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”.

References

1. Lapkin S, Fernandez R, Levett-Jones T, Bellchambers H (2011)The effectiveness of using human patient simulation manikins in the teaching of clinical reasoning skills to undergraduate nursing students: a systematic review.

JBI.

a. Alinier G, Hunt B, Gordon R, Harwood C. Effectiveness of intermediate-fidelity simulation training technology in undergraduate nursing education. J Adv Nurs. 2006;54(3):359 -69.

b. Brannan J, White A, Bezanson J. Simulator effects on cognitive skills and confidence levels. J Nurs Educ. 2008;47(11):495-500.

c. Hoffmann R, O'Donnell J, Kim Y. The effects of human patient simulators on basic knowledge in critical care nursing with undergraduate senior baccalaureate nursing students. Simulat Healthcare. 2007;2(2):110-4.

d. Howard V. A comparison of educational strategies for the acquisition of medical-surgical nursing knowledge and critical thinking skills: human patient simulator vs. the interactive case study approach. Pittsburgh, PA: University

of Pittsburgh 2007.

e. Jeffries P, Rizzolo M. NLN/Laerdal project summary report, designing and implementing models for the innovative use of simulation to teach nursing care of ill adults and children: a national multi-site study. New York: National

League for Nursing 2006.

f. Radhakrishnan K, Roche J, Cunningham H. Measuring clinical practice parameters with human patient simulation: a pilot study. Int J Nurs Educ Scholar. 2007;4(1):1 - 11.

g. Ravert P. Patient simulator sessions and critical thinking. J Nurs Educ. 2008;47(12):557-62.

h. Schumacher L. The impact of using high-fidelity computer simulation on critical thinking abilities and learning outcomes in undergraduate nursing students. Dissertation Abstracts International. 2004;65(10b).

2. Elliot S, Murrell K, Harper P, Stephens T and Pellowe C (2011) A comprehensive systematic review of the use of simulation in the continuing education and training of qualified medical, nursing and midwifery staff: a systematic

review. JBI.

a. Birch L, Jones N, Doyle PM, Green P, McLaughlin A, Champney C, Williams D, Gibbon K, Taylor K. Obstetric skills drills: Evaluation of teaching methods. Nurse Education Today 2007; 27: 915-922.

b. Crofts JF, Ellis D, Draycott TJ, Winter C, Hunt LP, Akande VA. Change in knowledge of midwives and obstetricians following obstetric emergency training: a randomised controlled trial of local hospital, simulation centre and

teamwork training. British Journal of Obstetrics and Gynecology 2007; 114: 1534-1541.

c. Crofts JF, Bartlett C, Ellis D, Donald F,Hunt LP. Draycott TJ. Patient-actor perception of care: a comparison of obstetric emergency training using manikins and patient-actors. Quality and Safety in Health Care 2008; 17: 20-24.

d. Crofts JF, Bartlett C, Ellis D, Hunt LP. Fox R, Draycott TJ. Training for Shoulder Dystocia. A Trial of Simulation Using Low Fidelity and High Fidelity Mannequins. Obstetrics and Gynecology 2006; 108(6): 1477-1485.

e. Ellis D, Crofts JF, Hunt LP, Read M, Fox R, James M. Hospital, simulation center, and teamwork training for eclampsia management. A randomized Controlled Trial. Obstetrics & Gynecology 2008 111(3): 723-731.

f. Owen H, Mugford B, Follows V, Plummer JL. Comparison of three simulation-based training methods for management of medical emergencies. Resuscitation 2006; 71: 204-211

g. Summerhill EM, Mathew MC, Stipho S, Artenstein AW, Jagminas L, Russo-Magno PM, Potter S, Shapiro MJ. A simulation-based biodefense and disaster preparedness curriculum for internal medicine residents. Medical

Teacher 2008; 30: 145 -151.

h. Shepherd IA, Kelly CM, Skene FM, White KT. Enhancing graduate nurses' health assessment knowledge and skills using low-fidelity adult human simulation. Simulation in Healthcare: The Journal of The Society for Medical

Simulation 2007; 2(1): 16 -24.

i. Lee SK, Pardo M, Gaba D, Sowb Y, Dicker R, Straus EM, Khaw L, Morabito D, Krummel TM, Knudson MM. Trauma Assessment Training with a Patient Simulator: A Prospective, Randomized Study. The Journal of Trauma

2003; 55(4): 651-657.

