentrated for 18 months and has a 25-bed government hospital and a rural health unit.
Each physician involved in the project chooses one barangay in his town and the programme will be based on 1 disease problem identified in their records.
Community population: 500–2000
Diseases selected: gastroenteritis, tuberculosis, schistosomiasis.
-----
Another project of the external R&D programme: “Underboard Program”.
For collecting information regarding health in rural areas.
Program participants: newly graduated physicians and nurses who have just taken their respective board examinations but do not know the results (not yet licensed – ‘underboard’).
The new graduated are required to serve in rural areas under the MOH
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Rural Health Practice Program for 4 months.
Supervision teams visit, assist and interact with the underboard participants.
Sharing of perceptions before, during and after the period of service.
----- R&D output can be utilized by other institutions or agencies as new ideas, fresh perspectives and innovative programmes
SHS Book
Philippines This analytical paper presents written accounts of the SHS students' memorable experiences in their home communities in different parts of the country during their service leaves following their Barangay Health Worker (BHW) studies The 146 accounts gathered were classified into categories of experiences: (1) traumatic/exhilarating personal experiences; (2) observations on the conduct of the community survey; (3) general observations about the service leave; (4) assisting in clinics and programmes of the RHU/BHS; (5) observations on the conduct of the community assembly; and (6) experiences related to the sharing session Out of the 146 accounts classified, 38 were included in this paper
– Barangay health worker students
Service leaves between the ladders in the ladder type curriculum of the School of Health Sciences (SHS) for health science students
Service leaves are observed between levels to be able to apply for 3 months the knowledge he/she has gained in a particular level of the programme.
It is an opportunity for the students to serve and learn at the same time.
– Quality:
The actual experiences of life and death situations made the students realize, assess and overcome their strengths and limitations.
The failures and hardships inspired them to study harder and strengthened their commitment to serve in their home communities. Other:
Among the 146 accounts gathered o 31% of the experiences were classified under traumatic/exhilarating personal experiences o 21% under observations during community surveys o Category 3 (18%) o Category 4 (15%) o Category 5 (9%) o Category 6 (6%).
BHW students faced a lot of challenges that they had not encountered before such as facilitating child delivery, saving a child, witnessing the death and suffering of people in the hospital, being caught in the middle of political conflicts, acquiring debts to help someone, experiencing natural disasters during their service leaves, meeting indifferent families, being threatened of physical harm in a household, and being in a life-threatening situation (drowning in the river).
Some also experienced being drunk and becoming a confidante for the legal problem of a community member during the conduct of community surveys.
Other BHW students were able to mingle with tribes in the community and were able to discover their very limited time perception when asked of the ages and birthdays of their family members and themselves.
The others on their service leaves were confronted by armed men such as members of the New People's Army (NPA) guerrillas.
Based from all the accounts gathered from BHW students, the service leaves proved to be a good teacher as experience is in itself a good educator.
Borrinaga RO et al. 2011. Significant service leaves experiences. In: Tayag JG, Clavel L, eds. Bringing health to rural communities, innovations of the U.P. Manila School of Health Sciences. Manila, University of the Philippines, pp. 137–145.
SHS Book
Philippines Interviews of the SHS medical students in 2009 were conducted by Josefina G. Tayag, one of the book’s editors The students were asked regarding their service leaves, plans after graduation, subjects in school, how they were chosen for the scholarship and their recommendations for improvement of the SHS education, specifically for the MD programme
– Medical students Service leaves between the ladders in the ladder type curriculum of the School of Health Sciences (SHS) for health science students
– Quality:
The medical students interviewed expressed favourable attitudes toward their service-leaves experiences.
Some of the benefits they got from these were: o being trusted with more responsibilities; o learning to communicate with the ordinary people; o recognition of inadequate health services and other imbalances in health-service delivery which resulted in a clearer perspective and desire to serve the less fortunate ones; o opportunities to apply knowledge and skills learned from school o a sense of accomplishment, and professional
Resources needed: As for the medical students’ recommendations for improvements to the MD programme, laboratory equipment and additional full-time instructors were the common suggestions. Updated books, additional LCD projectors and longer duration for each subject were also deemed helpful.
Tayag JG. 2011. The service leaves of current medical students. In: Tayag JG, Clavel L, eds. Bringing health to rural communities, innovations of the U.P. Manila School of Health Sciences. Manila, University of the Philippines, pp. 146–148.
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growth and development.
The students also plan to stay and serve in the country, particularly in their communities, after graduation. Other: They have also said that the Department of Health only chose 10 scholars from the list of the applicants and they felt lucky to be one of those
SHS Book
Philippines Descriptive study
The number of graduates produced by the SHS and other details on the alumni were gathered from an informal survey of 340 graduates and a more formal one of 90 graduates as respondents The list of 340 alumni and their whereabouts were obtained from the SHS alumni organization Out of the 250 survey forms sent through mail, e-mail or handed personally to graduates selected on a systematic sampling from the list, only 90 were retrieved Focus group discussions (FGDs) and key informant interviews (KIIs) were also conducted Visits to Palo, Leyte, Biliran and Palawan as well as attendance in alumni gatherings were also made to gather more information
Data gathered regarding the whereabouts of the SHS alumni was incomplete
Health professionals Ladder type curriculum of the School of Health Sciences (SHS) for health science students
– Quantity:
More than half (69.58%) of the 2860 SHS graduates were under the Community Health Work (CHW) degree programme (later known as Midwifery).
Only 17.69% graduated with a Community Health Nurse degree (revised to Bachelor of Science in Nursing in the late 1990s).
The BSN programme produced a total of 238 graduates (8.32%).
Only 4.41% of the graduates were under the Medical Degree program.
Out of the total graduates, 74.51% are registered health professionals.
Out of the 1990 graduates in the CHW programme, 66% are registered midwives.
On the other hand, 96.64% of the total CHN and BSN graduates are registered nurses.
From the 126 graduates of medicine, 77.77% are registered physicians.
Region VIII (Samar and Leyte) produced more than half (55.98%) of the total graduates.
Based from the 340 contacts list, 65% of the alumni came from Region VIII.
The data also showed that only 9.7% are working abroad and 4.41% work with private hospitals in Metro Manila.
Of the 252 females and 88 males still in the country, 38.82% work in the RHUs as nurses, midwives, rural health inspectors, municipal health officers, public health workers, sanitary inspectors and assistant MHO.
On the other hand, 18.53% are working in a district/private hospital.
In terms of regional distribution, the data gathered from the survey of 90 respondents reflect that of the 90 respondents, 43. 33% stayed in their sponsoring communities serving for an average of 14 years.
On the other hand, 32.08% of the 90 respondents later transferred to a nearby province or barangay still within their region due to unavailability of jobs in their sponsoring community, need for higher salary and for professional growth and development.
Some of the respondents (28.89%) worked elsewhere like in the academia.
Others ended up working as project officers and community development facilitators.
Only a very small proportion (<5%) was reported to be not doing any health or community work. Quality:
The respondents expressed that SHS made them recognize the importance of education and return service.
They learned discipline and they became service-oriented to the Filipino community
With the SHS education, they were able to see the real needs of the people. Other:
SHS values were also found to be of help
Recommendations from the respondents:
The respondents suggested some points for improvement for the SHS: o Most of them mentioned the benefits of offering a Master's Degree
to both the faculty and students; o Some suggested reviewing and updating policies, giving more
emphasis on English communication skills, maintenance of good community partnership and strengthening of clinical relationship;
o One respondent pointed out the importance of having an information system or channel that will enable SHS to track down their graduates;
o More books, computer units and other technologies as well as increased support to students were also suggested.
Tayag JG. 2011. Where are the Alumni? In: Tayag JG, Clavel L, eds. Bringing health to rural communities, innovations of the U.P. Manila School of Health Sciences. Manila, University of the Philippines, pp. 209–217.
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even with those alumni who ended in other professions such as in politics and academia.
Majority of the respondents also agreed on a written contract between the student and the community.
Most of them also gave positive feedbacks on their relationship with their sponsoring community.
However, political disputes, lack of financial support and lack of job placements were cited as causes of unfulfilled contracts.
OPENSIGLE
New Zealand, UK, USA The settings of the clinical ladders are usually in urban areas
Descriptive study 5 case studies (3 in the National Health Service or NHS in UK and 2 in the USA) Interviews with managers in 3 NHS Trusts in England which designed competency-based systems for nurses Discussions with managers in 3 trusts in Scotland that are thinking of shifting to competency-based systems Additional information was obtained from managers in hospitals using clinical ladders in new Zealand and the USA. Literature review on the use of competency-based pay and clinical ladders
– Nurses Competency-based ladders Designing clinical ladders: Approach 1: The employing organization forms a committee or working group comprised of nurse representatives from different specialties to consider options and formulate a clinical ladder Approach 2: In some NHS trusts, a new system is established which was primarily designed by external management consultants *Both approaches use methods and design systems based on previous theory and practice Clinical ladders in the USA: CASE 1 – UNITED STATES HEALTH SYSTEM; 300 BED TERTIARY CARE CENTRE PLUS 20 COMMUNITY CLINICS
Urban-based
4000 staff including 850 unionized RNs
1994: differentiated practice model for nurses’ remuneration
Based on Benner
5 levels: entry level, Clinical Nurse 1-4 o Clinical Nurse I – base salary o Clinical Nurse II – base salary +
3% o Clinical Nurse III – base salary +
7% o Clinical Nurse IV – base salary +
10%
Payment for ‘lifestyle compensation’ based on number of unsocial hours worked
‘Portfolio’, including examples of work, research report, performance appraisal and peer review, prepared by the nurse is the basis for advancement
CASE 2 – UNITED STATES: UNIVERSITY-LINKED TERTIARY CARE HOSPITAL
Urban-based
3000 staff including 800 unionized RNs
Clinical ladder is mainly for the
– Other:
Literature revealed that clinical ladders are used to address recruitment and retention difficulties, more scope for pay increases within clinical nursing and improvement of staff commitment and productivity.
Based on the discussions with NHS managers, the core rationales for a competency-based approach are: o retention o ‘valuing’ nursing practice/improving job satisfaction o establishing objective criteria for differentiating clinical practice.
Few working examples in the NHS could limit source material for consideration and over-reliance on consultants. Also, the USA examples might be over-emphasized limiting the sharing of information to other settings with different situations.
A successful ‘in-house’ system design would require a minimum of 18 months which is longer compared to ‘off-the-shelf’ models.
An in-house system design would also require management and staff’s time to participate in the development of the structure.
However, an in-house system design would be more representative of and relevant to the needs of the staff and organization.
Each and every competency-based ladder has its own unique components reflective of local needs and priorities. However, there are also some core characteristics: o number of rungs/levels (2–6 levels); o pay differentials between levels (5–10%); o skills/competencies/qualification-based criteria for advancement (point-system or a system based on levels of attainment); this covers professional practice, education and research; o review process for advancement.
Quota to limit proportion of nurses on advanced levels: o cash limit; o predetermined level ‘mix’ requiring a vacancy before one can apply for advancement; o ‘rationing’ through making the advancement criteria extremely difficult to achieve at the highest levels; o allowing the line manager responsible for the budget to refuse an application; done in settings where budgets are decentralized.
Many of the hospitals reported to be using clinical ladders redesigned their ladders to suit changing priorities and requirements.
In the USA, the use of ladders is primarily limited to coverage of first level qualified nurses.
In New Zealand, some hospitals have ‘parallel’ or ‘linked’ ladders for RNs, enrolled nurses and care assistants.
Various approaches to monitoring effectiveness of clinical ladders: o rudimentary cost-benefit analysis; o ‘basket of indicators’ approach (looking at trends in routinely collected data such as staff absence, turnover, patient satisfaction, etc.); o assessment of recruitment and retention. CASE 1 – UNITED STATES HEALTH SYSTEM; 300 BED TERTIARY CARE CENTRE PLUS 20 COMMUNITY CLINICS
Resources needed:
The Scottish Office Health Department as the sponsor of the research.
Cooperation of managers in the case study hospitals.
Assistance of certain people in obtaining information on the use of clinical ladders in New Zealand.
Assistance of the Washington State Nurses Association.
Nursing unions are part of the working group and are involved in fixing the union/management contract and agreeing to the go-ahead of the design.
In New Zealand, nursing union monitors the implementation of the ladders and conducts national workshops to share local experiences.
Committee for review of individual applications and also for assessing any necessary changes as well as leading redesign.
Benefits:
Clinical ladder system in the USA: o enhances professional development of nursing staff o improves staff relations o rewards competency o improves staff motivation o encourages continual updating of professional skills.
Challenges:
Implementation of a competency-based ladder requires that need for staff ownership be balanced with the need to address other organizational priorities and pressures.
Tension between the Human Resources Director and the Board regarding cost savings and budget management.
Buchan J, Thompson M. 1997. Chapter 4: Case studies. In: Recruiting, retraining and motivating nursing staff The use of clinical ladders. Brighton, UK, The Institute for Employment Studies (Report No.: IES-R-339). Definition: Clinical ladder: A grading structure which facilitates career progression and associated differentiation of pay through defining different levels of clinical and professional practice in nursing. Advancement through the ladder depends upon meeting the criteria of clinical excellence, skills and competency, professional expertise and educational attainment defined in each level. Individualized, places greater emphasis on continual development and appraisal, focuses on relevant skills and competencies instead of the nurse’s position
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retention of key staff
3 levels; each level has 12–15 increments (incremental progression by seniority) o Clinical Nurse I – base salary;
increments, shift pay, etc. o Clinical Nurse II – as Clinical I +
5% o Clinical Nurse III – as Clinical I +
8%
Nurses must apply to advance to levels II and III
Application can be twice annually
Review committee: staff nurses, nurse managers and human resource managers
Advancement criteria: peer review, continuing education credits, patient charts
Cash limit on the number of level II and III nurses
CASE 3 – UNITED STATES: COMMUNITY (GENERAL) HOSPITAL
Urban-based
Unionized workforce
1994: clinical ladder with 2 advanced levels of practice
Full-time and part-time nurses working for 6 months are eligible to apply
Application may occur any time of the year and will be reviewed within 4 weeks
Annual performance appraisal by the Unit Director as the foundation of the application process.
Re-application is every 6 months
RNs are hourly paid on a 15-point scale with progression based on length of service.
There are additional payments for unsocial hours worked.
Entry level: US$ 13.03/hr.
240 months: US$ 20.23/hr.
Additional hourly payment: o RN Level II + 0.75 o RN Level III + 1.25.
Clinical ladder in New Zealand: CASE 4 – NEW ZEALAND: TEACHING HOSPITAL SYSTEM
Multi-hospital system with 2400 qualified (and unionized) nurses.
Clinical ladder based on New Zealand Nurses Association’s original design.
Multiple track ladder with separate pathways for RNs, registered midwives, enrolled nurses and auxiliaries.
RN ladder (professional development
Other: Programme’s introduction costs were offset by the gains in productivity and better quality of care provided by the nurses.
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programme) offers 4 levels o progression based only on
performance and achievement of defined criteria (performance review scores, in-service training participation, certification, and demonstrated skills and competency in clinical leadership for levels III and IV);
o application packet to be accomplished includes: information on professional expertise, educational activities, case study exemplars and teaching session evaluations;
o 5-step salary scale with yearly incremental progression: allowances (additional payment) given related to the level of practice: Level IV + US$ 2000; Level III + US$ 1200; Level II + US$ 600;
o Shift premiums are based on salary scale plus allowance.
Clinical ladders in UK: CASE 5 – COMPETENCY-BASED PAY AT A LONDON NHS TRUST
Acute Trust in West London with 1200 staff and a budget of £47 million.
Competency-based structure to be able to address high turnover rate and recruitment difficulties.
Principle: to allow “each individual to move up their pay band as fast as their required skills are reached”.
Pay structures for nurse clinician and general nurse have 3-pay points each excluding unsocial hours premiums.
Proposed grading structure: Clinical Team Leader, Nurse Clinician, General Nurse, Health-care Worker.
Competencies that are assessed by a Nurse Clinician using various methods: o clinical practice o professional and educational
responsibilities o management and staff resources.
Within each area of competency are Elements of Competency: o undertake the assessment o planning o implementation. o evaluation of individual care
needs
Each element has criteria for the expected level of performance.
CASE 6 EAST OF ENGLAND HEALTHCARE NHS TRUST
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Fourth-wave Community Trust with 1400 people.
The new pay approach only benefits 4% of the 860 nursing and related staff.
The new approach is an attempt to: o simplify the 9-grade structure to 4
grades only o clarify the confusion caused by
clinical grading o control pay costs.
6-level ladder with core competency framework (clinical and behavioural) and performance assessment mechanism in each level.
1 unqualified (nursing assistant), 5 qualified.
Each level has 6-pay points.
All appointments to the structure are at the 3rd point.
Competencies were developed by a managerial project group; no involvement of nursing staff and no recognition agreement.
MCI framework as the basis of competency frameworks. .
CASE 7 SOUTHERN ENGLAND GENERAL HOSPITAL NHS TRUST
Funded by NHS Training Division.
Acute Trust with 1308 nursing staff.
4 major nurse roles: Ward Sister, Senior Staff Nurse, Junior Staff Nurse and Preceptorship.
Staff groups and unions are involved in the development of the roles and structures.
