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

SAAHE 2014 Convergence – divergence theme

Deborah Murdoch Eaton Sheffield, UK d.murdoch-eaton@sheffield.ac.uk

“Change – is the key developing staff and student resilience?”

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

Curricular trend changes Motivational theories

Motivating the learner of today or tomorrow (Kusurkar et al Acad med 2012)

• Apprenticeship
• Standardised / regulated
• Problem based
• Integrated
• Longitudinal integrated

clerkships

• Hull – drive theory (1943)
• Maslow – hierarchy of needs (1943)
• Self –efficacy / social cognitive

theory

• Self-determination theory (1985)
• Goal theory (2000)

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 21st 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)

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

Change

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

• r recover

from stress”

Resilience

• “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

“A dynamic capability which can allow people to thrive on challenges given appropriate social and personal contexts” ~

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
• f sources, including MSF

Mentor? Supervisor? Role Model?

Impact of attending SAAHE: Enhancing your “resilience” characteristics

Convergence and divergence … what remains centrally – as a practitioner and as a teacher

Hutchinson et al. Whole person care CMAJ 2009

“Cure when possible, care always”