The perceptions of final year medical students in rheumatology workshops when delivered by a consultant and a nurse clinical educator
K. Gadsby and
C. Deighton
Department of Rheumatology, Derbyshire Royal Infirmary, London Road, Derby DE1 2QY, UK.
Correspondence to: K. Gadsby. E-mail: kate.gadsby{at}derbyhospitals.nhs.uk
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Abstract
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Objective. To determine whether final year medical students' perceptions of teaching workshops delivered by a consultant rheumatologist are similar those of the same workshops delivered by an experienced nurse clinical educator (NCE).
Methods. The design was a semi-randomized post-test intervention study. The consultant and NCE alternated in presenting eight teaching workshops to four groups of six final year medical students. After each of the workshops, students evaluated the feedback by self-completed questionnaires.
Results. Seventy-three questionnaires were available from the consultant workshops and 65 from the NCE ones. There was no difference in the overall scores for the consultant and the NCE. The consultant scored significantly higher on two individual questions, but these differences were lost when we adjusted for multiple testing.
Conclusion. We were unable to demonstrate a major difference between the feedback received from medical students in workshops delivered by an enthusiastic consultant and an experienced NCE.
KEY WORDS: Consultant, Nurse Clinical Educator, Medical education, Medical student
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Introduction
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As with many United Kingdom medical schools, Nottingham has seen a gradual increase in the number of students, with 200 students per year in 1999 rising to 246 in 2004. In addition, a graduate entry medical (GEM) school based in Derby was opened in September 2003. This will lead to a large increase in students in February 2005 as a further 90 students are added to the clinical course with the GEM students mixing with the undergraduates. Final year students in Nottingham undertake the advanced clinical experience (ACE) course with a curriculum that includes 9 weeks of a musculoskeletal and disability medicine attachment consisting of rheumatology, orthopaedics, accident and emergency medicine, rehabilitation and neurosurgery. Students are divided between Nottingham, Derby and King's Mill Hospital in Mansfield. Currently in Derby we have 12 final year students attached to the rheumatology department at any one time. In 2006 this will rise to 40 students.
The approach taken to meet the increasing numbers of students in Derby has been to address the learning objectives for the ACE course and to determine what resources were needed to meet them. It was guided by the principles that good clinical education needed to retain a high concentration of direct interaction with real patients, and a low ratio of tutors to students. Consequently, more personnel were needed to help to deliver the teaching. In Derby we are fortunate to have a Hospital Trust that ring-fences the service increment for teaching (SIFT)the money paid by universities in the United Kingdom to recompense hospitals for clinical teaching of medical students. We know that in other hospitals SIFT tends to be lost amongst other monies paid into a Trust, so that it is difficult to identify, and tends not to be spent on teaching. Consequently those individuals and departments who are enthusiastic and effective in their teaching see no more of the SIFT resources than those who lack this interest. This can be demotivating when it comes to improving the teaching of medical students. In Derby we are able to put business cases together to bid for SIFT funds to increase teaching personnel and facilities. This has included a successful bid for a new consultant who started in October 2003. However, it was anticipated that further pairs of hands would be necessary if we were to continue to deliver high-quality teaching to increasing numbers of medical students.
Whilst trying to address the aim of maintaining a low ratio of students to tutors, we were also aware that patients seemed less accessible. Because of therapies such as anti-TNF therapy, and increasing pressure on medical beds, there are fewer rheumatology in-patients. Out-patient clinics are under pressure to concentrate on service delivery, and can be limited in their potential for student teaching. It was decided that one of the ways of ensuring that the demands of the ACE curriculum could be met whilst not disadvantaging patients, students or tutors, would be to organize workshops in which patients with specified disorders would volunteer to attend to have supervised histories taken, examinations performed and presentations given on their conditions. One of the tasks of the new consultant was to develop and deliver these workshops.
The business cases for new teaching personnel also considered alternatives to consultant-led teaching. A recent review suggested that an untapped resource of teachers lies in professions allied to medicine [1], and this has been shown to be successful in the teaching of basic clinical skills [2]. A concern is that the quality of the teaching provided by non-medically qualified teachers might be inferior to that of a consultant, and consequently the feedback from medical students might reflect this. We wanted to audit the student feedback of a nurse clinical educator (NCE) with that of a consultant delivering the same teaching, using a standardized questionnaire.