Competencies (behavioural like team working, planning and organizing) were developed with staff and a firm of management consultants and are set within the patient centred care framework.
Proposed pay structure: 3 spines within a range of 50 points (£13 500–£27 000).
Incremental steps on the spine: valued at 1.5% with a maximum of 3 increments in a year.
Journal of Nursing Administration (JONA)
USA Minnesota responds to its dynamic health-care environment through health-care reform The state also experienced a nursing shortage in the 1980s but has already declined
Evaluative study Discussion of programme planning, implementation and evaluation of Minnesota Project LINC (MN LINC) Needs assessment was conducted during the planning phase. This was distributed to nurse executives of the 151 Minnesota Hospital and Healthcare Partnership (MHHP)
The methodology does not aim to produce generalizable findings. Instead, it aims to provide programme staff members with “information-rich and highly meaningful
Nurses MN LINC (Minnesota Project Ladders in Nursing Careers)
Collaborative work of the Minnesota Hospital and Healthcare Partnership (MHHP) (151 hospitals), nursing administrators, educators and nursing organizations in Minnesota.
Provides services and funds for minority and low-income health-care employees
– Quantity: Only 6% drop-out rate over 3 years due to personal reasons not related to the programme Quality:
At the time of study, all MN LINC graduates had successfully passed their board examinations.
Students finished their studies on time with 9% finishing earlier.
All but one sponsored graduate has stayed to work for their sponsors.
Many of the minority graduates work in
Resources needed:
Competitive grant (1993) and 3-year implementation grant (from 1994) from the Robert Wood Johnson Foundation (#023381) as project fund.
Other sources of funds for tuition, books and other supplies: o foundations o Minnesota State Legislature o MHHP member contributions.
Collaboration of the Minnesota Hospital and Healthcare Partnership (MHHP), nursing administrators, educators, and nursing organizations in Minnesota.
10-member steering committee representing each MHHP region and
Dodgson JE, Bowman N, Carson LQ. 1998. Ladders in nursing careers: A program to meet community healthcare needs. Journal of Nursing Administration, 128:19-27.
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in 1993 member hospitals – 67% completed the needs assessment Programme evaluation in 1996:
Conducted by an independent evaluator.
A mixed-method approach of survey and interviews were conducted for 4 months.
All students (n=52) enrolled in April 1996 and all employers (n=42) were surveyed.
Purposeful sampling was utilized to gather a diverse and a broad range of respondents.
Student and employer surveys were formulated by the evaluator in collaboration with MN LINC staff members.
Content validity of tools was established through review and revision process.
Interview questions were formulated based on survey results.
Anonymity was ensured in surveys and interviews.
Additional questions regarding a particular problem area mentioned in previous interviews were asked in subsequent interviews.
3 sources of student data: Student Participant Survey (71% return rate), semi-structured interviews (n=23), 2 focus groups and demographic data.
44% of student population were interviewed or participated in a focus group.
Employers’ survey: 60.8% response rate for nurse executives and 31.5% for immediate supervisors.
Employers’ interview: 35% of nurse executives and 26% of immediate supervisors; representative of 3 small rural clinics, 2 rural community hospitals and 3 large urban medical centres.
SPSS data analysis software was used to analyse demographic and survey data.
Qualitative data were analysed by content analysis.
Categories, subcategories and themes of responses were defined.
conclusions”.
No effort to differentiate student responses based on level of education, gender, ethnicity or location.
Surveys were designed to gather subjective descriptive data related to their participation in MN LINC at one point in time; responses may change with subsequent surveys.
A more comprehensive evaluation of community impact cannot be done since only a few students have completed their studies.
Facilitates nursing education
Identification of community nursing needs.
‘Home growing’.
Major objectives: o meet changing workforce needs as
health-care reform progresses o move existing staff into more skilled
positions through facilitating their nursing education
o assist nursing students overcome barriers to higher education.
Aimed to improve health care and access to culturally competent care for underserved communities.
Health-care employers sponsor students to meet the facilities’ needs.
The steering committee reviews applications and makes selections.
Programme participants must make adequate progress in the programme and must communicate with their employer and MN LINC regarding their schedules and progress.
Contract between agency and sponsored student: o part-time work schedule with
maintenance of full salary and benefits.
o full-time attendance at a nursing school.
o return of service to the employer for a specified duration after graduation (average of 18 months for each year of support).
Some facilities co-sponsor students with one or more other agencies.
To meet grant requirements (20 students for the first year with a total of 100 over 3 years) during the tough times experienced by hospitals, applications were accepted from non-sponsored nursing students meeting any of the following: o person of colour o single parent with dependents
younger than 18 years old o personal/family income not to
exceed US$ 30 000.
There is a comprehensive orientation for students.
Trans-cultural nursing concepts (e.g. cultural assessment, understanding cultural values, exploring language interpretations) were applied by the staff to meet student needs.
Job-seeking skills programmes are provided to those preparing for graduation.
environments where they interact with clients from their own as well as other cultures.
In one small rural community: o physicals, histories and charting were completed on a regular basis after participating in the MN LINC; o less time in waiting rooms for clients and follow-up appointments are sooner; o handle small emergencies more efficiently; o female clients get regular check-ups due to presence of female care providers; o increased hospital referrals. Relevance: The programme effectively increased diversity within the nursing workforce and improved care for an increasingly diverse population Other:
During the planning stage, a needs assessment was formulated and nurse executives at each MHHP member hospital (n=151) were asked to assess the impact of state-wide legislated health-care reform on nursing role and needs (could not be met by cross-training, retraining, or work re-distribution) by 1998: o 101 (67%) completed needs assessment o 78% predicted changing nursing needs and expressed interest in MN LINC o identified needs: increasing number of nurse practitioners; hiring nurses reflective of their community diversity; moving employees into roles for the growing home health-care market.
Students found the support provided by the MN LINC staff helpful.
Mean grade point average: 3.6 on a 4.00 scale.
Students have favourable attitudes towards services offered and relationships with staff members in MN LINC.
Support services were reported to reduce factors causing students’ stress.
Recommendations of students: o additional support services (i.e. student support groups, study groups); o additional content by staff on time management and study skills; o library of community and study skill resources to assist in problem-solving.
70% of employers participated in the project to meet an existing or predicted community need.
55% of employers joined to assist needy employees.
5% of employers participated to fill an institutional need.
Employers have a favourable response regarding the project meeting workforce needs, aiding students to overcome barriers to higher education and transitioning staff.
88% of immediate supervisors expressed increased future needs for MN LINC services; 64% of nurse executives responded positively while 21% were neutral.
Employers reported the MN LINC to be an effective model in facilitating success for students and transitioning staff into needed positions.
Students of colour were also reported to be respected at MN LINC.
Employers suggested that the frequency of reporting on student progress must be improved.
representatives from educational institutions and state nurses’ association.
Steering committee reviews applications and selects students.
Maintenance of the programme: 4 staff members.
MN LINC staff to facilitate a contract between agency and sponsored student.
2 co-directors (1 full-time equivalent [FTE]) to administer, market and seek funding.
Academic liaison (0.75 FTE) for the maintenance of student records, contacting of students, and programme promotion through a quarterly newsletter.
Programme assistant (0.5 FTE) to provide support.
Independent evaluator.
Survey consisted of Likert-scaled questions for students and employers.
Interview questionnaires.
SPSS data analysis software for descriptive statistics. Benefits:
Non-traditional student employee barriers were removed (i.e. loss of income, educational expenses).
Health-care providers are positioned proactively to address community needs sooner.
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Multiple data sources were compared and contrasted to increase depth and accuracy of results.
Journal of Nursing Administration (JONA)
USA University of Colorado Hospital converted from a state institution to a private institution
Evaluative study
Report on the evolution of the clinical advancement programme and the outcomes associated over time.
Outline of the structure and progression of programme development and change.
23-item clinical ladder satisfaction scale developed by Strzelecki was utilized.
Content validity was established using a panel of experts.
Data collected in 1993, 1994, 1996 and 1998 using standard survey methods.
Data trends across units and time periods and comparison of these with other institutional evaluation data sets.
Respondents: convenience sample of all RNs holding clinical positions at the University of Colorado Hospital.
20 in-patient units over the 5-year period with a total aggregate subject number of 876 nurses.
Survey respondents and response rates: o 1993: 309 (55%) o 1994: 224 (35%) o 1996: 261 (43%) o 1998: 310 (44%).
Mueller and McCloskey satisfaction scale measured nurse job satisfaction.
Schutzenhofer’s nursing activity scale measured nurse autonomy.
– Nurses University Hospital’s Focus on Nursing Excellence in Clinical Care, Education and Leadership (UEXCEL) clinical advancement programme
Based on Benner’s novice-to-expert theoretical framework.
Utilizes a professionally framed performance standards for: o yearly employee evaluation o defining nursing role at each level o credentialing advancement
process.
Objectives: o create an environment promoting
professional behaviours and attitudes, including peer review to increase nurse accountability, autonomy and collaboration;
o define role expectations within each level;
o provide a guide for professional credentialing, including compensation and rewards corresponding with advancing levels of practice;
o provide opportunities for professional development and advancement while continuing clinical practice.
Levels differentiated by degrees of clinical expertise, competence and professional responsibility: o Level I (novice; new graduate); o Level II (competent; handles
acutely ill patients); o Level III (proficient; increased
clinical expertise and leadership on the unit; enrolled in or holder of BSN degree);
o Level IV (advanced; expert skills and leadership across services);
o Level V (MSN advanced practice nurse; clinical expert; engages in professional activities beyond the hospital setting).
Nurse performance measured in the following areas: o clinical practice; o education and professional
involvement; o quality management or research
and management or leadership.
Each area incorporates standards of care, practice and performance defining nurse role expectations.
Different weights of the practice areas
– Quality:
Nurses with higher levels of education are more positive when it comes to UEXCEL programme than nurses with less educational preparation (r = 2.34, P = 0.02). Other:
Programme was not well received on initiation in 1989. Nurses perceived the standards to be burdensome and difficult to comprehend. The process was seen as a complex one.
Demographic data: o Nurses at the University of Colorado Hospital were dominantly females (>90%); o female nurses on rotating shifts (60%) o female nurses working between 5–10 years at the hospital (55%); o from the baseline data in 1993, sample nurse population was 56% BSN graduates and only 2% MSN; o 10 years later, there were 62% BSN, 12% MSN and 1% Nursing Doctorate.
Nurse satisfaction with the programme steadily and slowly improved after each programme revision: o baseline mean score: 50.16 o 1996–1997: 64.00.
Significant positive satisfaction improvement over time: before 1998, 56.31 ± 79.83 (mean ± standard deviation); after 1998, 62.12 ± 17.99, Student’s t= 4.6, P = 0.000.
Of the 23 quantitative questions, all have statistically significant positive outcomes over the 5-year period when 1998 results were compared with other aggregate-year scores by student’s t test.
Areas with less significant improvement: improving peer review, encouragement to advance, rewards and incentives to credential.
Operating room nurses were consistently recorded to have the lowest satisfaction scores and the fewest number of baccalaureate-prepared nurses.
UEXCEL satisfaction is closely linked to job satisfaction while autonomy results seem independent of both variables.
Approximately 15% of nurses have advanced in the UEXCEL system. Evolution over 8 years:
Changes in the programme: o categories of performance were reduced from 7 to 4 through consolidation; o separate credentialing process was established for advanced practice nurses (Level V); o number of exemplars for credentialing was decreased; o wording of standards was streamlined; o credentialing process was clarified; o evaluation tool was streamlined to reduce time of evaluation; o expected performance standards were better defined; o weights at different levels were revised; o requirement to meet standards at the next level to exceed on the annual performance appraisal was eliminated;
Resources needed:
Task force of staff nurse and leadership representatives to create the advancement programme.
UEXCEL Board, which consists of staff nurse representatives from various clinical areas and representatives from nurse recruitment, management and human resources, to manage advancement process.
23-item clinical ladder satisfaction scale developed by Strzelecki as evaluation tool
A panel of experts to establish content validity of the evaluation tool.
Mueller and McCloskey satisfaction scale to measure nurse job satisfaction.
Schutzenhofer’s nursing activity scale to measure nurse autonomy.
Challenges: Availability of advancement dollars for promotion is one of the human resources constraints.
Krugman M, Smith K, Goode CJ. 2000. A Clinical Advancement Program: Evaluating 10 years of progressive change. Journal of Nursing Administration, 30,215–225. Definition: Clinical ladder programme – provides a professional framework for developing, evaluating and promoting registered nurses. Clinical ladders also shape a workforce that enters the nursing profession with different educational backgrounds, skill abilities and uneven levels of professionalism and career commitment. Clinical ladders provide opportunities for advancement through recognition and salary increases while allowing the nurse to continue clinical practice. Clinical advancement systems – often identified as clinical ladders and were formed in the 1970s for the promotion and retention of professional nurses working in acute care hospital setting.
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are observed in each level (i.e. Level V has equally distributed weights among all areas).
Strong peer review component as part of evaluation, advancement and credentialing process.
BSN or enrolment in a programme is required to apply for advancement beyond Level II.
UEXCEL Board manages advancement process.
In order to apply for credentialing, nurses must meet standards at the level they desire to advance.
Nurses prepare portfolios to demonstrate contributions and portfolio presentations include writing a narrative exemplar, peer and managers letters of support, and copy of the performance evaluation.
Unlimited opportunity for professional nurse advancement.
Advancement increases are in addition to and awarded separately from pay-for-performance increases.
o new titles of categories: clinical practice, leadership, practice outcomes and professional profile; o numbers of educational days for further advancement levels were increased; o improvement of recognition ceremonies and publicity for those advancing; o administrative time for projects designed to improve patient care outcomes or unit systems functions; o continued evaluation using satisfaction survey.
Handsearching bibliographies of relevant articles
USA Regional not-for-profit health-care system in central Virginia
Quantitative and qualitative programme evaluation Quantitative:
Convenience sample of 1021 RNs was surveyed (28% return rate) from a list given by human resources.
RNs were in current practice on the clinical ladder or had finished employment in the organization within a year prior to the study.
A research assistant sent survey packets to the RNs’ home addresses.
Participation was voluntary.
Anonymity was maintained by a numerical coding system and by reporting results as aggregate data.
Data were entered and analysed with the help of a contracted marketing firm.
Qualitative:
Purposeful sampling.
Recorded interviews with clinical nurses at levels II (3), III (2) and IV (1), and unit managers (2); written consent from participants.
Interviewees were selected
Convenience sample was used for the survey despite the rationale of giving every nurse a chance to respond.
The researcher was employed within the organization and so a researcher bias might have existed.
Response rate is low.
Nurses Clinical advancement process Original clinical ladder:
For the nurses’ professional growth.
Skill development.
Recognize clinical excellence.
Offer monetary compensation for advancement at the bedside.
Alternative to promotion into administrative and education roles.
Self-paced programme.
Based on Patricia Benner’s work From Novice to Expert.
4 levels of practice with increasing demonstration of competency at each successive level: o Clinical Nurse I – new graduate or
new nurse to the organization; will advance after 1 year of employment depending on the judgment of the unit manager based on satisfactory performance;
o Clinical Nurse II; o Clinical Nurse III – voluntary
advancement; work requirement of 24 hours per week;
o Clinical Nurse IV – voluntary advancement; work requirement of 32 hours per week.
Professional portfolio containing achievements and experiences.
Clinical exemplar of current practice is required for advancement to Level IV.
– OLD PROGRAMME Other:
The most important element to the nurses was salary but it was reported to be the least satisfying.
Autonomy and professional status were also identified as important elements.
Overall satisfaction score of the IWS was consistent with other organizations’ evaluations of career advancement processes using the same instrument.
Common themes during the interviews: o advancement process was time consuming; o required paperwork was overwhelming; o pay/compensation was not enough; o personal obligations were barriers to pursuing advancement; o some part-time job categories could not seek advancement; o respondents moved for some changes in the advancement process but still wanted its continuation; o advancement did not necessarily entail an improved performance in patient care delivery; o clinical expertise may not be totally assessed; o emphasis of the process was on tasks, committee work and continuing education;
Inconsistent matching of nurse skill to patient’s needs.
Unit managers were not as involved in the process as the staff desired. UPDATED PROGRAMME
Resources needed:
Nurse unit managers to support RNs in developing the professional portfolio, to budget for levels III and IV and to monitor those who advanced to levels III and IV on a quarterly basis.
Advancement committee comprised of registered nurses to review applications for advancement and conduct interviews.
Nursing executives and financial analyst to plan the yearly budget for levels III and IV.
Committee for advancement, staff, unit managers and clinical nurse specialists to design the new programme.
Benefits: Clinical ladder eliminated the need to work at least 2 8-hour shifts per 8 weeks) and the need for supplemental pool staff
Goodrich CA, Ward CW. 2004. Evaluation and revision of a clinical advancement program. Medsurg Nursing, 13:391–398. Definition: An alternative to promotion into administrative and education roles.
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based on having a potential to expand knowledge of programme evaluation.
Interview questionnaire developed by Schultz was used.
Index of Work Satisfaction (IWS) was also used as an instrument in evaluating the satisfaction of nurses with their work.
Peer review/advancement process – 4 times a year.
Those who were not promoted could re-apply.
Feedback regarding deficiencies in the portfolio.