j. Knudson MM, Khaw L, Bullard MK, Dicker R, Cohen MJ, Staudenmayer K, Sadjadi J, Howard S, Gaba D, Krummel T. Trauma Training in Simulation: Translating Skills From SIM Time to Real Time. The Journal of Trauma

2008; 64: 255-264.

k. Wayne DB, Didwania A, Feinglass J, Fudala MJ, Barsuk JH, McGaghie WC. Simulation-Based Education Improves Quality of Care During Cardiac Arrest Team Responses at an Academic Teaching Hospital. Chest 2008; 133:

56 -61.

l. Wayne DB, Butter J, Siddall VJ, Fudala MJ, Lindquist LA, Feinglass J, Wade LD, McGaghie WC. Simulation-Based Training of Internal Medicine Residents in Advanced Cardiac Life Support Protocols: A Randomised Trial.

Teaching and Learning in Medicine 2005; 17(3): 210-216.

m. Shapiro MJ, Morey JC, Small SD, Langford V, Kaylor CJ, Jagminas L, Suner S, Salisbury ML, Simon R, Jay GD. Simulation based teamwork training for emergency staff: does it improve clincil team performance when added to

an existing didactic teamwork curriculum? Quality & Safety in Health Care 2004; 13: 417-421.

3. Harder, B. N. (2010). "Use of simulation in teaching and learning in health sciences: a systematic review." The Journal Of Nursing Education 49(1): 23-28.

4. Weaver, A. (2011). "High-Fidelity Patient Simulation in Nursing Education: An Integrative Review." Nurs Educ Perspect 32(1): 37-40.

5. Cant, R. P. and S. J. Cooper (2010). "Simulation-based learning in nurse education: systematic review." Journal of Advanced Nursing 66(1): 3-15.

a. Alinier G, Hunt B, Gordon R, Harwood C. Effectiveness of intermediate-fidelity simulation training technology in undergraduate nursing education. J Adv Nurs. 2006;54(3):359 -69.

b. Birch L, Jones N, Doyle PM, Green P, McLaughlin A, Champney C, Williams D, Gibbon K, Taylor K. Obstetric skills drills: Evaluation of teaching methods. Nurse Education Today 2007; 27: 915-922.

c. Jeffries P, Rizzolo M. NLN/Laerdal project summary report, designing and implementing models for the innovative use of simulation to teach nursing care of ill adults and children: a national multi-site study. New York: National

League for Nursing 2006.

d. Shepherd IA, Kelly CM, Skene FM, White KT. Enhancing graduate nurses' health assessment knowledge and skills using low-fidelity adult human simulation. Simulation in Healthcare: The Journal of The Society for Medical

Simulation 2007; 2(1): 16 -24.

e. Brannan J., White A. & Bezanson J. (2008) Simulator effects on cognitive skills and confidence levels. Journal of Nursing Education

47(11), 495–500.

f. Brown D. & Chronister C. (2009) The effect of simulation learning on critical thinking and self-confidence when incorporated into an electrocardiogram nursing course. Clinical Simulation in Nursing 5(1), e45–e52.

g. Griggs R.R. (2003) The Effects of the Use of a Human Patient Simulator on the Acquisition of Nursing Knowledge in Undergraduate Nursing Students at a University in Illinois. PhD thesis, Southern Illinois University,

Carbondale, IL.

h. Howard V.M. (2007) A Comparison of Educational Strategies for the Acquisition of Medical-Surgical Nursing Knowledge and Critical Thinking Skills: Human Patient Simulator vs. the Interactive Case Study Approach. EdD thesis,

University of Pittsburgh, Pittsburgh, PA. Hravnak M., Beach M. & Tuite

i. Linden L.L. (2008) The Effect of Clinical Simulation and Traditional Teaching Versus Traditional Teaching Alone on Critical Thinking of Nursing

j. Ravert P.K.M. (2004) Use of a Human Patient Simulator with Undergraduate Nursing Students: A Prototype Evaluation of Critical Thinking and Self-Efficacy. PhD thesis, The University of Utah, Salt Lake City, UT.

k. Ruggenberg S. (2008) The Effect of Simulated Clinical Experience on Knowledge, Near Transfer, and Far Transfer in Nursing Education. EdD thesis, University of San Francisco, San Francisco, CA.

l. Scherer Y.K., Bruce S.A. & Runkawatt V. (2007) A comparison of clinical simulation and case study presentation on nurse practitioner students’ knowledge and confidence in managing a cardiac R.P. Cant and S.J. Cooper 14 _

2009 Blackwell Publishing Ltd event. International Journal of Nursing Education Scholarship 4(1), article 22.

6. Cook, D. A., R. Hatala, et al. (2011). "Technology-Enhanced Simulation for Health Professions Education A Systematic Review and Meta-analysis." JAMA: Journal of the American Medical Association 306(9): 978-988.

