Clinical Rotation Research Essay

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Clinical Rotation Research Essay

The major objective for a clinical rotation in exposure purposes is to integrate practical skills. Since there has to be a mentor who supervises a nurse and a nursing assistant, the challenge is that the mentor experiences an added responsibility of helping the learning nurses to attain their goals. However, such liability comes at the expense of quality patient care. With the health care system experiencing a shortage of workforce, the supervisors will be overworked and fatigued thus resulting to providing low-quality services to patients. Also, there is a concentration of primary services in outpatient clinical areas. However, with the overwhelming influx of patients, the chances are that nurses and nurse assistances may resort to providing such services to outpatients. Such step is most likely to put patients at risk due to the wrong diagnosis. Moreover, though the intention is to provide exposure to these nurses, the risk is that, by rotating them from one out -patient clinical area to another, they are unlikely going to adapt to their working environment.Clinical Rotation Research Essay. Hence, with the lack of adaptability, there will be low productivity due to the time taken to understand the new working conditions. Therefore, the risks involved are poor patients care due to added responsibilities on senior health personnel, fatigue, poor diagnosis and lack of adaptability in every outpatient clinical area they are exposed to work.

To contain patient risks involved in staff rotations, a health organisation must provide fully enough trained support staff to reduce the burden of supervising these nurses and nurse assistants. Also, is to have competent staff who can facilitate the learning if the nurses and nurse assistants. Secondly, the staffing rotation from one outpatient clinical area to another should not be done at short intervals. The approach will help increase the level of adaptability in every clinical area they are posted thus increasing their productivity in those areas.

In conclusion, though there is the need for nurse rotation to improve nurses practical skills, knowledge and professional attitude, there are risks involved in such process. Notably are the patient risks. For instance, the supervising staff is often added responsibility. More responsibilities on the supervising staff will likely lead to fatigue thus reducing their productivity, which results in low-quality patient care. Due to an influx of patients at the outpatient clinical areas, such nurses may get involve in providing primary care through the wrong diagnosis hence putting patients at risk. Finally, frequent staff rotation hinders staff adaptability to their areas of working hence resulting in lowering patient care as compared to when working within areas they have adapted to.

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Five A.M. mornings, navy blue scrubs, mental stability became the bases of my junior year. My most zealous intellectual task, so far, has been my experience with the Clinical Rotation Program at Plano West Senior High. This career course selected qualified students to rotate in three major Plano area hospitals as well as many outline medical sites, to be a part of a hands-on learning experience for medical professionals.Clinical Rotation Research Essay. The amount of opportunities offered through Clinical Rotations did not fall short to the level of dedication required. The ultimate challenge of working in a professional adult world was difficult at times from my teenage point-of-view, yet exploring it has not only allowed me to learn skills of the healthcare field but also has highly matured me for the real world and interpersonal relationships. I believe that my reflection of what true dedication requires has significantly tailored my knowledge of what I want for my future.
The first week of December I was assigned to the fourth-floor Oncology Unit at Medical Center of Plano. The floor consisted of cancer patients, open beds, and progressive care patients, which spread into left and right wings. It became a hassle at times to walk into a new site every week, meeting the staff and learning the routine of the facility. At times, as students, we would have to teach ourselves due to the hectic workflow that the physicians and nurses had during our time there. I knew to stay out of the way at this specific site, unless they asked me to go fill up certain patients water jugs, to check certain vital signs, or practice bed making. These task brought me in contact with most of the patients and some their families, as I walked in and out of the rooms.
Throughout the week there, every morning I would watch as people come and go, but one particular patient stayed. She was an elderly woman battling pancreatic cancer, who loved to watch the re-runs of Dancing with the St…

Clinical teaching in Australian medical schools has changed to meet the needs of substantially increased medical student cohorts. As such, formal feedback from these student cohorts is needed about the value they place on the educational input from each clinical rotation. This study aims to determine which aspects of clinical placements are most educationally useful to medical students.

Methods

In this study, final year medical students from the University of Western Australia (UWA) were surveyed via an anonymous online questionnaire, identifying which clinical placements were found to be the most and the least useful to their learning and the positive aspects of these placements. Two focus groups were conducted prior to the design of the questionnaire to determine the key areas of focus important to medical students. Ethics approval for this study was obtained from the UWA Human Research Ethics Committee.

Results

Our focus groups were consistent in finding that students enjoyed placements where they were included as a part of the medical team and played a role in patient care. This was consistent with the concept that inclusiveness and participation in the clinical setting are important in developing competence in tasks and skills. The ratio of students to doctors was crucial, with a low ratio given a higher rating as seen in the rural clinical school.