After advancement, the unit manager tracks goals of each Clinical Nurse III and IV on a quarterly basis to ensure criteria for that level are maintained.
Nurse unit managers could also recommend demotions.
Changes based on findings:
Revised requirements and criteria for advancement are more outcomes-based and less task-oriented.
Research utilization in each clinical level was emphasized.
Requirements offer more flexible choices in meeting requirements during scheduled work hours and this decreases time away from the patient care area.
Name of the process and committee were changed.
Increased compensation for advancement.
After the evaluation in 2000, the revisions were approved and new criteria took effect in February 2002.
New graduates = Level I.
Experience RNs = Level II.
Levels III and IV advancement remained voluntary and requires submission of a portfolio and a clinical exemplar to the clinical advancement process committee.
Requirement of 1200 hours per year gives more flexibility and more opportunities for advancement.
Interview was more individualized based on portfolio content.
Criteria have the same format for all levels.
Eligibility criteria, annual mandatory requirements and annual elective requirements were defined in each level.
Annual professional goals and bi-annual progress reports are required for levels III and IV. Also, nurses at these levels must work a minimum of 1200 hours per year and maintain the ability to assume the charge nurse role in their units.
RN III – 40 contact hours of continuing education or 32 contact hours + 3 academic credits annually.
RN IV – 48 contact hours of
Quantity:
15 nurses advanced.
Number of RNs at Level IV has doubled but still lower than the desired quantity by the committee. Quality:
65 nurses sought advancement.
Positive response to criteria changes: o criteria allow for variety and diversity o interview process was less stressful o feeling of being supported throughout the process o process was a motivating factor.
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continuing education or 40 contact hours + 3 academic credits; serving as a unit preceptor and providing at least 2 continuing education programmes per year.
Criteria categories for the annual elective requirements: o competency o customer service o teamworkquality o continuous learning.
Transfer across clinical divisions without loss of status; for 6 months after orientation, RN III or IV is allowed to meet competencies required for the new practice area; those unable to meet the competencies within 6 months must repeat interview with the committee.
Formal programme evaluation after 2 years of implementation.
Handsearching bibliographies of relevant articles
USA Regional not-for-profit health care system in central Virginia
Evaluative study design
Survey was conducted by the first author of this article who is also the co-chair of the clinical advancement process committee (CAPC).
Convenience sample of all RNs in the clinical advancement programme (n=960); response rate = 18.3% (n=176).
Survey was sent to different patient care units.
Participation was voluntary and anonymity was ensured.
The hospital’s nurse retention specialist gathered all survey responses through the organizational mail system.
Data were entered into SPSS and analysed by descriptive statistical methods.
Instrument: Clinical Ladder Assessment Tool by Dr. Sarah Strzelecki
Surveys were sent through the hospital mail system, which has an inconsistent method of distributing mail This may have affected the number of participants who received the survey in time to complete it by the deadline.
Some participants may also have been reluctant to send their responses through the inter-hospital mail.
Limited number of responses may not be representative of the majority of the staff.
Survey instrument only allowed a ‘yes’ or ‘no’ response.
Most of the missing data were demographic so no surveys were excluded based on missing data.
Nurses Re-evaluation of the clinical advancement process described in the study of Goodrich and Ward (2004) Recent changes:
Patient educators are eligible for advancement.
Nurses can return to the bedside without penalty of losing ladder designation.
New graduates could advance to RN II level within a year with submission of a portfolio to the unit manager.
Portfolio contents: o applicant’s resume or curriculum
vitae o absentee rate; o copy of most recent evaluation; o evidence of completion of
orientation competencies; o copy of continuing nursing
education record (including mandatory in-services);
o 2 peer reviews; o supporting documentation of
eligibility criteria; o annual mandatory requirements
and annual elective requirements; o written goals; o brief clinical narrative.
Submission requirement and peer evaluation tool for the RN II were modified. Requirements are based on the levels III and IV requirements.
After the hospital’s Magnet designation in 2005, applicants are required to relate their clinical exemplar to the forces of magnetism.
– Quantity:
Number of nurses advancing to Level III has increased over the years: o 2001 – 14 o 2002 – 28 o 2003 – 28 o 2004 – 29 o 2005 – 48.
Number of nurses advancing to Level IV has increased over the years: o 2001 – 1 o 2002 – 8 o 2003 – 7 o 2004 – 6 o 2005 – 11.
Percentage of nurses at each level has remained relatively constant. Quality:
Nurses believe that the advancement programme stimulates greater responsibility and accountability in their practice.
Nurses at higher levels have an increased professional view of their practice.
Increased responsibility and decision-making opportunities as they advanced: Level II = 68%, Level III = 84%, Level IV = 76%.
Use of personal initiative and judgement in providing care: Level II = 59%, levels III & IV = 80%.
Advancement process as encouragement to increase knowledge and sophisticated nursing skills: Level II = 57%, Level III = 74%, Level IV = 90%.
Advancement process offers opportunities for professional growth: Level II = 64%, Level III = 78%, Level IV = 90%.
Clinical advancement process as encouragement to be a role model for new staff members: Level II = 70%, levels III & IV = 90%.
Increased awareness of the need to describe the rationale for their care which validates their comprehension of the increased accountability: Level II = 57%, Level III = 80%, Level IV = 78%. Other:
Resources needed:
Comprehensive manual identifying criteria and process for advancement located in each nursing unit and on the hospital’s Intranet.
Advancement committee and nurse executive council to continually develop and enhance the advancement process in response to the needs of the organization, staff and the profession.
Information dissemination regarding the programme/process of advancement.
Committee and nurse retention specialist to publicize nurses’ advancements.
Ward CW, Goodrich CA. 2007. A clinical advancement process revisited: A descriptive study. MEDSURG Nursing, 16:169–173. Definition: Clinical ladders – first implemented in the 1970s to retain nurses and recognize nurses who stayed and excelled at the bedside. Clinical advancement programmes – methods to improve quality of patient care, reward nurses for clinical competence, increase job satisfaction, increase financial compensation, increase productivity and support professional growth of new staff members. These can also influence professionalism and dedication to career.
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Changes based on findings:
Education initiative: o members of the committee gave
information and answer questions regarding the programme during the hospital’s Nurses Week celebration;
o Powerpoint presentation was added to mandatory online education for each clinically based RN;
o instructions to access online manual were provided to each staff by e-mail;
o education programmes and unit managers’ responsibilities related to the process were presented during the leadership meetings of unit managers.
Advancements were publicized in the hospital newsletter and on the nursing home page on the intranet with the help of the nurse retention specialist.
All RNs III and IV were recognized by having their names written on a poster at the hospital’s Nurses Week celebration.
73% of respondents agreed that the clinical advancement programme gave them a sense of accomplishment and professional satisfaction.
Only 25% identified the advancement process as a major factor in continuing employment.
Only 34% would not consider working in a setting without an advancement programme.
Monetary compensation and peer recognition are important motivating factors for all levels.
Personal time constraints and perception that the process is intimidating were perceived as barriers to making a commitment to advancement.
Lack of unit manager’s involvement and support.
Staff members did not see practice differences among those who advanced.
Knowledge deficit about the clinical advancement process especially among the nurses at the second level of the programme; 20% of respondents incorrectly named the number of advancement levels while 45% expressed no comprehension or lack of comprehension of the process.
Comprehensive and accurate information regarding advancement was received from those who have previously advanced (54%) instead from the manuals located in each nursing unit and on the hospital’s Intranet.
Only 8% of respondents indicated receiving the best information about the process from their unit managers.
58% of respondents noted advancement should be accompanied by public and formal recognition.
Handsearching bibliographies of relevant articles
USA A magnet hospital: Methodist Hospital in Houston, Texas
Brief interview with Pamela Klauer Triolo, RN, PhD, a chief nursing executive and senior vice president at Methodist Hospital in Houston, Texas
– Nurses Nursing Clinical Career Progression Model
Dual career ladder integrating professional development within a clinical career progression.
Offers lifetime development through competencies.
Aimed to retain nurses at the bedside and to develop leadership at the front line.
5 clinical practice levels.
It utilizes the novice-to-expert theory differentiating the roles a nurse fulfils as he/she progresses.
Performance rating and years of experience are considered in compensation.
‘Pay for performance’.
Clinical nurses can achieve salaries competitive with management.
Pre-requisite: membership in a professional association.
Involves achieving certification in a specialty area or returning to school.
– Quantity: Summer of 2003: 1400 nurses were shifted into the Nursing Clinical Career Progression Model.
– Petterson M. 2004. Career Progression Model recognizes professional development. Critical Care Nurse, 24,119–120.
Handsearching bibliographies of relevant articles
USA Greenville Hospital System (GHS)
Descriptive study
A 3-year process of redesigning an existing clinical ladder to become a professional recognition programme was
– Nurses Clinical ladder to Professional Recognition Program First clinical ladder in GHS:
Clinical expertise by level (I-IV).
Title (level IV = ‘senior’ nurses).
– RESULTS OF THE FOCUS GROUP DISCUSSIONS REGARDING THE INITIAL CLINICAL LADDER Other:
Initial ladder was perceived to be very limited.
Leads only to positions away from the
Resources needed:
Ladder Committee to start the process of transforming the clinical ladder to a Professional Recognition Programme.
Ladder Committee members: o directors who volunteered – after literature search and initial
discussions, the following were asked to join: 3 nurse managers; 2
Glenn MJ, Smith JH. 1995. From clinical ladders to a Professional Recognition Program. Nursing Management, 26:41–42.
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described.
Focus groups of senior nurses and new employees to evaluate the initial clinical ladder.
Each level has its job description, evaluation criteria, salary range and point system where the salary increase will be based.
Difficult to differentiate competencies from requirements since some competencies were requirements on the specialty units.
Received negative comments. Suggestions for the new ladder:
Job performance evaluation is considered separately from promotion possibilities.
Peer evaluation is incorporated.
Stand-alone performance evaluation system.
Unit-specific competencies.
7 category indicators for bedside care and weights for each category (each specialty area decided on the weight it wanted for the 7 categories): o nursing process (30–45%); o other 6 (5% above or below the
suggested).
Nurses at Level II could try meeting the requirements of a newly designed “Credentialing Ladder” (self-initiated and earns the nurse a bonus instead of a promotion).
Credentialing Ladder is separated from the annual job evaluation.
Approved version of the new ladder:
1 job description/performance evaluation for bedside nurses.
Professional Ladder with system-wide and unit-specific requirements.
Those who will complete the Professional Ladder will receive a bonus.
What to submit to the Professional Recognition Committee in order to meet requirements: o a portfolio on Continuing Education
Units (CEUs) earned must be submitted;
o signatures validating positive peer reviews;
o proof of completion of role development classes;
o certification in the specialty.
Bonus: US$ 600 cash or a voucher for US$ 750 to be spent on education pursuits for every year in the programme.
bedside (nurse manager and educator).
Educational opportunities were limited by the number of nurse clinician and nurse clinical specialist positions available.
Not flexible for nurses to attend workshops.
Lack of information regarding the clinical ladder. CLINICAL LADDER TO A PROFESSIONAL RECOGNITION PROGRAM (3-year process) Other:
1st year: self-initiating credentialing ladder was established.
2nd year: one job description/performance evaluation was developed for bedside nurses.
3rd year: a professional recognition program, recognizing expertise and experience, emerged.
directors as co-chairs – expanded to include: - staff nurses from all areas and from all 7 hospitals within the system
– later on co-chaired by 1 director and 1 nurse manager.
Focus groups led by the hospital’s research department to evaluate the initial clinical ladder: o senior level nurses o new employees.
Professional Recognition Committee to replace the old Ladder Committee and to judge portfolios submitted: o 3 managers o 3 nurse clinicians o 5 staff nurses.
Handsearching bibliographies of relevant articles
USA Vanderbilt University Medical Center
Descriptive study The collaborative work by numerous nursing leaders and staff
– Nurses Vanderbilt Professional Nursing Practice Program (VPNPP); outline of the overall programme’s foundation, philosophical background and basic structure
– Other:
With the development of the 4 RN job descriptions and the implementation of the programme, the thinking and behaviour as related to nursing were changed, as well as the way the academic medical centre functions within the broader healthcare
Resources needed:
Steering committee to design the programme.
Central committee to standardize advancement to 2 highest levels of the system.
Robinson K et al. 2003. The Vanderbilt Professional Nursing Practice Program, Part 1: Growing and supporting professional nursing
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One of the most severe nursing shortages in the American health-care system history was experienced during the initiation of the programme. Also, the general population’s age was increasing as well as the age of the working RNs and there was a growing need for the management of chronic diseases.
to build a basic under structure for the VPNPP was discussed in this article.
VPNPP is a performance-based career advancement system.
Promotes, supports, recognizes and rewards application of clinical nursing expertise in direct patient care.
Clear levels of practice and observable practice differences.
Nurses are advanced based solely on their observed and consistent performance to standards.
The standards are broadly defined in job descriptions.
Process for performance evaluation is part of the ongoing performance appraisal system for each nurse.
There are salary equivalents to the performance of nurses.
It aims to encourage nurses to practice at the bedside as they advance in their careers.
Consistent with the educational mission of Vanderbilt.
VPNPP was also consistent with the organization’s requirements for performance evaluation.
Conceptual framework of VPNPP: o Vanderbilt Professional Nursing
Practice Model: - evolution of managed care in the
mid-1990s required new mindsets and behaviours for health-care organizations to achieve success;
- mindsets based on Karen Zander’s work: practice and thinking of nurses should be evolve from being task-oriented to outcome-oriented;
- 6 key functions of nurses engaged in direct patient care: planning and managing care; continuum of care planning; patient and family education; problem solving; communication and collaboration; and continuous learning;
o revised system for clinical advancement of nurses: - the initial clinical ladder was
focused on nurses on inpatient units and was considered as “laborious, insignificant, inapplicable to daily practice, unrealistic, and poorly rewarded”;
- the new system has 4 RN job descriptions where a central committee standardizes advancement to the 2 highest
system.
The collaborative work of developing the VPNPP lasted for 2.5 years and resulted in 4 RN job descriptions with a beginning vision for how nurses grow in their practice.
VPNPP was created for 1500 nurses working a wide variety of settings within a quaternary hospital.
Chief Nursing Officer to provide suggestions and recommendations throughout the process.
Experts in the area of human resources to participate in the development of the programme.
Involvement across the clinical enterprise with representation from a variety of practice settings.
A case study to aid nurses in seeing the practical difference between the newly developed job descriptions.
practice. Journal of Nursing Administration, 33:441–450.
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levels; - Measurement of practice through
focusing on integrated, collaborative practice;
o Benner’s model for developing clinical excellence.
LEVELS OF PRACTICE
RN 1 (novice) – basic, uncomplicated, seeks appropriate information, and may require assistance; 15% of nursing staff are expected to be in this category.
RN 2 (competent) – consistent, independent, able to individualize care, and prioritizes care activities; 60% of nurses in the academic medical centre.
RN 3 (proficient) – anticipates, critically analyses, a role model, and resource person; 20% of nurses in the academic medical centre.
RN 4 (expert) – expertly, initiates, mentors, and leads; 5% of staff nurses of the academic medical centre.
Handsearching bibliographies of relevant articles
USA Vanderbilt University Medical Center One of the most severe nursing shortages in the American health-care system history was experienced during the initiation of the programme. Also, the general population’s age was increasing as well as the age of the working RNs and there was a growing need for the management of chronic diseases.
Descriptive study Discussion on the development of evaluation tools used in the VPNPP, implementation and management of the new system, programme evaluation and programme improvements. Challenges and lessons from the implementation are also presented. Evaluation tool development Focus group discussions to gain staff and manager input.
– Nurses Vanderbilt Professional Nursing Practice Program (VPNPP); description of the development of evaluation tools, implementation and management, programme evaluation and programme improvements, as well as challenges and lessons learned. VPNPP:
4-tiered performance-based career advancement system.
Recognizes and rewards performance of clinical nursing expertise in direct patient care.
Integrated performance appraisal system and career advancement programme.
Same data collection tools are used to evaluate performance for annual review and to assess at which level the nurse was practicing.
EVALUATION TOOLS
Step 1: defining behaviours associated with each critical element within the 4 job descriptions: o a list of behaviours and outcomes
was generated; o behaviours listed were the same
across practice areas; o languages used in different
practice areas vary.
– Quality:
Staff nurses and managers have very favourable attitudes toward the 1:1 evaluation conference between both groups.
Increased interest and motivation toward growth by many of the nurses.
Nurses utilize their newly realized empowerment in communicating with peers and other health-care team members about quality of care issues.
Nurses attempt to solve problems on their own.
Nurses want to be involved in formal teaching of new RNs.
Many nurses participate or coordinate staff education.
There is an increased awareness of nursing research. Other:
There was an improvement in documentation after the new evaluation process.
Tools have successfully differentiated practice levels but were not enough in evaluating quality of performance in each level.
Some criteria were not clear.
Quality of peer feedback was poor.
Most users expressed that the process was complex and lengthy:
Revision of the evaluation tool: o continue a single process for evaluation; o inclusion of all criteria for all levels on all tools; o scoring sums were removed to focus better on feedback rather than the score.
Resources needed:
Steering committee to define the staff nurse role among and within the more diverse health-care team.