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Methods
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The question that we wanted to address was whether or not the feedback from medical students was similar for a consultant (CD) and a NCE (KG) when they led the same rheumatology workshops. The study design was a semi-randomized post-test intervention study. A series of eight workshops were designed by CD with the help of KG to address some of the curricular requirements of the ACE course for final year medical students visiting Derby from Nottingham Medical School. The topics covered are summarized in Table 1. The 12 final year students attached at any one time to the Derby rheumatology unit were divided into two groups of six. Throughout the attachment each group of six students stayed together in the same group. Both groups of six students participated in each of the eight workshops over their 9 week attachment. KG and CD alternated leading the workshops for the two groups, so that each group received the same number of contacts with each of the workshop leaders. The alternate leading of the workshops was not strictly random, and was dictated to some extent by leader availability, but we ensured that the two leaders ended up teaching the same number of similar workshops. The study period was from October 2003 to March 2004, and covered two sets of 12 students. If all students attended all workshops this would have given us 192 feedback questionnaires. However, students have weeks when two of them attend the accident and emergency department and so are absent from the workshops. Furthermore we anticipated that students would fail to attend for other reasons such as illness, and some would forget to complete their questionnaires.
CD and KG discussed with each other the content of each workshop prior to delivering it to try to minimize differences in the way in which the individual workshops were run. Each workshop was attended by two patients suffering from one of the diseases being covered that day. After the leader (KG or CD) had discussed the learning objectives for each workshop (an example is given in Table 2), the students split into two groups and took histories from the patients. These were then presented by a designated student to the group. Supervised regional examination of the patients then took place. Finally, an interactive PowerPoint presentation was given by the workshop leader to draw attention to important points from the histories and examinations, and clinical features of the disease being covered, as well as management. Each workshop lasted 90 min.
Following each of the workshops the students completed an anonymous evaluation questionnaire with 14 questions covering their enjoyment of the session, and whether it had been useful as a learning experience (Table 3). Each of the questions was scored from 1 (strongly disagree) to 5 (strongly agree). These questions were designed at Flinders University, in Adelaide, South Australia. They have been used in previous studies to evaluate feedback from clinical teaching of medical students in comparing patient partners with traditional medical teaching [3], and comparing structured clinical instruction modules with traditional teaching in rheumatology and orthopaedics [4]. Neither the authors nor ourselves have conducted formal reliability or validity studies on these questions (M. Smith, personal communication). In this study we addressed the internal consistency of the questionnaire by using Cronbach's alpha. The students were not aware that we were comparing the workshops delivered by CD and those by KG, which we felt was appropriate as we were auditing our usual teaching practice. The results of the feedback questionnaires were compared between those sessions led by CD and those led by KG. A t-test was used. All statistical evaluations were performed on SPSS10.1.
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TABLE 3. Questions on the feedback forms, and comparison of the results of feedback for the consultant (CD) and the nurse clinical educator (KG)
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Previously the questionnaire was able to demonstrate that in comparing two groups of 40 students, a mean difference of 0.7 on an individual question was statistically significant at P<0.01 [3]. Based on this difference between the response to questions for the two teachers, we calculated that for a standard deviation of 0.9 (taken from previous studies in the department), a significance level of 0.004 (correcting for 14 statistical tests) and a power of 90%, we would require data from 42 questionnaires in each group.
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Results
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Seventy-three feedback forms were available from the consultant-led sessions and 65 from the nurse-led sessions (see Table 3). The total mean scores for the consultant and the NCE were 60.9 and 60.3 respectively out of a possible 70 (ranges 4970 and 4870 respectively). There was no significant difference between the consultant and NCE for the overall score. Looking at individual questions, the consultant scored significantly higher on two questions: 1. I enjoyed learning clinical skills in this way, and 13. The session was very effective for my learning. However, when we corrected for the number of statistical tests we performed, there was no significant difference between the consultant and the NCE. On the other 12 questions there was no significant difference between the consultant and the NCE.
Cronbach's alpha was calculated for all the data from the questionnaires. The reliability coefficient was 0.88 (0.8 or higher is usually an acceptable level of internal consistency for a questionnaire).
