SAAHE 2014 Convergence divergence theme Change is the key - PowerPoint PPT Presentation

SAAHE 2014 Convergence – divergence theme “ Change – is the key developing staff and student resilience ?” Deborah Murdoch Eaton Sheffield, UK d.murdoch-eaton@sheffield.ac.uk

Training and learning for the future:  Changing nature of healthcare  Ageing population, mountain biking, multiple co- morbidities, stark health inequalities, rising patient expectations about quality of care ...  Tomatoes, Technology advances, delivery, globalisation and transmission of disease

New models of care...  Impact of economic austerity vs aspiration for universal health coverage  But is education and training similarly changing to meet the challenge, and develop workforce capable of “transformative thinking capable of posing a challenge to the status quo ” * * Buchan J, Campbell J. Challenges posed by the global crisis in the health workforce. BMJ 2013 347; Ian Couper SAAHE 2014; Steve Reid SAAHE 2014

Challenge to status quo of training  Structures of rotations  Blocks of time -> longitudinal approach, patient centered *  Patient centredness  A skill every HC professional should be brilliant at??  Skilled communicator, co-production techniques, team working...  leadership, self-awareness require significant support and development * Hirsch, Holmboe, ten Cate. Time to Trust.... Acad Med 2014 89:201-4

Curricular design: has it been guided by “motivational” theories? *  Cognitive - what to learn  Affective / motivational - why learn  Metacognitive regulation - how to learn * Kusukar et al Acad Med 2012

Motivating the learner of today or tomorrow (Kusurkar et al Acad med 2012) Curricular trend changes Motivational theories  Hull – drive theory (1943)  Apprenticeship  Maslow – hierarchy of needs (1943)  Standardised / regulated  Self – efficacy / social cognitive  Problem based theory  Integrated  Self-determination theory (1985)  Longitudinal integrated  Goal theory (2000) clerkships

Curricular design: has it been guided by “motivational” theories? *  Motivation  drives learning  Influences academic performance  Gender differences in motivational mechanisms  Stimulate instrinsic motivation  Autonomy support “I am doing it because I want to”  Competence “feeling one has the capability to do the goals” - Adequate feedback  Relatedness “feeds into being able to relate to or matter to significant others” (parents , peers, patients) - Emotional support * Kusukar et al Acad Med 2012

How are our graduates fit for uncertain future?  Higher proportion of mental health difficulties amongst university students *  Buffers include “outside interests” and “strong group identity”  Mental health amongst practicing doctors  Brian Hodges (twitter)  “ doctors and nurses must work together to understand and address burnout. They are both canaries in the same coal mine” * Mavor et al 2014 Beyond prevalence to process, self and identity…Med Ed 2014

Knowing your learner?

And what about “this generation” Generation Me (Twenge Med Ed 2009, +++ )  Score highly on  Assertiveness  Self-liking  Narcissistic traits  High expectations  Some measure of stress, anxiety and poor mental health  Score lower on  Self reliance

And what about “this generation” Generation Me (Twenge Med Ed 2009, +++ )  Convergence  Consider that there are and should be opportunity for ALL  Divergence  Discrepancy between ambition and reality / what is right for the individual  (Self esteem does not predict success)

Our graduates?  What is a doctor and what is a nurse? *  Evolution of IP interaction between physicians and nurses  Framework for multiple and varying roles, interdependencies  Simplistic to ignore complexity of HC environment  What is a 21 st century Doctor? #  Profession or occupation?  The more important emerging question - What will future team of HC professionals require?  Convergence and divergence again  shifting focus from inside to outside the patient’s body, and back again  Entrustable professional activities emerging * Romano & Pangaro – Academic Medicine’s 2013 Question of the Year. Acad med 2014; 89 # O ten Cate. … Rethinking the significance of the Medical Degree. Acad Med 2014 89; 7