A workgroup (staff nurses from different specialties, representative managers and case managers) to define essential practice elements in each key function identified in the Vanderbilt Professional Nursing Practice Model.
Spreadsheet design for computations for performance evaluation.
Chief nursing officer (CNO) to sponsor the programme and ensure the availability of financial and human resources.
Project manager to guide the development and implementation of the programme.
Management teams (manager, assistant manager(s), unit educator or designated charge nurses) to support the programme.
Communication between the management and staff was important during programme implementation.
Project manager, committee members and the manager are responsible in educating staff nurses.
Project manager and members of steering committee to facilitate patient care centre leadership meetings.
Steering committee with several manager volunteers to revise the evaluation tools.
Recommendations:
Constant communication and collaboration with teams from other organizations.
Extensive pilot test should be undertaken prior to full implementation.
Commitment to a structured training and implementation process.
Provision of regular and visible support.
System for rapid responses to identified problems.
O’Hara NF et al. 2008. The Vanderbilt Professional Nursing Practice Program, Part 2: Integrating a professional advancement and performance evaluation system. Journal of Nursing Administration, 33:512–521.
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Step 2: designing of evaluation tools by posing questions of who would most likely observe the behaviours listed in step 1 and where would these behaviours be seen.
Step 3: separate data collection tools: documentation audits; manager/assistant, manager/charge nurse feedback; peer feedback and physician feedback in outpatient and procedural practices; self report.
Evaluation for each nurse: every quarter using a different feedback tool every time.
Weights for each tool used: o 4 documentation audits: 35% o manager/charge nurse feedback:
25% o self-report: 25% o peer and physician feedback: 7.5%
each.
Area-specific RN staff meetings periodically.
Web-based programme on giving and receiving feedback.
Centralized seminars. IMPLEMENTATION
Inter-rater reliability sessions for each management team to ensure consistency within and across practice areas.
Management and staff forums as well as e-mails as means of communication.
Staff nurse education regarding the tools and overall process.
PROGRAMME EVALUATION
Debriefing sessions were scheduled after the 1st evaluation year
Managers, assistant managers and charge nurses gave direct feedbacks through guided discussion in patient care centre leadership meetings
Staff nurses provided feedback through: centralized sessions, monthly staff council meeting, or written survey.
Revised tools were found easier to use, address quality and distinguish the level of performance.
Handsearching bibliographies of relevant articles
USA Vanderbilt University Medical Center One of the most severe nursing shortages in the American health-care system history was
Descriptive study Review of the advancement process, roles of individuals involved and the outcomes
– Nurses Vanderbilt Professional Nursing Practice Program (VPNPP); review of the advancement process and roles of the people involved; outcomes and lessons learned are also described VPNPP:
Performance-based career advancement system implemented in
– Quantity:
At the time of the study, 106 nurses had already advanced through the central committee process.
83 out of 85 applicants for RN 3 had successfully advanced.
23 out of 24 applicants for RN 4 had successfully advanced.
After 18 months of an active central committee, the distribution of nurses among the 4 levels did not meet the expected proportions. 82.7% of
Resources needed:
An established evaluation system.
Project manager.
Central committee and managers to review nurse’s performance.
Central committee, steering committee (10 people) and ad hoc area representatives to assist nurses in advancement.
Resource manuals and Vanderbilt web site to inform nurses of the process and requirements for advancement.
VPNPP e-mail address for staff and managers to communicate with the
Steaban R et al. 2003. The Vanderbilt Professional Nursing Practice Program, Part 3: Managing an advancement process. Journal of Nursing Administration, 33:568–577.
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experienced during the initiation of the programme. Also, the general population’s age was increasing as well as the age of the working RNs and there was a growing need for the management of chronic diseases.
April 2000.
4 levels: RN 1-4.
All nurses advance to level 2 at the end of the first year of their employment
Advancement to levels 3 and 4 is voluntary.
An established performance evaluation is used for each nurse on an annual basis.
Data are gathered from different perspectives over time to show consistency of the nurse’s performance.
Advancement to RN 3 and RN 4 levels:
Advancement to RNs 3 and 4 levels requires a central committee plus the manager’s review of the nurse’s performance.
The committee assesses the nurse against a single standard with a single interpretation.
To advance to RN 3: o RN must receive manager
endorsement; o RN must secure endorsement from
a health-care team professional in a discipline other than nursing;
o RN must provide written examples of his/her practice at an RN 3 level or undergo an interview with the central committee.
To advance to RN 4: o RN must receive manager
endorsement; o RN must secure endorsement from
a health-care team professional in a discipline other than nursing;
o RN must undergo an interview with the central committee.
Resource manuals are available to describe the programme, process of advancement and requirements.
Vanderbilt website helps inform nurses of the programme.
Also, there are 3 orientation sessions in a year to provide information on advancement.
VPNPP e-mail address enables nurses to access project manager.
The manager ensures that the candidate is ready for advancement prior to submitting portfolios to the Central Committee.
All completed portfolios are submitted to the project manager for review before forwarding to 2 committee members.
The 2 committee members act as
all nurses are in the RN 2 level.
5% to 10% of nurses in each of the 3 practice locations advanced to RN 3 or 4 during the first 18 months.
11% of those who have advanced to RN 3 and 4 are in procedural areas (areas that provide episodic and procedurally driven care: operating room, cath. lab and emergency room); 8% in inpatient area; and 8% in the outpatient area. Quality:
Greater use of research by staff nurses.
Greater awareness that research findings must guide practice changes.
Nurses are reading journals more consistently.
Improved level of nursing performance in some areas.
RN 3s and 4s demonstrated effective and efficient practice and were found to standardize practice wherever applicable.
There is an increase participation of staff nurses in developing clinical pathways and patient teaching standards and tools.
There is an improvement in the documentation.
RN 3s and 4s and managers have increased their confidence and assertive leadership.
There is an increased staff participation in both formal and informal-incidental coaching and mentoring.
There is an increased responsibility of RN 3s and 4s in improving the practice of less experienced nurses and ensuring that standards of care are practiced by all. Other:
After 18 months, the review process by the central committee in their sessions was reduced to 30 minutes per candidate compared to a 1-hour process earlier.
Also the time lag between the receipt of the portfolio and the central committee review has been reduced from 6–10 weeks to 3–6 weeks.
Most nurses, who have advanced, found the process gratifying and rewarding.
VPNPP is becoming embedded in the culture of nursing throughout the system.
project manager.
Chief nursing officer to notify the nurse of successful advancement.
A massive amount of time and energy in developing and refining the programme, tools and process.
Challenges:
Two committee members must meet to interview candidates and managing the logistics of gathering 3 busy clinicians had been a challenge.
Due to the bulk of the applications, there was a time lag of 2–3 weeks between the receipt of the application and the actual interview.
The presentation of candidates and the process of review by the committee members took a long time at first since each member challenged the understanding of the criteria of the other members.
Some nurses were endorsed by managers but were found to have no evidence of higher level practice behaviours when interviewed by the central committee.
Absence of a role model in the group has made understanding and recognition of professional practice at levels 3 and 4 difficult.
Cost:
Advancements to RN 3 and 4 levels have increased the total nursing salary budget by 1%.
Printing of materials and manuals.
Nourishment during the training sessions and meetings.
Central committee meetings (4–8 hours a month) attended by 20 staff nurses and managers who are also being paid for their time.
2–3 hours’ preparation by the central committee members for the interview and presentation of each applicant.
Salaries of a full-time project manager and 0.5 full-time equivalent administrative assistant.
Database to support the evaluation system, which is being enhanced every year.
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advocates of the applicants in front of the other committee members.
Committee members vote to recommend the advancement of nurses. If the recommendation is not for advancement, a remedial plan is established.
Chief nursing officer notifies the nurse of successful advancement.
Nurses who will advance will receive recognition and compensation (additional US$ 2/hr for RN 3 and US$ 3/hr for RN 4).
If an RN transfers to another department, he/she may choose to remain at the designated level as long as he could perform adequately.
Central Committee:
Membership is by appointment of the chief nursing officer.
Members: o Master’s-prepared nurses from
each patient care centre (PCC) o a nurse at the RN 3 or 4 levels from
each PCC o director of nursing research o clinical consultant from the learning
centre o nursing administrator.
Ex officio members: o ad hoc nursing representative from
each PCC o VPNPP project manager o programme’s administrative
assistant.
CNO as committee sponsor.
Consultants: a representative from the Center for Clinical Improvement and Human Resource Services.
Ad hoc members only take part in discussing the candidates’ performances.
All members of the committee have their own expertise to share to aid in the advancement process of the nurses.
– = Not determined.
Recommendation 9: Health professionals’ education and training institutions should consider implementing Inter-professional education (IPE) in both
undergraduate and postgraduate programmes.
Methodological quality issues
Population Intervention Comparison Reported results
(outcomes) Additional comments Reference
None reported Medical students (31 students in 2005 and 30 in 2006), and biomedical students (63 in 2005 and 43 in 2006)
IPE activity within the established teaching schedule in medicine and biomedicine, which consisted of an intra-professional phase (2-hour introductory session followed by 3 laboratory sessions and house half-days for the medical and biomedical students, respectively) and an interprofessional phase (1 half-day in 2005 and 2 half-days in 2006).
No comparison
Quality:
39% of medical students in 2005 rated the interprofessional session as 'good' or 'very good' and 17% as 'bad' or 'very bad', while 24% of biomedical students rated the session as 'good' or 'very good' and 46% as 'bad' or 'very bad'. They were not statistically significantly different.
The medical students were more enthusiastic, appreciative of the IPE activity while the biomedical students wanted more explicit learning objectives.
The study was supported by Strategic Pedagogical Funds of Karolinska Institutet and the Stockholm County Council Foundations
Lewitt MS, et al. 2010. Stereotyping at the undergraduate level revealed during interprofessional learning between future doctors and biomedical scientists. Journal of Interprofessional Care, 24: 53–62.
It measured short-term effect. Longer-term follow-up is required to see if short-term benefits translate into improvements in the workplace.
Medical and nurse educators and research staff. 4th year medical students undertaking the Healthcare of Children module and third-year children's branch nursing students.
IPE paediatric simulation workshop using learning outcomes common to both professions, and essential in the clinical management of sick children, included basic competencies, communication and teamworking skills.
No comparison
Quality: Quantitative results showed that responses were positive for both groups of students across 4 domains: acquisition of knowledge and skills; communication and teamworking; professional identity and role awareness, and attitudes to shared learning. Quality: Qualitative results showed that students felt that an IPE approach to paediatric simulation improved clinical and practice-based skills and provided a safe leaning
High-fidelity manikin Simulation suite Information technology
Stewart M et al. 2010. Undergraduate interprofessional education using high-fidelity paediatric simulation. Clinical Teaching, 7:90–96.
environment.
Benefit: Large-scale quantitative studies which track students' attitudes to change over time. Limitation: Students may artefact the response to show their enthusiasm for IPE to tutors. And it is possible that some of the findings from the present study may be related to certain artefacts of longitudinal research.
Pre-registration students in dentistry, dietetics, medicine, midwifery, nursing, occupational therapy, pharmacy, and physiotherapy (Undergraduate and diploma students).
A substantial interprofessional education course which students from all health-care disciplines had experienced joint learning in a number of topics including communication skills and ethics.
Pre- and post-intervention
Quality:
The strength of professional identity in all professional groups declined significantly over time for some disciplines, students' identification towards their own profession varied significantly over their course (F3.768=22.89, p<0.001).
Students’ scores on the RIPLS measure fluctuated significantly over their course (F3.688=47.24, p<0.001).
The strength of professional identity varied significantly over time for nursing (F3.792=15.57, p<0.019), dentistry (F=3.860=3.32, p=0.019) and dietetic students (F2.769=3.35, p<0.036). The decline in professional identity scores between baseline and year 4 was statistically significant for nursing (t6.88=3.53, p<0.001), dentistry (t6.87=3.05, p=0.002), dietetics (t=8.31=2.10, p=0.036), and physiotherapy students (t=8.46=2.04, p=0.042). RIPLS
None Coster S. et al. 2008. Interprofessional attitudes amongst undergraduate students in the health professions: a longitudinal questionnaire survey. International Journal of Nursing Studies, 45:1667–1681.
scores varied significantly over time in students. Nursing students were the only group whose enthusiasm for interprofessional learning together did not alter significantly over time.
The levels of contact reported by almost all professional groups altered significantly over the 4-year period, with the exception of midwifery and physiotherapy.
Correlations between professional identity scale score and RIPLS were typically positive.
Short-term follow-up IPE students groups limited to medical and nursing students
4th year paediatric medical and third year children's branch nursing students
An IPE workshop to facilitate learning of knowledge, core competencies, communication and teamworking skills in paediatric drug prescribing and administration at undergraduate level The practical, ward-based workshop was delivered to 4th year medical and 3rd year nursing students
Pre- and post-intervention
Quality:
Students reported an increase in their knowledge and awareness of paediatric medication safety and the causes of medication errors (pre 43.0; post 65.9, p < 0.001). Highly significant changes in students' attitudes to shared learning (pre- 67.9; post- 76.6; p<0.001) were observed.
No significant differences were observed in pre- and post-workshop scores, or within each discipline.
Qualitative data revealed that students' participation in the workshop improved communication and teamworking skills, and led to greater awareness of the role of other
– Stewart M et al. (2010). An interprofessional approach to improving paediatric medication safety. BMC Medical Education, 10:19.
health-care professionals.
The cohort was characterized by a disproportionally higher number of nursing students due to the fact that the interprofessional course was already mandatory for them. Also, the robustness of this methodology is not yet clearly established.
Students from nursing, pharmacy, kinesiology, nutrition, occupational therapy, psychology, medicine, physiotherapy, and community health
Intensive training consisting of a 45-hour programme, offered each semester, which was divided into 3 x 15-hour weekend courses. The 3 courses were designed sequentially, and students were strongly advised to take them in order. It was mandatory in the undergraduate nursing programme and has been gradually mandatory in other course too.
Pre- and post- assessment
Quality: Results showed a significant increase from the students' point of view in the knowledge and benefits to be gained from interprofessional collaboration training
Health Canada funded
Dumont S et al. 2010. Implementing an interfaculty series of courses on interprofessional collaboration in prelicensure health science curriculums. Education for Health, 23:395.
This study is only a pilot with small numbers of participating student. The amended questionnaire was note tested before use. There was competition in attending all of the whole sessions for student doctors and nurses, contributing to their non-attendance.
Student midwives, nurses and doctors A scripted conversation between two fictitious health-service planners was triggered to 5 IPE groups consisting of 7–8 students and 2 facilitators. The discussion was on the commissioning of a working party to develop a 'user's guide' to uncomplicated pregnancy, labour and the puerperium.
Pre- and post-intervention
Quality:
Out of 40 students, 32 (80%) answered both pre- and post -intervention questionnaires.
Student midwives improved their post-test scores for 'teamworking' by two points (54–56), the student doctors by one point (54–55), the nursing students by one point (56–57).
With 'interprofessional working', the student midwives had increased their scores by 2 points (67–69), student doctors by 4 points (66–70) and student nurses by 2 points.
Qualitative data showed that all students enjoyed
None Furber C et al. 2004. Interprofessional education in a midwifery curriculum: the learning through the exploration of the professional task project (LEAPT). Midwifery, 20:358–366.
the opportunity to learn in an interprofessional team, that sharing is a fundamental reason for implementing interprofesional learning and that they had mixed feelings about the PBL experience.
Due to the fact that the intervention group consisted of students who volunteered to take this course, quantitative results revealed some expected biases Conflicting schedules were another problem in obtaining numbers of participants for the course
2 second-year nursing, two BS health psychology, 3 fourth-year pre-medical and health, and 3 fifth-year pharmacy students
One-semester, three-credit course that met weekly in a self-contained interprofessional class
Non-intervention group
Quality:
Intervention group had significantly more positive attitudes towards team collaboration compared to controls both pre- and post-assessment (p<0.001).
These students also scored higher both pre-intervention and post-intervention on a measure of perceived ability to meet the needs of older adults (p=0.004).
The RIPLS subscale of singular professional identity was no different between intervention and control groups pre-intervention but a noted difference between groups at follow-up approached significant (p=0.061).
Before the course, the intervention group demonstrated a strong and significant negative correlation between the RIPLS subscale of patient centeredness and a professional identity (r=-0.0771; p=0.009).
At follow-up, this correlation was
None Dacey M et al. 2010. An interprofessional service-learning course: uniting students across educational levels and promoting patient-centered care. Journal of Nursing Education, 49:696–699.
neither as strong nor as significant (r=-0.051; p=0.889).
Qualitative findings support the trend toward changes noted in the quantitative data.
None reported First-year students from the Mayo Medical School Class of 2011 and the Mayo School of Health Science, Doctor of Physical Therapy Program Class of 2010
A two-day interdisciplinary education session, an informal social event over lunch
Pre- and post-intervention
Quality:
Positive comments were related to opportunities for developing a better understanding of the nature and scope of each other's programmes, encouraging teamwork and communication, mutual respect, and reducing the perceptual divide between disciplines.
92% of the students agreed that interprofessional learning would help them in becoming a more effective member of the health-care team.
None Hamilton SS, et al. 2008. Interprofessional education in gross anatomy: experience with first-year medical and physical therapy students at Mayo Clinic. Anatomical Sciences Education, 1:258–263.