7. McGaghie, Issenberg, S. B., W. C et al. (2011). "Does simulation based medical education with deliberate practice yield better results than traditional clinical education – a metanalytic comparative review of the

evidence." Academic Medicine 86(6): 706-701

8. Laschinger, S., J. Medves, et al. (2008). "Effectiveness of simulation on health profession students' knowledge, skills, confidence and satisfaction." International Journal of Evidence-Based Healthcare 6(3): 278-302.

a. Alinier G, Hunt B, Gordon R, Harwood C. Effectiveness of intermediate-fidelity simulation training technology in undergraduate nursing education. J Adv Nurs 2006; 54: 359–69.

b. Alinier G, Hunt W, Gordon R. Determining the value of simulation in nurse education: study design and initial results. Nurs Educ Pract 2004; 4: 200–7.

c. Curran V, Aziz K, O'Young S, Bessell C. Evaluation of the effect of a computerized training simulator (ANAKIN) on the retention of neonatal resuscitation skills. Teach Learn Med 2004; 16: 157–64.

d. Jeffries P, Woolf S, Linde B. A comparison of two methods for teaching the skill of performing a 12-lead ECG. Nurs Educ Perspect 2003; 24: 70–4.

e. Morgan PJ, Cleave-Hogg D, McIlroy J, Devitt JH. A comparison of experiential and visual learning for undergraduate medical students. Anaesthesiology 2002; 96: 10–16.

f. Engum S, Jeffries P, Fisher L. Intravenous catheter training system: computer-based education versus traditional learning methods. Am J Surg 2003; 186: 67–74.

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

1

Bruce TA. Physicians for the American homelands. Academic Medicine 1990; 65: S10–S4.

CrossRef,

PubMed,

CAS,

Web of Science® Times Cited: 7

“Full Text provided by your WHO Libraries”

2

McDonald IM. Education for Rural Health in Saskatchewan. Academic Medicine 1990; 65: S90–S92.

CrossRef,

PubMed,

CAS,

Web of Science® Times Cited: 2

“Full Text provided by your WHO Libraries”

3

Strasser RP. Attitudes of Victorian rural GPs to country practice and training. Australian Family Physician 1992; 21: 808–812.

PubMed,

CAS

“Full Text provided by your WHO Libraries”

4

Rosenblatt RA, Witcomb ME, Cullen TJ, Lishner DM, Hart LG. Which medical schools produce rural physicians? Journal of American Medical Association 1992; 268:

1559–1565.

CrossRef,

PubMed,

CAS,

Web of Science® Times Cited: 95

“Full Text provided by your WHO Libraries”

5

Ricketts TC. The changing nature of rural health care. Annual Review of Public Health 2000; 21: 639–657.

CrossRef,

PubMed,

CAS,

Web of Science® Times Cited: 46

“Full Text provided by your WHO Libraries”

6

Vanselow NA. Medical education and the rural health crisis: a personal perspective from experiences in five states. Academic Medicine 1990; 65: S27–S31.

CrossRef,

PubMed,

CAS,

Web of Science® Times Cited: 11

“Full Text provided by your WHO Libraries”

7

Hastings A, Rao M. Doctoring deprived areas. British Medical Journal 2001; 323: 409–410.

CrossRef,

PubMed,

CAS,

Web of Science® Times Cited: 2

“Full Text provided by your WHO Libraries”

8

Rosenthal MM, Frederick D. Physician maldistribution in cross-cultural perspective: United States, United Kingdom, and Sweden. Inquiry 1984; 21: 60–74.

PubMed,

CAS,

Web of Science® Times Cited: 4

“Full Text provided by your WHO Libraries”

9

Olubuyide IO. The geographical distribution of physicians in Oyo State, Nigeria. Tropical and Geographical Medicine 1995; 47: 42–44.

PubMed,

CAS,

Web of Science®

“Full Text provided by your WHO Libraries”

10

Barnett JR. Where have all the doctors gone? Changes in the geographic distribution of general practitioners in New Zealand since 1975, 1: Regional and urban–rural

differences. New Zealand Medical Journal 1991; 104: 314– 316.