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Conclusions
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Main findings
Comparing the feedback from final year medical students on rheumatology workshops delivered by a consultant and an experienced NCE showed no overall difference. Only two out of 14 questions were answered in a way that expressed a preference for either consultant or nurse teaching, but these differences were lost when we adjusted for multiple testing. In Derby we have had a NCE (KG) teaching third year and final year students for the past 3 yr. Prior to this she had 12 years of clinical experience in rheumatology. Her contribution to the delivery of the curriculum is similar to that of the medical staff in terms of the delivery of sessions on clinical skills, history taking, examination and seminars on musculoskeletal diseases. Informal feedback from medical students suggested that KG's teaching sessions were well received. Although KG is an experienced teacher of medical students we would like to think that we set her an exacting challenge. We sought to compare her with an enthusiastic consultant teacher in CD. We believe that to demonstrate no major differences in the student feedback is a significant achievement.
Limitations of the study
The dominant methodological approach in education evaluation research is qualitative [5]. This is because there are a large number of complex interactions within an educational setting that are difficult to control for in randomized controlled trials. We tried to minimize confounders as much as we could by discussing the content and delivery of the workshops beforehand, and by giving the same workshops with the same learning objectives. However, we could never make the delivery of the workshops identical between the teachers. The numbers that can be assigned to responses to questions only capture a small and limited amount of information on what the students might gain from their teaching experiences. In evaluating further any differences between consultant teachers and NCEs we will seek to employ qualitative methodology such as interviews and focus groups.
The questionnaires that we used have not had formal reliability or validity studies performed on them either by ourselves or by the authors. Other studies have shown that systematic student ratings are reliable. A long-term review at Kansas University, reported that previous studies of student ratings, using various internal consistency measures of reliability, show high reliabilitiesin the .80s and .90s [6]. These findings are echoed by others [7, 8]. In the current study, Cronbach's alpha was calculated at 0.88 for this questionnaire, showing a high level of internal consistency. In terms of face validity the questions that we used have been used in a number of different settings by experienced rheumatology educational researchers [3, 4].
The feedback is purely asking the students to comment on their perception of the quality of the teaching but not the effectiveness. We intend to extend the study and introduce tests before and after each teaching session to determine whether students are acquiring and retaining knowledge to equivalent levels in consultant and NCE workshops. A business case for SIFT money asked for a further 2.5 clinical educators, and we recently appointed three individuals from a nursing, physiotherapy and occupational therapy background. They started in their posts in January 2005. We will be training them in generic and rheumatology teaching skills in the hope of eventually putting them on a par with KG. We will be studying their sessions and comparing this with other medical clinical teachers for the quality and effectiveness of their teaching.
Implications of the study
This is a limited, evaluative study that we now want to take further. The study was restricted to a comparison of just two teachers and covered two groups of medical students, albeit over eight separate workshops. Because of KG's experience, it would be inappropriate to extrapolate from her feedback to other nurses or other allied professionals potentially involved in teaching medical students. However, the consistently good feedback she has generated suggests that an enthusiastic and energetic nurse certainly has the capability to teach medical students in a way that they find very acceptable. It has previously been demonstrated that multiprofessional teaching can be an effective educational strategy when the intended educational objectives are clearly defined [9, 10]. We would strongly agree with this. CD and KG designed the workshops and their learning objectives together to meet the requirements of the Nottingham curriculum. In the absence of clearly defined objectives in the workshops the feedback might have been very different.
A previous report from North Carolina failed to demonstrate any major differences between physicians and physical therapists in the effectiveness of teaching musculoskeletal examination to medical students [10]. There are a number of studies that have demonstrated the quality of nurse teaching to medical students in other non-rheumatological clinical settings, such as a community-based geriatric clinic [11], a family medicine unit [12], midwives in an obstetric department [13] and a department of orthopaedics [14]. We know that allied health professionals are already involved in teaching medical students in many units around the country, and would welcome correspondence on their experiences. In the face of more demands on our time, and ever increasing numbers of medical students, we would strongly encourage colleagues to consider allied health professionals for teaching medical students in their own departments.
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Acknowledgments
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The authors would like to thank Dr Louisa Badcock. Without her hard work in putting together business cases, Derby would not have the successful undergraduate teaching that it has today. Dr Nicholas Raj provided invaluable help in putting this manuscript together.
The authors have declared no conflicts of interest.
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Submitted 3 December 2004;
revised version accepted 12 April 2005.