Limitation is the voluntary nature of the trial and the lack of a randomization process. Moreover, heterogeneity of teaching staffs for the workshop, short-term evaluation of the study, and selection bias of the participants were possible limitations.
1st year students from medicine, nursing, physiotherapy and occupational therapy
IPE intervention, which included a staff-training programme, e-leaning materials and interprofessional teamworking skills workshops
Non-intervention group
Quality:
IPE promoted theoretical learning about team working, it enabled the students to learn with and from each other (p<0.001).
It significantly raised awareness about collaborative practice (p<0.05), and its link to improving the effectiveness of care delivery (p<0.01).
Qualitative data show that it served to increase students' confidence in their own professional identity and helped
Funded by Cheshire and Merseyside Health Authority
Cooper HE et al. 2005. Beginning the process of teamwork: design, implementation and evaluation of an inter-professional education intervention for first year undergraduate students. Journal of Interprofessional Care, 19:492–508.
them to value difference making them better prepared for clinical placement.
None reported Pre-registration nursing students 2-day child and adolescent mental health services workshop, which was included in the curriculum of the third-year pre-registration programme for mental health students
– Quality:
26 students who attended 2-day workshop answered the questionnaires.
Of these, 96% were satisfied and enjoyed the workshop, 11% expected more information on mental health symptoms and treatment, 15% gave positive comments, and 35% made comments with regard to increasing the length of sessions or the overall workshop.
– Terry JE et al. 2009. Inter-branch initiative to improve children's mental health. British Journal of Nursing, 18:282–284, 286–287.
Sample size and use of the RIPLS as a post-test measure, as well as participant attrition Selection bias (17 out of 19 students were female)
Students from paramedics, nursing, midwifery, occupational therapy, physiotherapy, and nutrition and diabetes.
Six 1.5-hour IPE workshops during the end of semester teaching period between October and November 2009. IPE is taught in small groups where all disciplines are viewed as equal, and the material presented is relevant to all fields, and based on real-life clinical problems.
Pre- and post-intervention (immediately before, shortly after, and 6 months after the IPE workshop)
Quality: “Learning with other students/professionals will make me a more effective member of a health and social care team” showed an increase between Time 1 and 2 (Wilks' Lambda =0.54, f(2,17)=7.17,p<0.01, partial eta squared =0.46). “It is not necessary for undergraduate postgraduate health and social care students/professionals to learn together” showed a consistent decrease over the reporting occasions (Wilks' Lambda =0.58, f(2,17)=6.23,p<0.01, partial eta squared =0.42).
Funding provided by the State government of Victoria, Department of Human Services (service and Workforce Programme)
Williams B et al. 2011. A pilot study evaluating an interprofessional education workshop for undergraduate health care students. Journal of Interprofessional Care, 25:215–217.
“Shared learning and practice will help me clarify the nature of patients' or clients' problems” showed an increase in Time 2 and then lowered slightly in Time 3 (Wilks' Lambda =0.624, f(2,17)=5.19, p<0.05, partial eta squared =0.38). “Shared learning before and after qualification will help me become a better teamworker” showed an increase in Time 2 and then lowered slightly in Time 3 (Wilks' Lambda =0.60, f(2,17)=5.78, p<0.05, partial eta squared =0.41).”
None response rate and lower percentages of 4th-year nursing students and pharmacy students agreed to participate in the study
Nursing, nutrition, pharmacy, and physical therapy students
Quality improvement exercise evaluating a case about elderly patients in transition from acute care to community care One 1.5–3 hour uniprofessional session and 2 interprofessional group sessions (3 hours in total) and 3 assignments (2 individual and 1 group)
Pre- and post-intervention
Quality:
Significant increases were found between pre-intervention and post-intervention reflection scores for 12 of 16 items (p<0.05). Few significant differences were seen based on professional designation. Post-intervention group evaluation scores reflected a high level of satisfaction with the experience.
There were no significant differences in the group evaluation scores based on professional designation.
Marks for the assignments 1 and 2 were both relatively high (85.6% and 80.8%, respectively).
Funded by the Patient Centered Interprofessional Team experiences (P-CITE) Program, Interprofessional Education for Collaborative Patient-Centred Practice (IECPCP), Health Canada Project
Dobson RT et al. 2009. A quality improvement activity to promote interprofessional collaboration among health professions students. American Journal of Pharmacological Education, 73:64.
The use of Students from 2 medical schools (1 The intervention consisted of an 8-week course 1) Schools Quality: None Hansson A et al. 2010). Medical
Jeffferson Scale, small sample size, cross-sectional nature of the study, and participation rate of intervention school Further, almost 10% of the students did not answer one or more questions
provided IPE and the other not) Undergraduate students from medicine, medical laboratory technology, nursing, occupational therapy, community- care supervision and physiotherapy.
during their 1st term to study HEL I together, a 2-week follow-up course (HEL II) and 2-weeks' practical experience at a specially designed orthopaedic ward and 2 geriatric training wards
which provide IPE and those that do not. 2) Male and female students. 3) Students with or without previous experience of working in health care. 4) First and final year students.
1) No significant difference in attitude towards nurse-doctor collaboration between 1st-year students between the two schools (p=0.31). Nor was there significant difference detected. in students' attitudes towards collaboration between final year students at both schools (p=0.61). 2) There was a small but statistically significant difference in attitude towards collaboration between female and male students for the whole group at both schools (p=0/017; 95%CI 0.24-2.48). 3) There was no correlation between work experience and attitudes towards collaboration, irrespective of the number of years spent working (p=0.978). 4) There was a very small but still statistically significant difference in attitude between 1st year and final year students, with students in their final year being less positive (p=0.021), irrespective of gender and university.
students' attitudes toward collaboration between doctors and nurses – a comparison between two Swedish universities. Journal of Interprofessional Care, 24:242–250.
Self-reporting from a subset of students from the pharmacy class The focus groups were held 6 months after the IPE session Only 3 of 232 pharmacy
Students from dentistry, medical radiation sciences, medicine, nursing, occupational therapy, pharmacy, physical therapy, speech language pathology, and social work
The 2006 session was held in a theatre near campus for 21/2 hours in the late afternoon in mid October Students were informed that the session was a required component of the curriculum focusing on a single patient case and 2 possible discharge scenarios
Pre- and post-intervention
Quality:
43 (18.5%) of the pharmacy students responded to the open-ended questions.
Positive feedback about the content/process. of the session was reported.
The most frequently reported gains from
None Cameron AM t al. 2009. An interprofessional education session for first-year health science students. American Journal of Pharmaceutical Education, 73:62.
students who attended the session participated in the focus group Further, the response rate for the open-ended questions was low
attending the session were recognition of teamwork importance to benefit the patient (30%) and understanding of other professionals' roles (29%).
Shortfalls reported by students related to the content/style of presentation (26%) and technical/organizational (23%) aspects of the session.
Moreover, many of the students in the focus group responded that they were encouraged by other health professional students' interest in cooperation and that the session had made them want to become involved in making interprofessional patient care a reality.
All students agreed that there were benefits for patients in IPE and interprofessional care (IPC), particularly for more complex cases.
Students also mentioned the legal ramifications of deferring patient-care decisions to another professional.
Selection bias (data collected from only those who chose the course)
Allied health students Participants were recruited from the course ‘Evidence-Based Practice in Allied Health’ at the University of Queensland.
Participants were undergraduate final year occupational therapy students and postgraduate physiotherapy students.
A multi-professional university course that included evidence-based practice skills and concepts.
Pre- and post-course
Quality:
Attitudes towards evidence-based practice did not significantly improve; however, attitudes were already positive prior to
37% did not response to post-course questionnaires
Bennett S, Hoffmann T, Arkins, M. 2011. A multi-professional evidence-based practice course improved allied health students' confidence and knowledge. Journal of Evaluation in Clinical Practice, 17:635–639.
The course was run over a 13-week period (2 hours per week) and utilized didactic lecture, tutorial and work-shop formats, and a hand-on database searching session.
The pre-course questionnaire was completed at the beginning of the first lecture and the post-course questionnaire was completed during the last lecture of the course.
undertaking the course.
There was a statistically significant improvement in confidence with a mean increase of 9.02 [score range 6–30, 95% confidence interval (CI) 8.21, 9.82].
Perceived knowledge improved with a statistically significant mean increase of 14.15 (score range 5–25, 95% CI 12.55, 15.75) and there was a statistically significant mean increase in actual knowledge of 3.56 (score range 0–10, 95% CI 2.83, 4.29).
Other (conclusions and recommendations): Teaching evidence-based practice skills and concepts to allied health students within a multi-professional university curriculum improved confidence, and perceived and actual knowledge regarding evidence-based practice
Selection bias (data collected from only one University)
Nursing and allied health students The study compared perceptions of interprofessionalism between 4 cohorts of health-care students at Oslo University College before and after the introduction of the common core in 2003.
A questionnaire designed to elicit perceptions of ‘‘interprofessionalism’’ was administered to these 4 groups using a quasi-experimental approach: o Group 1 without the common core for nursing
(in 2001) o Group 2 without the common core for allied
health professions (in 2001) o Group 3 with the common core but taught
separately for nursing (in 2003) o Group 4 with the common core taught together
for allied health professions (in 2003).
Without common core (groups 1 and 2) and with common core (groups 3 and 4)
Quality:
Students with a common core (groups 3 and 4), regardless of professional group were more convinced than those without that knowledge (groups 1 and 2) about how other health professions would make them better health workers and how interprofessional education was as
Almas SH, Barr H. 2008. Common curricula in Norway: differential implementation and differential outcomes in undergraduate health and social care education. Journal of Interprofessional Care, 22:650–657.
a way of achieving such knowledge.
Surprisingly, even though the differences were minor, the nursing students without a common core recognized more strongly the purpose of interprofessional work (statements 7 and 9), compared with nursing students with a common core.
Other: (conclusions and recommendation) Students with a common core were more convinced than those without of the need for knowledge of the competence of other professions to improve their own professional competence and those where it was taught together even more so.
Measurement bias: Component IV could not be evaluated due to the lack of feedback from website visitors.
Family medicine, nursing, and social work students
45-hour-undergraduate curriculum with 4 components These were the sustainability of the educational activities, and the enthusiasm of the different partners led to the creation of the Collaborative Network on Interprofessional Practices at the university level and its affiliated health and social services clinical network.
No comparison
Quality: The sustainability of the educational activities, and the enthusiasm of the different partners led to the creation of the Collaborative Network on Interprofessional Practices at University level and its affiliated health and social services clinical network.
None Bilodeau AS et al. 2010. Interprofessional education at Laval University: Building an integrated curriculum for patient-centred practice. Journal of Interprofessional Care, 24:524–535.
Unclear for how long such an intervention would have an effect
Medical and nursing students All 170 2nd-year medical students (MS) from Peninsula College of Medicine and Dentistry, universities of Exeter and Plymouth, and 45 2nd-year nursing students (NS) from the Faculty of Health and Social Work, University of Plymouth, were invited to participate in a study of ILS skills education.
The students were blinded to the study objectives.
Those with previous ILS, advanced life support (ALS) training or health-care qualifications were excluded.
71 randomly selected consenting students were allocated to either the uniprofessional (UP) group
Interprofessional (IP) and uniprofessional (UP) teams
Quality:
The Behaviour Description leadership (LBDQ rating) was strongly and significantly correlated with Emergency Team Dynamics scale (ETD) rating (r = 0.562, P < 0.01) and had a medium-strength significant correlation with the
None Bradley P et al. 2009. A mixed-methods study of interprofessional learning of resuscitation skills. Medical Education, 43:912–922.
in Exeter or the interprofessional (IP) group in Plymouth, based on the geographical location of the student’s place of study.
Background data were collected immediately before each ILS session.
Intervention focused on resuscitation skills in uniprofessional or interprofessional settings, prior to undergoing observational ratings of video recorded leadership, teamwork and skills performance and subsequent focus group interviews.
Resuscitation (RTT) measure (r = 0.367, P < 0.01).
The ETD and RTT were not significantly correlated.
MANOVA indicated there was no significant difference in performance between the IP and UP teams on the LBDQ, ETD and RTT.
No differences were found to be significant using a Bonferroni-adjusted a level of 0.01 Interview analysis showed broad support for interprofessional education (IPE) matched to clinical reality with perceived benefits for teamwork, communication and improved understanding of roles and perspectives Concerns included inappropriate role adoption, hierarchy issues, professional identity and the timing of IPE episodes.
No significant difference between interprofessional and uniprofessional teams for leadership, team dynamics or resuscitation tasks performance ‘…from the start, if you mix it from the start then you don’t have any of that us and them at all, it’s like we’re all in it together.” (IPMS).
Other (conclusions and recommendation):
An intervention based on common,
relevant, shared learning outcomes set in a realistic educational context can work with students who have differing levels of previous IPE and skills training experience.
Qualitatively, positive attitudes outlast quantitative changes measured using the RIPLS.
Further quantitative and qualitative work is required to examine other domains of learning, the timing of interventions and impact on attitudes towards IPE.
Small sample size
Dentistry, medicine, nursing, and pharmacy students
Participants were students from 4 faculties (dentistry, medicine, nursing and pharmacy) and 2 schools (Medical Rehabilitation and Dental Hygiene) at the University of Manitoba.
The development of this project occurred in partnership with two service-provider organizations, the Winnipeg Regional Health Authority (WRHA) and the J.A. Hildes Northern Medical Unit (NMU) of the University of Manitoba.
Data were collected at 4-time points; prior to an IPE- classroom intervention, following an IPE-classroom intervention, following the IPE-immersion experience, and 4 months post-IPE immersion experience.
2 types of interventions implemented: first, in the classroom where participants took part in sessions on collaboration and interprofessional group discussion, and second, in collaborative practice settings where small interprofessional groups of pre-licensure students were immersed in 1 of 4 settings in urban (Winnipeg, Manitoba), and rural and remote locations (Manitoba and Nunavut).
Before and after response was compare for qualitative method intervention groups and control groups were compared
Quality:
Demographic data showed no difference by group (C vs. E vs. I; one-way ANOVA) for factors including age, sex, professional programme of enrolment, or the programme year of participants.
There was a significant increase for Group I (n = 18) in the summary mean score of all traits between baseline (first survey) and post-education (second survey), and between first survey and post-immersion (third survey).
However, there was no further (statistically significant) increase in the summary mean score of all traits for any profession between the
None Ateah CA et al. Stereotyping as a barrier to collaboration: Does interprofessional education make a difference? Nurse Education Today, 31: 208–213.
second survey and the third survey.
Mean ratings of individual traits for each profession for Group I (n = 18) were then examined to determine changes occurring between the baseline and post-immersion.
The mean rating of the traits of professional competence, leadership, independence, team player, practical skills and confidence increased over time in a parallel manner across professions.
All of these 6 traits increased significantly between the 1st survey (baseline) and the 3rd survey (post-immersion); that is, participants ranked all professions significantly higher (p < 0.05) on these 6 traits post-immersion relative to the baseline survey.
It would seem that working together in a practice setting would provide the most fruitful and beneficial experiences for development of students' interprofessional relationships.
The incorporation of IPE curricula that address the role and functions of other health care professions to facilitate the development
collaborative patient-centred care health-care teams.
1-week intensive course
Medical students and master of social work and social welfare
An intervention tackling 1 community health issue by students
No comparison
Quality: The interdisciplinary, community-oriented exercise allows students to appreciate health problems as they occur in society, giving them insight into the interaction of the local community with health care agencies.
None Art B et al. 2008. An interdisciplinary community diagnosis experience in an undergraduate medical curriculum: development at Ghent University. Academic Medicine, 83:675–683.
Nursing, physiotherapy, occupational therapy, children's nursing, mental health nursing, midwifery, radiotherapy and social work
Cohorts 1 & 2.
581 students completed scales concerning their communication and teamwork skills, their attitudes towards interprofessional learning, their perceptions of interaction between health and social-care professionals, and their opinions about their own (inter)professional relationships.
Questionnaires were completed at both entry and qualification by 526 students, and at all three points by 468 students.
Cohort 3 250 students in comparison group
Quality: Students on the interprofessional curriculum showed no significant change in their self-assessment of their communication and teamwork skills between entering the faculty and qualification. However, there was a negative shift in their attitudes to interprofessional learning and interprofessional interaction.
Nevertheless, most students were positive about their own professional relationships at qualification.
Students with previous experience of higher education were comparatively positive about their communication and teamwork skills, as were female students about interprofessional learning.
However, the strongest influence on students’ attitudes at qualification appeared to be professional
None Pollard KC et al. 2006. A comparison of interprofessional perceptions and working relationships among health and social care students: the results of a 3-year intervention. Health and Social Care in the Community, 14:541–552.
programme.
This suggests that interprofessional education does not inhibit the development of profession-specific attitudes.
Students who qualified on the interprofessional curriculum were more positive about their own professional relationships than those who qualified on the previous uniprofessional curricula.
An insufficient number of groups (4 MultiG groups and 2 MedG group).
Medical, nursing and pharmacy students
Multidisciplinary group (MultiG) that consisted of 6 students, 2 from medical, pharmacy and nursing, and a medical student group (MedG) consisting of 6 medical students only who were given a two-day problem-based learning programme using evidence-based medicine (EBM) methodology. The students’ knowledge on clinical epidemiology was assessed at the beginning of the study.