PubMed,

CAS,

Web of Science® Times Cited: 2

“Full Text provided by your WHO Libraries”

11

Gushue J. Aggressive recruiting of rural students may help end Newfoundland's shortage of rural MDs. Canadian Medical Association Journal 1993; 148: 1211–1215.

PubMed,

CAS,

Web of Science® Times Cited: 2

“Full Text provided by your WHO Libraries”

12

Yang BM, Huh J. Physician distribution and health manpower policy in Korea. Asia Pacific Journal of Public Health 1989; 3: 68–77, 85.

CrossRef,

PubMed,

CAS

“Full Text provided by your WHO Libraries”

13

Kobayashi Y, Takaki H. Geographic distribution of physicians in Japan. Lancet 1992; 340: 1391–1393.

CrossRef,

PubMed,

CAS,

Web of Science® Times Cited: 26

“Full Text provided by your WHO Libraries”

14

Blumenthal DS. Geographic imbalances of physician supply: an international comparison. Journal of Rural Health 1994; 10: 109–118.

Direct Link:

Abstract

PDF(859K)

References

“Full Text provided by your WHO Libraries”

15

Cooper JK, Heald K, Samuels M. Affecting the supply of rural physicians. American Journal of Public Health 1977; 67: 756–759.

CrossRef,

PubMed,

CAS,

Web of Science® Times Cited: 7

“Full Text provided by your WHO Libraries”

16

Bruening MH, Maddern GJ. A profile of rural surgeons in Australia. Medical Journal of Australia 1998; 169: 324–326.

PubMed,

CAS,

Web of Science® Times Cited: 9

“Full Text provided by your WHO Libraries”

17

Colditz GA, Elliott CJP. Queensland's rural practitioners. Background and Motivations. Medical Journal of Australia 1978; 2: 63–66.

PubMed,

CAS,

Web of Science® Times Cited: 15

“Full Text provided by your WHO Libraries”

18

Western J, Makkai T, McMillan J, Dwan K. Issues for rural practice in Australia. General Practice Evaluation Program. Commonwealth Department of Health and Aged

Care, 2000 Report no. 535.

“Full Text provided by your WHO Libraries”

19

Rolfe IE, Pearson SA, O'Connell DL, Dickinson JA. Finding solutions to the rural doctor shortage: the roles of selection versus undergraduate medical education at

Newcastle. Australian and New Zealand Journal of Medicine 1995; 25: 512–517.

Direct Link:

Abstract

PDF(575K)

References

Web of Science® Times Cited: 39

“Full Text provided by your WHO Libraries”

20

Makkai T. Origins and Destinations: Geographical Mobility of General Practitioners from 1966 till 1993. Canberra: Research School of Social Sciences, Australian

National University, 1995.

“Full Text provided by your WHO Libraries”

21

Piterman L, Silagy C. Hospital interns’ and residents’ perceptions of rural training and practice in Victoria. Medical Journal of Australia 1991; 155: 630–633.

PubMed,

CAS,

Web of Science® Times Cited: 5

“Full Text provided by your WHO Libraries”

22

Silagy CA, Piterman L. Attitudes of senior medical students from two Australian schools towards rural training and practice. Academic Medicine 1991; 66: 417–419.

CrossRef,

PubMed,

CAS,

Web of Science® Times Cited: 10

“Full Text provided by your WHO Libraries”

23

Strasser R. Rural General Practice in Victoria. The Report from a Study of Attitudes of Victorian General Practitioners to Country Practice and Training. Melbourne:

Department of Community Medicine, Monash University, 1992.

“Full Text provided by your WHO Libraries”

24

Fryer GE, Stine C, Vojir C, Miller M. Predictors and Profiles of Rural Versus Urban Family Practice. Family Medicine 1997; 29: 115–118.

PubMed

“Full Text provided by your WHO Libraries”

25

Wilkinson DW, Beilby JB, Thompson DJ, Laven GA, Chamberlain NL, Laurence COM. Associations between rural background and where South Australian general

practitioners work. Medical Journal of Australia 2000; 173: 137–140.

PubMed,

CAS,

Web of Science® Times Cited: 6

“Full Text provided by your WHO Libraries”

26

Easterbrook M, Godwin M, Wilson R et al. Rural background and clinical rural rotations during medical training: effect on practice location. Canadian Medical

Association Journal 1999; 160: 1159–1163.