Identity formation  professional identity construction – medics relatively late in developing professional identity  Why?  Presence of two dominant but competing discourses within medical education  Promoting diversity  Standardization and uniformity  Lack of acknowledgement by medical educators of this conflict between discourses Frost & Regehr Acad Med 2013; Jarvis-Selinger et al Acad Med 2012; Crossley 2009

Identity formation  Integrating identity formation into the Medical Education Discourse *  Consequence of translating physician role into “measurable competencies” emphasis on assessment missing underlying meaning of role of a Dr  Include “identity” alongside competency “being” not just “doing” Jarvis-Selinger Pratt & Regehr . Acad Med 2012;

Change: developmental stages  Identity formation constantly being changed as progress through training *  Quantitatively different understandings of role  “junior students / doctors are not just immature versions of expert physicians”  Training stages  Inevitable multiplicity of changes * Lingard 2009 Adv Health Sci Educ Pract . … notes on a God term

Well being and identity formation  Impact of “hidden curriculum” – role models, community of practice, culture of HC disciplinary practice Concentric circles of influences  “you can know everything if you try hard enough”  “Drs do not make mistakes”  Students feel taken advantage of / abused (*)  Perceptions of  “ the more I spend with certain physicians, the more I see that many of them are jaded, and the more I feel like I’m naïve ” ^.  Workaholism - burnout  Expectations of society – social status, family pressures, working practice vs service. * Dyrbe 2005, ^ Allen 2008,” Dobkin &Balass 2014

Professional self -identity  Multiple roles  Personal insight  Skills identification  Gains in self-awareness, insight and clarity  Reflection on resilience characteristics of others  Why are they more likely to get the promotion/ career change?  Why are they more highly valued?

Addressing learner disorientation…Give them a road map anchored in the “world of the practitioner rather than the world of the educator” (Crossley Med Teacher 2014, Cilliers)

Change ‘Health professionals for next century’ : convergence But Student diversity, expectations of HC graduates, expanding higher education systems... : divergence

is the key developing staff and student resilience?

Resilience...  “ resiliens ” ( latin) “elastic quality of a substance – its ability to be stretched and then return to its normal state of functioning” “ability to bounce back or recover from stress”

Resilience “A dynamic capability which can allow people to thrive on challenges given appropriate social and personal contexts” ~  “ resilience” is often touted as a solution for HP burnout. And I agree. But the disease is more about systems and context than individuals” * ~ Howe et al Med Ed 2012; * Another Brian Hodges Tweet ! 16 June 2014

Resilience – the key to well being? * Relationship between personality traits and resilience in Drs +ve correlation  Self directedness  Persistence  Co-operativeness -ve correlation  Harm avoidance * Eley et al (2013) PeerJ 1: 216

Eley et al 2013

Resilient people are …  Mature  Responsible  Optimistic  Persevering  Co-operative Strategies to enhance resilience?  Self / professional identity  Enterprise skills  Team work (support / collegiality) ( more than just counselling??)

Topics in resilience training*  Change  Motivation  Stress  Locus of control  Skills identification  Positive psychology  Tools  Resilience Quotient Questionnaire #,  Skills self assessment > *Tregoning BMJ 2014 (lit review) ; Carver J Soc Issues 1998. # Nicolson McBride RQQ www.testyourrq.com, >Windmills. windmillsonline.co.uk/.

Definition of insight  “ a readiness to explore intellectually and emotionally how and why I, and those I interact with, behave, think, and feel as we do, and for me to adapt my behaviour accordingly”  culmination of set of actions which goes further than just being self aware.  Recognises importance of motivation for a change in behaviour

Why is insight important?  Poor performers have little insight into their deficiencies  Improve quality and patient safety

Can you enhance insight?  Need to know where you started  Working definition * incorporates  Reflection  Emotional intelligence  Self-awareness  motivation * National Clinical Assessment Service – assessment of 300 doctors with performance problems, plus lit review. Brown, McAvoy, Joffe 2014

Evaluating insight (to give feedback)?  Purposeful use of information from variety of sources, including MSF

Mentor? Supervisor? Role Model?

Impact of attending SAAHE: Enhancing your “resilience” characteristics