MutliG and Med G
Quality:
Correct answers to assess clinical epidemiology knowledge increased significantly in both groups (4.1–9.9 points in MultiG, p < 0.001: 3.6–9.7 points in MedG, p = 0.002), while scores at baseline and post-programme were not significantly different.
The number of additional patient information cards requested was not significantly different (p = 0.10).
After the programme, the VAS for clinical decision-making was significantly different (54 mm and 89 mm, p = 0.013), although pre-programme values for both groups were similar. Results showed that the clinical decision-making by medical students was affected through PBL programmes
None Nango E, Tanaka Y. 2010. Problem-based learning in a multidisciplinary group enhances clinical decision making by medical students: a randomized controlled trial. Journal of Medical and Dental Sciences, 57:109–118.
with multidisciplinary health-care students compared to those with medical students only.
Measurement bias: The lack of assessment of the role of two independent lecture-style IPE subjects implemented in the first academic year.
Nursing, laboratory science, physical and occupational therapies students
No intervention (the IPE programme consists of 2 types of subjects, 1is a lecture style, which includes 2 subjects delivering information to 1st-year students and teaches the details and value of interprofessional working (IPW) Another type is Teamwork Training, which builds on the professional expertise acquired in the 2nd year; 3rd-year students participate in this mandatory training subject, a core programme of our IPE
No comparison
Quality:
Over all, 1418 respondents out of a possible 1629 students completed the survey, for a total response rate of 87.1%. Cronbach's alpha of 10 items was 0.793, revealing high internal consistency.
The percentages of positive responses for "fully understand" and "understand" changed from 71.5% in 1999 to 86.0% in 2007.
When mean scores of the surveyed year were compared by MANOVA model, the mean score and 95% CI in 1999 (2.99; 95%CI 2.84–3.14) was significantly lower than that in 2004 (3.33; 95%CI 3.21–3.45), 2006 (3.30; 95%CI 3.17–3.43), and 2007 (3.32; 95%CI 3.19–3.44).
The mean scores during 2000/2007 were not significantly different Results suggested that development of a better understanding of
None Ogawara H et al. 2009. Systematic inclusion of mandatory interprofessional education in health professions curricula at Gunma University: a report of student self-assessment in a nine-year implementation. Human Resources for Health, 7:60.
how professional team members manage hierarchy and authority may play an important role in an effective health team.
The present four subscales measure "understanding", and may take into account the development of interprofessional education programmes with clinical training in various facilities.
The content and quality of clinical training subjects may be remarkably dependent on training facilities, suggesting the importance of full consultation mechanisms in the local network with the relevant educational institutes for medicine, health care and welfare.
None reported Medical students No intervention Each school combined family medicine, ambulatory paediatrics, and ambulatory medicine into contiguous clerkship blocks In all institutions, each clerkship maintained certain distinct features while the integrated aspects contained longitudinal curriculum of certain primary care topics
No comparison
Quantity:
Evaluations by students demonstrated favourable responses to the new content and integrated methods of teaching, as did results of the Association of American Medical Colleges graduation survey.
Faculty at each institution reported that their multidisciplinary approach had stimulated important educational collaborations, many of which require an economy of scale not often
None Pipas CF et al. 2004. Collaborating to integrate curriculum in primary care medical education: successes and challenges from three US medical schools. Family Medicine, 36(Suppl.):S126–S132.
achievable within a single clerkship.
These included innovative evaluation/documentation efforts; centralization of administrative tasks; enhanced recruitment, retention, and development of community-based faculty; an increase in the active core group of local and national primary care leaders; and an increase in scholarly activities.
The collaborations have not occurred without challenges, primarily in the need for identifying sustainable resources for these and future collaborative educational endeavours.
The benefits involved in developing an integrated primary care experience include expansion of curriculum content and methods, as well as enhancement of collegial support and resources to community-based and academic faculty.
Small sample size.
Senior year student from health professional course
4 week-programmes, with activities comprising appox. 2.5 hours per week. An interactive team building workshop facilitated patient care discussion, structured participation in ward meetings, observation and participation in other professions' assessment/treatment procedures, and opportunities for reflection on team performance.
Pre-post test Quality:
Results from the analysis of written case scenarios showed an overall increase in the level of students’ understanding of health professional roles (p < 0.01).
FGDs: [Interprofessional teamwork] “It’s about client-focused therapy, working with other
None Nisbet G et al. 2008. Interprofessional learning for pre-qualification health care students: an outcomes-based evaluation. Journal of Interprofessional Care, 22:57–68.
disciplines to ensure the patient or client receives the best therapy and that each discipline’s goals are incorporated into the overall goals for the patient . . . I think with everyone discussing their opinions of what they’ve found with the patient, each individual is given a broader view of where the patient’s at and so they can adjust their intervention strategies accordingly . . . you can get the best out of it, also as an individual you feel part of something and that your opinion is valued and respected.” Results indicate that students' understanding of the roles of other team members was enhanced, and students and supervisors perceived the programme to be of value for student learning.
These kinds of programmes have the potential to expand students' understanding of the contributions made by other professionals/colleagues to effective patient care, although challenges persist in overcoming pre-existing role stereotypes.
None reported Medical and nursing students The aim of this study was to create conditions under which effective learning could take place and positive attitudes be fostered.
Key features included opportunities to work as equals in pairs and small groups on shared tasks
16 Nursing students and 23 medical students
Quality:
Both groups evaluated the programme positively; the
None Carpenter J. 1995. Interprofessional education for medical and nursing students: evaluation of a programme. Medical Education, 29:265–272.
in a cooperative atmosphere.
Topics included communication between nurses, doctors and patients, deliberate self-harm by patients, and ethical issues in clinical care.
nurses thought it more useful than the doctors (M 5.38 vs. 4.91) and significantly more interesting (F(1,37)=6.44,P<0.05 [ M 6.13 vs. 5.17]), but both these ratings are high.
A comprehensive evaluation of the effects of the programme on 1 cohort of 39 participants revealed that overall attitudes towards the other profession had improved.
Participants reported increased understanding of the knowledge and skills, roles and duties of the other profession
The programme was positively evaluated by both groups of participants.
Using pervious data (face-to- face) and current data (self-administered questionnaire) to compare
Health and social care students Cohort 1: Interprofessional curriculum (students from all 10 professional programmes). Cohort 2: Interprofessional curriculum (students form adult, mental health and children’s nursing). Cohort 3: Uniprofessional curriculum (students from nursing programmes, midwifery, physiotherapy, diagnostic imaging and radiotherapy).
With and without experience of interprofessional curriculum education
Quality:
The professionals were more confident at qualification about their communicative skills, their interprofessional relationships and other professionals’ interaction, and showed positive correlations between perceptions of their relevant skills and their interprofessional relationships.
They were also more positive about their interprofessional relationships than practitioners educated on uniprofessional
None Pollard KC et al. 2008. From students to professionals: results of a longitudinal study of attitudes to pre-qualifying collaborative learning and working in health and social care in the United Kingdom. Journal of Interprofessional Care, 22:399–416.
curricula.
Age and previous experience of higher education influenced professionals’ attitudes negatively: mature individuals may require more support when entering the workforce.
Between qualification and practice, respondents from the interprofessional cohorts grew more critical of interprofessional education.
However, experience of interprofessional education appears to produce and sustain positive attitudes towards collaborative working, suggesting that individuals’ perceptions of their own educational experience are inadequate as an evaluative measure of interprofessional learning initiatives.
This study reinforces the argument for including IPE in pre-qualifying curricula.
None reported Health science students The introductory module of a new interprofessional curriculum for health science students, which included a client's perspective of the health-care team: to gain familiarity with one another’s professional role, and initiate appreciation of health-care from the perspective of different professions. (The focus groups enabled in-depth exploration of key issues, perceptions, and experiences)
Pre-post (Pre-(baseline) - 1 to 2 weeks before the IPE course Post-completion of the course
Quality: An indication of the effects of early IPE on students' attitudes and perceptions of interprofessional issues.
The repeated-measures analysis of variance revealed that there was a significant main effect of time for the IAQ (F[l,388] = 113.03, mean standard error [MSE] = 1.15, p < 0.01] and the IEPS (F[l,376] = 86.87, MSE = 1.44, p < 0.01), with overall scores higher at post-test than at pre-test. There were significant time by item interactions for both the IAQ (F[13, 5044] = 24.99, MSE = 0.298, ? < 0.01) and the IEPS (F[17, 6392] = 4.79, MSE = 0.289, ? < 0.01), indicating that the increase in scores from the pre-test to the post-test varied by item.
Figures 1 and 2 provide details on changes in students' attitudes and perceptions for the 399 matched responses in relation to the IAQ and the IEPS. The quantitative data demonstrate some significant shifts in many indicators after this single intervention. Open-ended questions generated replies from 234 students who provided more detailed
None Cameron A et al. 2009. An introduction to teamwork: findings from an evaluation of an interprofessional education experience for 1000 first-year health science students. Journal of Allied Health, 38:220–226.
perceptions of the event. Table 4 presents the key themes that emerged from this element of the evaluation. Several quotes within each theme are provided; these highlight diverse opinions generated by the session.
However, the comments also substantiate the need for further discussion of IPE/collaborative care in the curriculum in an effort to address the perceptions and challenges identified by these students.
Qualitative comments reveal both positive feedback and areas to improve the process.
None reported Curriculum reform leaders, course directors, and first year medical students
No intervention No comparison
Quality:
Students highlighted the impact of integration on their learning and the challenges of sequencing and scaffolding content.
Both students and course directors focused on course monitoring and conceptual links for student learning.
None Muller JH et al. 2008. Lessons learned about integrating a medical school curriculum: perceptions of students, faculty and curriculum leaders. Medical Education, 42:778–785.
The response rate for the open-ended questions was low. FGDs held after six months after IPE session with interested students
Health science students To implement and evaluate the effectiveness and short-term impact of an interprofessional education (IPE) session in the first year for health sciences students representing 9 health professions. A two and half hour introductory interprofessional education session focusing on the story of a patient recovering from a stroke and 2 possible discharge scenarios requiring the interaction of various health professionals.
Pre- and post-IPE session
Quality:
The session served as an effective introduction to IPE; debriefing and integration with uniprofessional curricula should occur.
Students need additional small group interaction with other health professional students, and can contribute as members of the planning committee.
Pharmacy students who participated in one of the focus groups stated the session demonstrated the benefits as well as facilitators and barriers to collaborative care.
FGDs : All students agreed that there were benefits for patients in IPE and interprofessional care (IPC), particularly for more complex cases; they were surprised that some current care, as illustrated by the patient's story, was not as collaborative as it should be.
When asked if they see any potential barriers to interprofessional work, students indicated that the need to change attitudes would be the most difficult, yet important so that other professionals would be open to working with the team.
None Cameron A et al. 2009. An interprofessional education session for first-year health science students. American Journal of Pharmalogical Education, 73:62.
Recommendation 10: National governments should introduce accreditation of health professional education where it does not exist and strengthen it where it does exist
Country/setting Study design/sample size Methodological quality issues
Population Intervention Comparison Reported results (outcomes) Additional comments Reference/definition
USA 257-bed acute care facility (St. Elizabeth) located in a Midwest metropolitan area
Descriptive study design This article describes the experiences with a clinical ladder programme for 20 years in a 257-bed acute care facility located in a Midwest metropolitan area There were 382 registered nurses and 42 licensed practical nurses who participated in the programme in 1998 while in 2008, there were 611 RNs and 23 LPNs as participants
– Nurses Clinical ladder programme for nurses in a 257-bed facility
Patricia Benner’s Novice to Expert Model as a reference for the conceptual framework for the clinical ladder programme.
Initially, there were 4 levels in the ladder.
The programme committee members planned different advancement criteria.
In order to advance in the clinical ladder, nurses would need to meet the minimum score for the level to which they desired to advance in each of the 6 major categories: education, experience, professional and leader, provider, teacher, and advocate.
An annual performance appraisal is done to validate the maintenance of the nurses’ clinical ladder status.
There is a quality/practice council in charge of maintaining a list of projects for those nurses who wish to advance on the ladder.
Clinical ladder advancement involves salary increases.
Annual policy review was also included in the programme.
Also, exemplars, which are rich stores of the relationships in which care is provided, are employed in the programme to validate the provider, teacher, and advocate roles of nurses.
Over time, the programme shifted towards a differentiated practice model, adding the licensed practical nurse (LPN) track.
The RN track was also transformed into 5 levels.
– Quantity:
54 to 70 nurses advanced in the ladder in each of the last 3 fiscal years.
Number of nurses in each RN track ladder and in the LPN2 level continued to increase over time.
Quality:
It allowed nurses to reach out of their comfort zones.
The clinical ladder programme increased professional self-awareness in nurses.
Other:
The clinical ladder programme for nurses became integral to the facility’s recruitment and retention, professional development, and evidence-based practice initiatives.
Was also proven a useful tool in succession planning since there was a continuous movement of nurses in and out of the facility.
The programme promotes and supports professional development and has enabled the facility to recognize talents in nurses that were previously unidentified.
It makes "selling" work at the institution easier to prospective hires.
Resources needed:
A team of staff nurses from a wide range of practice settings was commissioned to develop the programme.
Extensive literature review was conducted to be able to determine what nurses wanted to be recognized for.
The team also needed to benchmark with known successful programmes in the same geographical area.
An annual budget plan to include salary increases from advancements in the ladder.
Social acceptability: There is a continued interest in clinical ladder advancement among nurses
Pierson MA, Liggett C, Moore KS. 2010. Twenty years of experience with a clinical ladder: a tool for professional growth, evidence-based practice, recruitment, and retention. Journal of continuing education in nursing, 41:33–40. Epub 2010/01/28. doi: 10.3928/00220124 20091222-06. PubMed PMID: 20102141 Definition: Clinical ladder programme – has a potential to serve the following functions:
Enhance recruitment and retention of competent, experienced staff.
Foster professional development.
Establish an effective reward system for improved clinical performance.
Strengthen the quality of nursing practice.
Recognize staff nurses for excellence in patient care
Identify excellent nurses as role models.
USA Kaiser Permanente of Colorado (KPCO) is a large health maintenance organization with 595 RNs working in ambulatory care offices and regional support
Descriptive study design: There were 68 nurses as participants in the study (45 career ladder participants and 23 non-participants) 53% response rate
– Nurses RN Career Ladder The RN Career Ladder at KPCO was started by a Labor Management Partnership Committee in 2003
It gives financial incentives (5–
Absence of an RN Career Ladder
Quality: Career ladder RNs were more involved in:
leadership (F (1, 57)=13.9, p<0.001).
quality improvement (F (1, 57)=5.90, p=0.02).
preceptorship (F (1, 57)=13.4, p=0.001).
activities than non-career ladder RNs in the same job role.
– Nelson JM, Cook PF. 2008. Evaluation of a career ladder program in an ambulatory care environment. Nursing Economics, 26:353–360. PubMed PMID: 19330969 Definition: Clinical ladders or career
roles for ambulatory care 7.5% salary differential) to RNs who show commitment to continuing education, leadership activities and programme development on a local and regional level.
The career ladder was designed to enhance and reward role expansion, rather than performance.
Participation in interdisciplinary committees, task forces, and guidelines development teams are rewarded in the programme.
A nurse can participate in the career ladder if he/she has served for at least 1 year at KPCO and at least half-time work status.
Criteria for career ladder advancement
Educational level.
Participation in continuing professional education.
Experience as an RN.
Professional nursing certifica-tions and memberships.
Engagement in leadership, communication and research activities, and health.
Care-related volunteer work. The programme also requires nurses to articulate an organizational goal related to improving health care quality or cost, with measurable outcomes. Applicants must reapply to the programme annually and applications are reviewed quarterly.
Other: No difference in job satisfaction (F (1, 57)=2.02, p=0.16) between career ladder RNs and non-career ladder RNs in the same job role
Career ladder participation was correlated with: o knowledge of the career ladder (F (1,
57) = 67.0, p<0.001); o belief in the career ladder philosophy
and perceived benefits of participation (F (1, 57)=49.1, p<0.001);
o career ladder participation was not correlated with nurse manager support.
advancement systems are designed to enhance professional development, provide a reward system for quality clinical performance, promote quality nursing practice, and improve job satisfaction among nurse
Descriptive study design
Development and implementation of the career ladder in ambulatory care nursing was described.
Barriers and key success factors were also discussed.
No sample size was mentioned.
Relevance: In addition to acquiring points, specific, measurable, realistic, time-phased, and collaborative annual goals are required for career ladder RNs. As a result of the programme, there have been several successful goal-related projects completed such as the development of a post-surgical teaching tool and the mechanism of identification and reaching out to patients who had not received an HbA1C test in over a year. Other: The data from Nelson and Cook (2008) indicate that participation of nurses in the career ladder programme enabled nurses to be involved in activities that were beneficial to their professional growth and to the priorities of KPCO. ----------- Challenges encountered
Communication about individual RN projects in order to manage collaboration with each other.
Burdensome and time-consuming application review process.
Initial lack of administrative support.
There were times when nurses found it difficult to gather support for their projects.