PubMed,

CAS,

Web of Science® Times Cited: 34

“Full Text provided by your WHO Libraries”

27

Potter JM. Characteristics of Alaskan family physicians as determinants of practice location. Alaska Medicine 1995; 37: 79.

“Full Text provided by your WHO Libraries”

28

Shannon CK, Gunel E. A study of the future practice location intent of family medicine residents in West Virginia. West Virginia Medical Journal 1999; 95: 261–264.

PubMed,

CAS

“Full Text provided by your WHO Libraries”

29

Jarratt LG, Leonardson GR, Nord WJ. Practice location factors influencing South Dakota school of Medicine graduates (1977–85). South Dakota Journal of Medicine

1989; 42: 15–21.

PubMed,

CAS

“Full Text provided by your WHO Libraries”

30

Leonardson G, Lapierre R, Hollingsworth D. Factors predictive of physician location. Journal of Medical Education 1985; 60: 37–43.

PubMed,

CAS,

Web of Science® Times Cited: 29

“Full Text provided by your WHO Libraries”

31

Rhodes JF, Day FA. Locational decisions of physicians in rural North Carolina. Journal of Rural Health 1989; 5: 137–155.

Direct Link:

Abstract

PDF(991K)

References

“Full Text provided by your WHO Libraries”

32

Elam CL, Rosenbaum ME, Johnson MS. Geographic origin and its impact on practice location in Kentucky. Kentucky Medical Association Journal 1996; 94: 446–450.

PubMed,

CAS

“Full Text provided by your WHO Libraries”

33

Becker P, Hartz A, Cutler J. Time trends in the association of a rural or urban background with physician location. Journal of Medical Education 1979; 54: 544–550.

PubMed,

CAS,

Web of Science® Times Cited: 7

“Full Text provided by your WHO Libraries”

34

Carter RG. The relation between personal characteristics of physicians and practice location in Manitoba. Canadian Medical Association Journal 1987; 136: 366–368.

PubMed,

CAS,

Web of Science® Times Cited: 19

“Full Text provided by your WHO Libraries”

35

Rabinowitz HK, Diamond JJ, Markham FW, Paynter NP. Critical factors for designing programs to increase the supply and retention of rural primary care physicians.

Journal of American Medical Association 2001; 286: 1041–1048.

CrossRef,

PubMed,

CAS,

Web of Science® Times Cited: 90

“Full Text provided by your WHO Libraries”

36

Rabinowitz HK, Diamond JJ, Hojat M, Hazelwood CE. Demographic, educational and economic factors related to recruitment and retention of physicians in rural

Pennsylvania. Journal of Rural Health 1999; 15: 212–218.

Direct Link:

Abstract

PDF(604K)

References

Web of Science® Times Cited: 34

“Full Text provided by your WHO Libraries”

37

Stewart TJ, Miller MC, Spivey L. Community of origin of spouse and physician location in two southwestern states. Journal of Medical Education 1980; 55: 53–54.

PubMed,

CAS,

Web of Science® Times Cited: 7

“Full Text provided by your WHO Libraries”

38

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”

39

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

Database Country/ setting

Study design/sample size

Methodological quality issues

Population Intervention Comparison Reported results (outcomes) Additional comments Reference/definitions

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

Study design/sample size

Methodological quality issues

Population Intervention Comparison Reported results (outcomes) Additional comments Reference/definitions

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

Study design/sample size

Methodological quality issues

Population Intervention Comparison Reported results (outcomes) Additional comments Reference/definitions

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

Database Country/ setting

Study design/sample size

Methodological quality issues

Population Intervention Comparison Reported results (outcomes) Additional comments Reference/definitions

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

Study design/sample size

Methodological quality issues

Population Intervention Comparison Reported results (outcomes) Additional comments Reference/definitions

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

Study design/sample size

Methodological quality issues

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

Database Country/ setting

Study design/sample size

Methodological quality issues

Population Intervention Comparison Reported results (outcomes) Additional comments Reference/definitions

(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.

Database Country/ setting

Study design/sample size

Methodological quality issues

Population Intervention Comparison Reported results (outcomes) Additional comments Reference/definitions

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

Database Country/ setting

Study design/sample size

Methodological quality issues

Population Intervention Comparison Reported results (outcomes) Additional comments Reference/definitions

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.

Database Country/ setting

Study design/sample size

Methodological quality issues

Population Intervention Comparison Reported results (outcomes) Additional comments Reference/definitions

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.

Database Country/ setting

Study design/sample size

Methodological quality issues

Population Intervention Comparison Reported results (outcomes) Additional comments Reference/definitions

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.

Database Country/ setting

Study design/sample size

Methodological quality issues

Population Intervention Comparison Reported results (outcomes) Additional comments Reference/definitions

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.

Database Country/ setting

Study design/sample size

Methodological quality issues

Population Intervention Comparison Reported results (outcomes) Additional comments Reference/definitions

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

Database Country/ setting

Study design/sample size

Methodological quality issues

Population Intervention Comparison Reported results (outcomes) Additional comments Reference/definitions

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.

Database Country/ setting

Study design/sample size

Methodological quality issues

Population Intervention Comparison Reported results (outcomes) Additional comments Reference/definitions

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.

Database Country/ setting

Study design/sample size

Methodological quality issues

Population Intervention Comparison Reported results (outcomes) Additional comments Reference/definitions

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.

Database Country/ setting

Study design/sample size

Methodological quality issues

Population Intervention Comparison Reported results (outcomes) Additional comments Reference/definitions

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.

Database Country/ setting

Study design/sample size

Methodological quality issues

Population Intervention Comparison Reported results (outcomes) Additional comments Reference/definitions

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.

Database Country/ setting

Study design/sample size

Methodological quality issues

Population Intervention Comparison Reported results (outcomes) Additional comments Reference/definitions

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.

Database Country/ setting

Study design/sample size

Methodological quality issues

Population Intervention Comparison Reported results (outcomes) Additional comments Reference/definitions

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

Database Country/ setting

Study design/sample size

Methodological quality issues

Population Intervention Comparison Reported results (outcomes) Additional comments Reference/definitions

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.

Database Country/ setting

Study design/sample size

Methodological quality issues

Population Intervention Comparison Reported results (outcomes) Additional comments Reference/definitions

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.

Database Country/ setting

Study design/sample size

Methodological quality issues

Population Intervention Comparison Reported results (outcomes) Additional comments Reference/definitions

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

Database Country/ setting

Study design/sample size

Methodological quality issues

Population Intervention Comparison Reported results (outcomes) Additional comments Reference/definitions

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.

Database Country/ setting

Study design/sample size

Methodological quality issues

Population Intervention Comparison Reported results (outcomes) Additional comments Reference/definitions

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

Database Country/ setting

Study design/sample size

Methodological quality issues

Population Intervention Comparison Reported results (outcomes) Additional comments Reference/definitions

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.

Database Country/ setting

Study design/sample size

Methodological quality issues

Population Intervention Comparison Reported results (outcomes) Additional comments Reference/definitions

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.

Database Country/ setting

Study design/sample size

Methodological quality issues

Population Intervention Comparison Reported results (outcomes) Additional comments Reference/definitions

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.

Database Country/ setting

Study design/sample size

Methodological quality issues

Population Intervention Comparison Reported results (outcomes) Additional comments Reference/definitions

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.

Database Country/ setting

Study design/sample size

Methodological quality issues

Population Intervention Comparison Reported results (outcomes) Additional comments Reference/definitions

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.

Database Country/ setting

Study design/sample size

Methodological quality issues

Population Intervention Comparison Reported results (outcomes) Additional comments Reference/definitions

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.

Database Country/ setting

Study design/sample size

Methodological quality issues

Population Intervention Comparison Reported results (outcomes) Additional comments Reference/definitions

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.

Database Country/ setting

Study design/sample size

Methodological quality issues

Population Intervention Comparison Reported results (outcomes) Additional comments Reference/definitions

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

Database Country/ setting

Study design/sample size

Methodological quality issues

Population Intervention Comparison Reported results (outcomes) Additional comments Reference/definitions

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.

Database Country/ setting

Study design/sample size

Methodological quality issues

Population Intervention Comparison Reported results (outcomes) Additional comments Reference/definitions

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.

Database Country/ setting

Study design/sample size

Methodological quality issues

Population Intervention Comparison Reported results (outcomes) Additional comments Reference/definitions

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.

Database Country/ setting

Study design/sample size

Methodological quality issues

Population Intervention Comparison Reported results (outcomes) Additional comments Reference/definitions

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.

Database Country/ setting

Study design/sample size

Methodological quality issues

Population Intervention Comparison Reported results (outcomes) Additional comments Reference/definitions

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