Resources needed:
In partnership with United Food and Commercial Workers Local 7, a labour management partnership (LMP) committee created the RN career ladder programme to be able to define the roles and responsibilities of the RN in KPCO.
An interest-based problem-solving committee was formed, which consisted of 5 management and 5 labour employees, to come up with multiple alternative solutions and eventually develop a shared resolution.
Consensus decision-making was also employed.
A volunteer career ladder committee was also formed, with representatives from both labour and management, to review applications to the career ladder.
A point tool was developed to be able to assess the eligibility of an applicant to advance in the career ladder.
Nelson J, Sassaman B, Phillips A. 2008. Career ladder program for registered nurses in ambulatory care. Nursing Economics, 26:393–398. PubMed PMID: 19330975
USA Tennessee is experiencing acute nursing shortages in the area hospital and medical centres. Northeast Tennessee also has an unstable economic environment
Descriptive study design A report on a year-old project that assists LPNs to obtain a baccalaureate degree in nursing (BSN) To determine the level of interest of LPNs for an LPN to BSN programme; prior to the start of the project, 1833 LPNs were surveyed in Dec.
– Licensed practical nurses (LPNs)
LPN to BSN Career Mobility Project; Educational mobility for licensed practical nurses (LPNs) to obtain baccalaureate degree in nursing.
The specific concerns of the LPNs about returning to school were noted and included as retention strategies in the project.
The LPN to BSN Career Mobility Project also partners with
– Quantity: 93% retention rate at the end of the first year. Quality: 85% of the respondents wanted to pursue a BSN degree and 75% wanted to begin within the next 6–12 months from the survey. Others: 30 students were admitted in the first year of
Resources needed:
The funds for this project come from the Division of Nursing (DN), Bureau of Health Professions (BHPr), HRSA, DHHS under grant number 1-D11-HP-00224 for US$ 852 967.
Several health-care agencies and an LPN programme at a local community vocational centre
Ramsey P et al. 2004. Community partnerships for an LPN to BSN career mobility project. Nurse Educator, 29:31–35. PubMed PMID: 14726797
2000 (21% return rate)
several health-care agencies and with an LPN programme at a local community vocational centre.
Due to the complexity of the project and agency policies, there is an advocate assigned in each agency who holds an administrative position.
The 6-year curricular plan allows an LPN to "earn and learn".
LPN students were fully supported by the available resources in the university.
4 unique features of the project: (1) role transition seminars for each cohort entering during the same semester (2 cohorts per year); (2) a project faculty mentor for each LPN student throughout the curriculum; (3) a BSN clinical nurse mentor for clinical courses; (4) advanced practice nurse mentors (nurse practitioners or NPs) in nurse managed clinics for clinical experiences.
Invitations were sent to those who indicated an interest in the project.
the project (23 in the fall semester and 7 in the spring). Admission rate for the 2nd and 3rd year of the project was estimated to be at least 25 and 30, respectively The average number of semester credit hours was 8 (2–3 courses) with an average grade point average of 2.99.
as partners.
An advocate assigned in each agency to perform administrative functions.
Expertise of directors of the Center for Adult Programs and Services (CAPS) in support of project participants.
CAPS offers a variety of support programmes for project participants of all age groups.
Key staff, identified by the admission, bursar and financial aid offices, to work with the LPN students.
A support service like the Nursing Undergraduate Resource for Successful Education (NURSE) centre offering peer mentoring and tutoring for those in the nursing major.
Mentors and tutors for students.
Pre-nursing assessment test and interactive interviews to identify students at risk.
Advertisements of the programme such as in newspapers.
Social acceptability: Project LPN students expressed their satisfaction and benefits gained from the project.
USA Akron Children's Hospital (ACH)
Descriptive study design/programme evaluation study 174 registered nurses in the Career Achievement and Recognition of Excellence (C.A.R.E.) Ladder programme were included in the sample population; however, only 136 were able to complete the survey.
– Nurses Career Achievement and Recognition of Excellence (C.A.R.E.) Ladder programme
Based on Benner's theory and was articulated by a group of staff registered nurses, nurse educators, and nurse managers.
5 levels of the ladder are: novice, advanced beginner, competent, proficient and expert.
Education, leadership and research are integral in each level.
Focuses on different nursing roles and has three tracks: clinical, education, and management.
In each track and in each level within the track, there are specified capability statements, which will assess the eligibility of a nurse to advance based on
– Other:
Mean overall satisfaction score for all respondents: 83.5 out of 100.
Respondents agreed that advancement in C.A.R.E. Ladder provides a sense of accomplishment and professional satisfaction about their nursing career (M = 4.16 out of 5). Those in the education track reported the highest score on this item (M = 4.38).
Respondents agreed that participation in the career ladder is an effective way for nursing expertise to be recognized (education track (M = 4.10); clinical track (M = 3.94); management track (M = 3.80)).
No significant difference in overall satisfaction scores related to nursing education degree and to the level on the C.A.R.E. Ladder was found.
The mean satisfaction scores of those who advanced did not differ significantly by track (clinical = 83.23; education = 81.55; management = 79.00).
Resources needed:
Professional development tool that assigns points for activities in education, leadership and research.
Partial funding was provided by the Akron Children's Hospital, Pediatric Nursing Research Grant, and Delta Omega Chapter of Sigma Theta Tau International Honorary Society of Nursing.
It was also mentioned that in 2007, the financial investment in C.A.R.E. Ladder benefits was approximately US$ 215 508 for the 295 C.A.R.E Ladder participants US$ 730 per participant per year, averaging all benefits of bonus, education days, and other).
The programme was
Korman C, Eliades AB. 2010. Evaluation through research of a three-track career ladder program for registered nurses. Journal for nurses in staff development, 26:260–266. Epub 2010/12/02. PubMed PMID: 21119379 Definition: Clinical ladders – recruitment and retention tool that provide a framework for the bedside nurse to advance and gain professional recognition.
his/her practice.
Allows recognition and reward for any registered nurse.
In each track, there is a focused set of criteria to show the advancement from the novice to the expert level.
Advancement is voluntary and a nurse must apply to advance or maintain C.A.R.E. Ladder status.
Validation of the nurse's level of expertise involves the creation of a portfolio of his/her professional activities.
Professional growth and financial rewards such as paid education hours; lump sum initial and maintenance bonuses; reimbursement for a variety of professional practice items of the nurses; and paid education time to attend conferences (fully reimbursed registration fees) are the motivations for the nurses to participate in the programme.
Among those who did not advance, a significant difference was observed (p = 0.03). Those in the education track who have not advanced reported to have the highest overall satisfaction score (90.70) while those in the management track had the lowest (77.10).
Results suggest that nurses participating in the C.A.R.E. Ladder view the programme positively regardless of nursing education preparation, level of advancement, or selected track.
considered to be cost-effective as a nurse retention strategy when compared with the estimated cost of replacing a registered nurse (US$ 82 000–US$ 88 000) (Jones, 2008).
Taiwan Cross-sectional study design A total of 1500 nurses were given the questionnaires to be filled out However, only 431 were considered valid Literature review
Common method bias concerning the relationship between organizational commitment and turnover intention Career stage measures concerning work experience were classified based only on the relevant studies and results from interviews with nurse
Nurses Career development programmes that It was hypothesized that nurses at different career stages (exploration, establishment, maintenance, disengagement stage) have different career needs.
It was also hypothesized that there is a positive association between the career needs and career development programmes gap and turnover intention.
The last hypothesis was that organizational commitment will be able to mediate the relations between the gap of career needs and career development programmes as well as turnover intention.
Career needs are classified into career goal needs, career task needs and career challenge needs.
– Quantity:
The gap between career needs and career development programmes influenced turnover intention caused by the decline in nurses’ commitment towards the hospital.
From the hierarchical analysis, the gap between career needs and career development programmes significantly
increased turnover intention (β = 0.183, P <0.01).
Others:
Nurses have different career needs at different career stages (F = 6.10, P < 0.001).
There is a significant difference (F = 3.51, P = 0.015) in career goal needs occurring at the establishment and maintenance of career stages.
There are greater career goal needs among nurses in the maintenance stage compared to those in the establishment stage.
No significant differences (F = 2.52, P = 0.057) found between career task needs at each different stage.
When it comes to the career challenge needs, there was a significant difference (F = 5.07, P = 0.002) found between nurses in the establishment stage compared to those in the exploration or disengagement stage.
Those in the establishment stage have less career challenge needs than those in
– Chang PL, Chou YC, Cheng FC. 2007. Career needs, career development programmes, organizational commitment and turnover intention of nurses in Taiwan. Journal of Nursing Management, 15:801–810. Epub 2007/10/20. PubMed PMID: 17944605
the exploration or disengagement stages.
The gap between career needs and development programmes was found to have significant contributions to
organizational commitment (β = -0.209, P < 0.01).
Organizational commitment was considered as the mediator and it was found to have significant negative
contributions (β = -0.453, P < 0.01) to the outcome (turnover intention). When this mediator was controlled, the coefficients for the gap between career needs and career development programmes
significantly decreased from β = 0.183, P
< 0.01 to β = 0.093, P < 0.05. This shows that organizational commitment reconciles the gap between career needs and career development programmes, and turnover intention.
USA Descriptive study design; 9 fellows completed the course in its first year: 5 geriatric medicine fellows, 2 geriatric dental fellows, 2 geriatric psychiatry fellows Fellows included 1-year medicine fellows and 2-year medicine, dentistry and psychiatry fellows
– Interdisciplinary geriatric medicine, dentistry, and psychiatry fellows
Academic career development in geriatric fellowship training
The University of Rochester’s Division of Geriatrics, in partnership with the Warner School of Graduate Education, formulated a yearlong course to achieve excellence in teaching and career development during geriatric fellowship.
This course is accredited by the Accreditation Council for Graduate Medical Education (ACGME).
Offered to geriatric medicine, dentistry, and psychiatry fellows who are participants in the traditional geriatric medicine fellowship.
Participants met twice a month for 1 1/2 hours.
There were reading assignments, class participation and presentations, and fellow product development.
The fellows were asked to complete a series of projects such as academic portfolio development. curriculum vitae revision, abstract submission and poster presentation at national meetings, lay lecture series development, and geriatric grand rounds presentation to be able to attain skills necessary for a clinician-teacher-scholar.
The course also gave opportunities to teach and assess all 6 of the ACGME core competencies.
– 9 fellows completed the course in its first year (2005–2006) Quality: The course enabled the participants to acquire teaching and leadership skills necessary for clinician-educators in an academic setting and for an effective communication with patients, families and colleagues. Relevance: The fellows focused on different areas such as diabetes mellitus, palliative care, end-of-life care, sexually inappropriate behaviour, agitation and anxiety disorders, mild cognitive impairment, apathy and depression, elder abuse, osteoarthritis, and dental prosthetics. Others:
All abstracts for poster presentations submitted by the fellows were accepted by the American Geriatrics Society (AGS), American Dental Society, and American Association of Geriatric Psychiatrists.
They were also able to participate in a mock poster presentation in 2006.
2 of the posters submitted were selected for the Presidential Poster Session of the AGS.
The fellows received positive feedback on their brief case-based presentations regarding their niche areas done in Monroe Community Hospital, which is a university-affiliated, teaching nursing home.
All of the fellows reported that the course would positively affect their career development, with 6 of them choosing academic careers.
Resources needed:
Needs assessment of the traditional geriatric medicine fellowship or the Rochester’s Health Resources and Services Administration (HRSA) – funded interdisciplinary geriatric fellowship.
Current faculty members developed the topics with the former geriatric fellows and the needs assessment influencing them.
Speakers came from the University of Rochester faculty based upon their expertise in each topic area. They were not offered any financial incentive for participation.
Course directors attended each class and taught 30% of the classes.
The costs were for the faculty time (support from the HRSA interdisciplinary fellowship and the Dean's Teaching Fellowship) and the reproduction of teaching materials.
Implementation limitations: No comparison data available on career choice of former fellows to show the effect of the course to the participants' career paths toward academic geriatrics. Salary support and protected time for the course directors
Medina-Walpole A, Fonzi J, Katz PR. 2007. Academic career development in geriatric fellowship training. Journal of American Geriatrics Society, 55:2061–2067. Epub 2007 Oct 29. PubMed PMID: 17971139
Fellows evaluated the course and will be tracked for 5 years after completion to determine intermediate and long-term outcomes of scholarly activity.
The completed course evaluation at 6-month intervals showed that the mean individual-session Likert score for the entire year was 4.0, with a range of 3.5 to 4.6.
are big factors to success, which may be difficult for smaller programmes with limited resources.
Norway Norway has a history of nursing shortage in the 1990s
Cross-sectional survey design This study was part of a larger study entitled “Job satisfaction and competence in nursing service” (Bjørk, 2004). There were 541 clinical nurses who participated in the study. All of them were participants in the clinical ladder programmes of 4 hospitals in Norway.
The study participants were from hospitals selected on the basis of those offering clinical ladder programmes since the late 1990s Hospitals without a relatively long history of systematic professional development programmes may have provided different results
Clinical nurses Clinical ladder programme
Since the 1990s, the design of clinical ladders in Norwegian hospitals shifted from recognition systems to systems for developing competence.
5-year programme of continuing development in clinical nursing.
Awarded the title of clinical specialist to nurses fulfilling the specified criteria.
Voluntary.
Regulated by nursing leaders.
Criteria of the clinical ladder programme were: o 5 years’ clinical practice
within one specific field of nursing;
o 150 hours of coursework: 50% related to the specific field of nursing and the rest related to general aspects of nursing such as ethics, nursing theory, documentation, communication, quality assurance, and health policy;
o 120 hours of supervision equally divided with individual, group, and peer supervision
o 4000 pages of literature (obligatory and self-elected in relation to patient group and theme of developmental work);
o developmental work grounded in the field of nursing, decided in collaboration with the unit manager, and documented in a paper.
Nurses move to the next level upon completion of learning tasks specified at each level.
Nurses receive a financial incentive.
– Quantity: It was reported that the intent to stay at the hospital for more than a year increased, as nurses moved upward in the ladder Quality:
The valuation of organizational aspects increased as one moves up the ladder.
There was an increase in the use of acquired competence (i.e. clinical work with patients and supervision of colleagues) as the nurses move up the ladder.
Nurses in level 3 used their acquired competence much more in quality assurance. work. Other: Intrinsic motivational factors: updating of nursing knowledge and skills, personal development, possibility of salary increase, development of the quality of nursing, and of clinical skill with own patient group were found to be of high importance when it comes to the reasons for joining the clinical ladder.
External motivational factors such as those involving the influence of other people were ranked at the lowest level of importance: benefits from participating in the clinical ladder increased as nurses moved upward in the ladder system, with the largest increase between nurses in levels 2 and 3, lack of managerial involvement in nurses' professional development, leaders were reported of not giving as much encouragement and engagement to nurses in clinical ladders.
Benefits: Personal and professional benefit and the use of new competence were some of the perceived benefits from a clinical ladder programme
Bjørk IT et al. 2007. Evaluation of clinical ladder participation in Norway. Journal of Nursing Scholarship, 39:88–94. PubMed PMID: 17393972 Definition: Career advancement programmes – clinical ladders which have shown to enhance professional development, improve staff relations, reward competency, and heighten nurses’ motivation in their work. Clinical ladders – can be ladders that are primarily defined as systems for recognition and reward of skill in nursing practice or ladders that are defined as systems for development of new expertise.
Recommendation 11: Health professionals’ education and training institutions should consider implementing continuous
professional development and in-service training of health professionals relevant to the evolving health-care needs of their
communities
Country
Study design/sample size
Methodological quality
issues
Population
Intervention Comparis
on Content
Frequency of CPD
Increase
coverage of
services
Participation of
education/training
institute in design and execution
Reported results
(outcomes)
Resource use
Additional comment
s Reference
USA Study design: Prospective, randomized, controlled trial comparing the process and outcome of care for HIV-infected patients delivered by generalists in generalists at the general medicine clinic (GMC) and specialists in an infectious disease clinic
Lack of blinding The study was performed in a single academic medical centre in the context of a resident-run clinic
Generalists at GMC
Generalists at GMC received HIV-related training and evidence-based practice guidelines in the university hospital
Specialists in an IDC without receiving training
Addressed the population need in improving HIV care in the ambulatory setting.
8 x 2 lectures each year of patient enrolment and quarterly care conferences Trainees received supervision from faculty both in GMC and IDC
No information on increase in coverage of services
CPD was being delivered in a medical centre
Quality: Similar proportion of patients in GMC and IDC received appropriate preventive care services, e.g. screening for TB was more frequent in GMC (89%, p=0.001). However, GMC patients had higher use of health-care services.
Research supported by a grant from Robert Wood Johnson Foundation and the Lawrence S. Linn Foundation for the study of quality of life in HIV-infected patients.
The residents in GMC provided good care equal to that provided by physicians with more experience in the IDC. However, patients assigned to IDC had significantly less use of hospital services than those patients assigned to GMC. The differences are not explained by differences in the
Keitz SA et al. 2001. Primary care for patients infected with human immunodeficiency virus. Journal of General Internal Medicine, 16:573–582.
(IDC). Both clinics are in a university hospital. Sample size: 63 (47 in GMC received the training course).
receipt of care, but may be due to physician experience in HIV care or structure of the clinic.
USA Study design: Prospective, randomized, observational case-controlled study to determine whether pharmacists who adopted a CPD approach were more or less likely to assess and identify their professional learning needs, develop
No statistical justification of sample size was performed. The study may subject to selection bias for those who are more innovative tend to volunteer in the study.
Practicing pharmacists
A certificate programme designed to instil, expand, or enhance practice competencies
Practicing pharmacists without intervention
Addressed the population needs in structured CPD among pharmacists to enhance the professional knowledge to a larger extent.
1 initial workshop, and 2 follow-up workshops spaced over 1 year
No information on increase coverage of services
Programme initiated by state pharmacy associations, National Association of Board Pharmacy (NABP), Accreditation Council for Pharmacy Education (ACPE), and academia. CPD was being delivered in 5 states (Indiana, Iowa, North Carolina, Washington, and Wisconsin).
Quality: Pharmacists in the study group were more likely to use a structured self-assessment tool to help identify practice strengths and areas for improvement compared to pharmacists in the control group (p<0.01).
Financial support was not specified. Technical support was received from state pharmacy associations and research institutes.
CPD should shift from provider-driven, hour-based model to a learner-driven, need-based model for lifelong learning and professional development.
Dopp AL et al. 2010. A five-state continuing professional development pilot program for practicing pharmacists. American Journal of Pharmaceutical Education, 74:28.
and implement a personal learning plan, evaluate their learning outcomes, and document each of these elements compared to pharmacists who utilized a traditional approach to CE without a structured intervention. Sample size: 28 study subjects, and 29 controls.
Taiwan
Study design: Convenience sampling, quasi-experimental pre-test/post-test design. The important concepts and scenarios were presented in 70 min., followed by a 20 min. period for discussion. Sample size: 59 nurses in intervention group, and 70 nurses in the control group.
The generalizability of the findings may be questioned due to the study design
Nurses In-service education programme developed based on literature and authors' clinical experience in nursing departments in universities
Nurses without the training
Addressed population needs in the practice of physical restraints to patients
1-time 90 min. short training
No information on increase coverage of services
The study was carried out in 2 branches of 1 private general hospital in Southern Taiwan
Quality: There was significant improvement in the intervention group in terms of knowledge (p=0.000), attitudes (p=0.007), and self-reported practices (p=0.048) related to physical restraint used after programme completion. No significant differences in participant attitudes towards the use of physical restraints between 2 groups after programme completion.
Financial support by Chung Hwa University of Medical Technology in Taiwan
Short-term courses are easy to arrange and manage, and they are more attractive to nurses. The long-term effect of this short-term training course is unknown.
Huang H-T, Chuang Y-H, Chiang K-F. 2009. Nurse's physical restaurant knowledge, attitudes, and practices: the effectiveness of and in-service education program. Journal of Nursing Research, 17:241–248.
Sri Lanka
Study design: Before-
Some characteristics may not
Midwives, nurses, and
A training programme based on
Midwives, nurses, and
Addressed population needs in
4-day training programm
No information on
CPD covered obstetric units in 5 hospitals
Quality:
Practice of
Supported by the
The practice implication
Senarath U, Fernando DN, Rodrigo
and-after study with an intervention group and a control group. Sample size: Study group: 27 midwives, 19 nurses and 13 doctors. Control group: 26 midwives, 19 nurses, and 16 doctors.
be comparable between intervention and control group, e.g. availability of resources, ethnicity of the participants, and the mode of delivery that may have an influence of the outcome independent from training.
doctors WHO Training Modules on Essential Newborn Care and Breastfeeding were offered in the hospital which aimed to increase knowledge of essential newborn care (ENC) and develop the corresponding skills among midwives, nurses, and doctors in obstetric units. The forms were lecture discussions, demonstrations, hands-on training, practical assignments, and small group discussions.
doctors who did not participate in the training programme
improving newborn health in Sri Lanka
e consisting of 32 training hours
increase coverage of services
in the Puttalam district in Sri Lanka
cleanliness, thermal protection, and neonatal assessment improved significantly in the intervention group.
The intervention was effective in improving skin-to-skin contact by 1.5 times and early initiation of breastfeeding by 3.4 times.
Undesirable health events declined from 32 to 21 per 223 newborns in the
National Science Foundation, Sri Lanka, Family Health Bureau, health staff of the Puttalam district
s of this study are applicable to nursing and midwifery communities that care for mothers and newborns in developing countries. However the ENC concept may be applicable to developed countries.
I. 2007. Effect of training for care providers on practice of essential newborn care in hospitals in Sri Lanka. Journal of Obstetric, Gynecologic and Neonatal Nursing, 36:531–541.
intervention group and from 20 to 17 per 223 newborns in the control group.
UK Study design:
Single-blind case-control study
One ward was designated the intervention ward and the other served as the control ward.
The outcome measures are point prevalence of delirium among older people established by
The research old age psychiatrists were not blind to the status of each ward
House staff (house officers, middle grade doctors and consultants), and nursing staff.
Intervention aimed to increase awareness and knowledge of delirium among staff, comprised three components.
House staff (house officers, middle grade doctors, and consultants), and nursing staff who did not receive the training.
Addressed population need in improving delirium prevention and management
(i) 1-hour session including a formal presentation and small group discussion; (ii) written information and guidelines on how to prevent, recognize and manage delirium in older people; (iii) 1 hour regular one-to-one and small group discussion on cases.
No information on increase coverage of services
The study was carried out on 2 acute medical assessment wards at a teaching hospital in inner London.
Quality: The point prevalence of delirium was significantly reduced on the intervention compared to the control ward (9.8% versus 19.5%, p<0.05) and clinical staff recognized significantly more delirium cases that had been detected by research staff on the control ward.
Not specified
This educational package was to make it comprehensive but simple, inexpensive and achievable beyond the research phase without the need for substantial further resources.
Tabet N et al. 2005. An educational intervention can prevent delirium on acute medical wards. Age and Ageing, 34:152–156.
researchers, and recognized and case-note documentation of delirium by clinical staff.
Sample size: 2 acute admission wards, number of house staff not specified.
Turkey
Study design: A before-and-after evaluation design (quasi-experimental study) was used and the data were gathered over 14 months, between Dec. 2005 and Jan. 2007. Sample size:
Possible existence of social desirable effect, especially the study was on organizational behaviour such as leadership.
Charge nurses
A transformational-leadership training programme composed of 5 sections:
Management transformational leadership.
Process of influencing (power).
Motivation.
Exemplar
UCNs and observers' evaluation before training
Addressed the importance of transformational-leadership skills, which links to the increase of effectiveness of patient care services.
Theoretical (14 hours) and individual study (14 hours) at 2 university hospitals.
No information on increase coverage of services
CPD was delivered in 2 university hospitals in Turkey
Quality:
Leadership practices (model the way, inspire a shared vision, challenge the process, enabling others to act, encourage the heart, and total) increased.
Financial support from Hacettepe University Research Center
There is a need to develop programmes to improve leadership skills, a record system to monitor development changes. Inventory used in the study can be a helpful evaluation tool.
Duygulu S, Kublay G. 2011. Transformational leadership training programme for charge nurses. Journal of Advanced Nursing, 67:633–642.
30 unit charge nurses (UCNs) with a baccalaureate degree, and 151 observers to observe the UCNs (did not received training).
y leadership practices.
Becoming an effective leader.
significantly with the implementation of the programme
Self-rating score of was significant higher than those of the observers.
Turkey
Study design:
A before-and-after study (quasi-experimental study).
An Empathic Communication Skill-B (ECS-B) measurement form was used both pre-
Nurses may not fill in out the questionnaire carefully or attend training the next day after night-shifts
Nurses A training programme on enhancing empathic skills composed of lectures, role playing, discussions, film watching, and case studies. The training programme used a hierarchical emphatic cycle as a model.
Same participants before training
Addressed the importance of developing empathy, which is teachable and crucial in helping patients.
1-time training of 4 hours a day, 5 days of training in total
No information on increase coverage of services
CPD was delivered to nurses employed at Hacettepe University Hospital in Turkey
Quality:
The average score of ECS-B increased after training (from 155.6 to 180.5).
Training played a role in enhancing nurses' skills with regard to all variables (p<0.05).
Not specified
More comprehensive and continuous training should be planned, and its impact on behaviour and patient outcomes should be investigated.
Ançel G. 2006. Developing empathy in nurse: an in-service training program. Archives of Psychiatric Nursing, 20:249–257.
intervention and post-intervention.
Sample size: 263 nurses in the inpatient wards.
Spain Study design: Quasi-experimental design. Questionnaire administered before and after counselling training programme, and one follow-up 2 months later. Sample size: 226 nurses who voluntarily attended the programme.
Nurses who answered the follow-up assessment were perhaps also the nurses who felt more motivated and involved in the their interactions with patients and families.
Nurses A counselling training programme designed and implemented in a general university hospital. The programme included concepts of counselling, effective communication skills, emotional support skills, palliative care and teamwork improvement.
Same participants before training, after the training, and 2 months after the programme was delivered
Addressed the need to improve communication skills among nurses
Program lasted a total of 18 hours and was held in 1 week
No information on increased coverage of services
CPD was designed and implemented in a general hospital in Spain
Quality: A significant decreased in difficulties after the course in aspects related to interaction with the patient and family, and lesser difficulties at the 2-month follow-up. However, in interaction with co-workers, difficulties increased at first following training, but decreased to a level
Not specified
This programme may provide necessary interpersonal skills to less experienced nurses. Programme is not of high cost, and information can easily be ascertained at the hospital or at a nearby training centre.
Arranz P et al. 2005. Evaluation of a counseling training program for nursing staff. Patient Education and Counseling, 56:233–239.
even lower than pre-training.
USA Study design: Quasi-experimental study Sample size: Not specified
Rate of patients who declined testing was not explicitly evaluated
General obstetric team (attending physicians, residents and advanced practice nurses)
Targeted educational interventions specific to each ordering provider type were followed by audit and feedback.
Residents received a didactic lecture followed by role play and discussion; nurse practitioners received an informational hand-
HIV-testing rate before training
Addressed the importance of prenatal HIV screening
6 education sessions were held from Mar–Oct 2007.
HIV testing rate increased significantly from 79.2% to 94.2%
The setting for the study was single, rural academic tertiary-care centre
Quality: The HIV-testing rate increased significantly from 79.2% to 94.2%. Rates greater than 90% were maintained for 10 of 11 months reported.
The Dartmouth-Hitchcook Leadership Preventive Residency provided the time of 1 resident to work on this project.
An integrated, multi-model approach can significantly increase prenatal HIV screening in an outpatient, general ob/gyn setting.
Prairie BA, Foster T. 2010. Improving prenatal HIV screening with tailored educational interventions: an approach to guideline implementation. Quality and Safety in Health Care, 19:1–5.
out with an informal discussion using modified consensus process; attending physicians were visited for on-on-one conversations.
Regular team-level meetings were held for audit and to ensure HIV testing performance and seek for feedback.
UK Study design: Both quantitative (quasi-experimental study) and qualitative data were collected. Sample size: 16 registered nurses and health visitors. Qualitative data was collected using a focus group conducted 6 months after the training.
The reliability of the instrument developed for the quantitative part of the study was not established. The sample size was not made purposefully, and the evaluation embraced all those who applied for the training. 6 lost of follow-up in quantitative study, and 11 were not available for focus groups.
Registered nurses
A training programme on solution-focused brief theory (SFBT)
Same participants before training
Addressed the importance of nurses' communication skills
4-day training programme delivered as a full day over an 8-week May–Jul 2000
No information on increased coverage of services
CPD was accredited within the BSc (Hons) Nursing Practice and on the completion of summative assessment led to the award of 20 credits at Level 3
Quality: Quantitative data indicated positive changes in nurses' practice following the training on 4 dimensions, and changes in nurses' willingness to communicate with people who are troubled reached levels of significance. Qualitative data uncovered changes to practice centred on the rejection of problem-oriented discourses and reduced feelings of inadequacy and emotional stress in
Financial support by West Yorkshire Education and Training Consortia
SFBT appears to provide a coherent framework and techniques for therapeutic conversation, which may be a useful approach to the training of nurses’ communication skills.
Bowles N, Mackintosh C, Torn A. 2001. Nurses' communication skills: an evaluation of the impact of solution-focused communication training. Journal of Advanced Nursing, 36:347–354.
the nurses.
USA Study design: Quasi-experimental study Sample size: 55 registered nurses
Not all residents participated at the monthly Resident Development Days due to misunderstanding or time conflicts, which lessened the possible impact of peer support and learning. More nurse preceptor/sponsor
Registered nurses
A local nurse residency training programme consisted of 2 phases: (Phase I) 3 months, 2-week orientation, 12 weeks of working side-by-side with a nurse preceptor; (Phase II) 9 months, each resident was guided by a sponsor
Same participants before training
Addressed the importance of training, which improved nurses' clinical competency, emotional stableness retention, and support.
A year-long local nurse residency programme at 2 hospitals. Participants are two cohorts who entered the programme in 2008 and 2009.
No information on increase coverage of services
CPD is a regular training in local training institution based on the goals of Bureau of Health Professions (BHPr) and Health People 2010.
Quality: Improved clinical competency throughout the programme, a decreased sense of threat, and improved communication and leadership skills. Quantity: The first-year cohort's
The project was supported by funds from the Division of Nursing (DN), Bureau of Health Professions (BHPr), Health Resources and Services (DHH).
The role of preceptors and the nurse educators is vital for resources in the residency programme. Nurse managers, with input from the Residency Coordinator, are intimately involved in the
Kowalski S, Cross CL. 2010. Preliminary outcomes of a local residency programme for new graduate registered nurses. Journal of Nursing Management, 18:96–104.
development is needed.
(same person as the previous preceptor, but not necessarily working in the same shift).
employment retention rate was 78%, and the second-year cohort is presently 96%.
placement of new residents with preceptors to ensure a mutually benefit match.
USA Study design: Two-phase, mix-methods design was used
Phase 1 used qualitative methods for content development of the in-service programme.
Phase 2 used a 1-group pre-test and post-test
Lack of randomization or control, the use of small convenience sample in Phase 2, and low-response rate
Nurses Training programme in meeting the intimate partner violence (IPV) learning needs of the nursing staff (Phase 2). The training programme provides knowledge, skills and resources on helping IPV patients.
Same group pre-test and post-test design
Addressed the need to increase knowledge and skills to enhance response to IPV
The programme components were 90 min. lecture, 15 min. training video followed by a 20 min. discussion, and 2 hours of panel presentation of representatives from local community agencies that provide resources and
No information on increase coverage of services
CPD was delivered in 2 university hospitals in Turkey
Quality:
In Phase I, nurses perceived a need for knowledge about community IPV prevention resources and enhancement of interviewing skills.
In Phase 2, no significant difference was noted in
Partial funding was supported by the National Institute of Health, National Institute of Nursing, and UTHSCSA SON Department of Chronic Nursing Care. Nursing school of a local university
Continuing education is an effective means to enhance nurses' IPV knowledge and skills and improve their ability to provide quality-nursing care to survivors of violence.
Davila YR. 2006. Increasing nurses' knowledge and skills for enhanced response to intimate partner violence. Journal of Continuing Education in Nursing, 37:171–177.
design to evaluate the effectiveness of the programme.
Sample size:
Phase 1: 7 registered nurses, 6 staff members and 1 supervisor.
Phase 2: 36 registered nurses, 4 licensed vocational nurses, and 1 nurse practitioner.
services to IPV survivors .
level of IPV knowledge between pre-test and post-test (p<0.107).
A significant increase in skill level was noted between pre-test and post-test (p<0.003).
provided an auditorium for the classroom training.
UK Study design: This quasi-experimental study was a randomized, controlled,
Small sample size
Intensive-care nurses
Teaching intervention on research recommendations for endotracheal suctioning including actions,
Comparison group also received a teaching programme but with a different focused
Addressed the importance of practice of endotrcheal suctioning according to current research
2-hour period of didactic and interactive teaching, and bedside demonstra
No information on increase coverage of services
CPD was delivered in a large intensive-care unit
Quality:
No baseline difference between 2 groups.
Not specified
The study highlighted the need for changes in nursing practice, with clinical
Day T, Wainwright SP, Wilson-Barnett J. 2001. An evaluation of a teaching intervention to improve
single-blinded comparison of two research-based teaching programmes. Sample size: 16 intensive-care nurses
risks and recommended practice.
on humidification (humidification during mechanical ventilation).
recommendations
tions Following teaching, significant improvements (p<0.01) were seen in both knowledge and practice.
Experimental group had a higher score in knowledge (22.9, median 23) than control group (16.8, median 17.5).
Experimental group also had higher score in practice (22.37, median 22.50), than the control group (11.81,
guidelines and focused practice
the practice of endotracheal suctioning in intensive care units. Journal of Clinical Nursing, 10:682–696.
median 11.75).
4 weeks later these differences were generally sustained, and provide evidence of the effectiveness of the educational intervention.
CDMNS: Clinical Decision Making in Nursing Tool
GPA: Grade point average
LPI: Leadership Inventory
WSI: Index of Work satisfaction
NSS: Nursing Stress Scale
MBI: Maslach Burnout Inventory
ssment Leadership instrument
based comprehensive examination
GPA: Grade point average
are Attitude Inventory
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