Conclusion

The results of this project could benefit both the local and national medical curricula in identifying the most effective clinical attachments for learning and preparation for prevocational training. This is relevant especially due to the limited number of clinical placements and growing cohort of medical students. The results of this study can also be extrapolated to international medical education. Clinical Rotation Research Essay.

Keywords: educational value, clinical rotations, medical students, satisfaction

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Introduction

Medical students experience a variety of different learning environments throughout their medical course, from structured lectures and tutorials, group or team-based peer-assisted learning sessions to clinical community and hospital-based attachments. Students’ perceived value from these experiences vary greatly and need to be evaluated in order to determine the most effective environments for learning. Failure to integrate student input regarding effective teaching and learning methods can lead to the disproportionate allocation of resources to methods with less value and effectiveness.

Evolving medical education in Australia: changes in student numbers and workforce needs

The changing landscape of medical education in Australia has meant that the number of medical students and graduates is rising significantly.1 Insufficient medical workforce numbers, an aging medical workforce and increasing rates of chronic diseases have driven the increase in the number of medical schools and medical students in recent years.1 From 2004 to 2012, the number of medical students graduating was reported to be more than doubled, from 1500 to ~3700.2 The development of competent medical graduates relies on adequate, well-supervised training. Unfortunately, the increase in the number of students has not been matched by a proportionate increase in the number of medical educators and clinical learning placements.3,4 Consequently, there are increasing constraints on educational time and value for each student. Clinical Rotation Research Essay.

Five solutions for limited resources

Increase the number of trained medical educators across the spectrum from interns to consultants. Developed and established supervisory programs could be used to engage these doctors.
Increase the utilization of available resources. For this to occur, the aspects of clinical placements that provide the most educational value to students need to be identified, as we have explored in this study.
Data from this study and others can be used to develop new collaborations and cultivate new teaching and supervisory relationships with other health professionals. Key areas where this could be established include supervision of practical procedures, e.g., venesections, cannulations, urinary catheterizations and nasogastric tube insertions.
Optimize case mix and patient encounters with a blend of metropolitan, regional and rural clinical placements.
Maximize modern technology to equilibrate learning opportunities across clinical placements, e.g., with videoconferencing, e-learning, discussion boards and social media. Student learning from experienced and expert clinical practitioners can occur despite issues with distance and time zones.

What do medical students and junior doctors want and need in their clinical learning?

Educational value to medical students may come in the form of adequate training in clinical, technical, analytical, communication and management skills. It also includes effective learning from participation and engagement. Quality supervision has been identified as a key factor for maximizing the educational value of clinical learning.5Supervisors who are experienced and engaging make students more interested in critically analyzing patients’ clinical conditions, studying them and utilizing this work to formulate management plans.6 When supervision is disorganized and not constructive, students become frustrated and lose interest in clinical learning.Clinical Rotation Research Essay. A quality supervisor who increases the educational value for students is someone who is knowledgeable, skil-full and able to encourage a problem-solving approach.7 Effective learning in the clinical setting can be enhanced by encouragement or invitation to students to engage in interactions with peers and practitioners and to participate fully as a member of the health care team. Useful and constructive feedback from clinical teachers may also enhance the educational value for students.8

Previous studies investigating the factors that are most important in creating effective learning environments for junior doctors found that the level of participation students are afforded in the workplace is key in clinical practice learning.9 It has been established that greater participation in the workplace facilitates greater confidence and competency, especially in clinical practice.1,9

A 2006 American study that sought to identify key variables perceived by students to be associated with educationally valued surgical clerkship sites found that direct patient care experiences, teaching during rounds, opportunities to practice procedures and skills and average hours per week of teaching by attending doctors contributed significantly to overall educational value.10 The variables that were found not to contribute to overall educational value included outpatient exposure, conferences and feedback.

A 1997 study from Ireland that looked at the intern education and training program found that a majority of interns considered that they were not prepared for all the skills/competencies needed as an intern.11 It identified that work experience, rather than formal training, helped them to acquire skills and professional competencies. Clinical Rotation Research Essay. The staff that helped them the most were nonconsultant hospital doctors and fellow interns. It was also noted that placements that are too specialized, such as cardiothoracic surgery, have limited value because the experience is mainly clerical and the duties are nonclinical. In regard to learning needs in the undergraduate clinical curriculum, the study found that graduates considered that their clinical experience had been too variable, too fragmented and, for some attachments, too specialized. Graduates also felt that their roles and duties were not clearly defined and that their exposure to common clinical problems was inadequate.

A 2008 study from South Africa investigating the perceived educational value of a 2-week rural clinical rotation for medical students in South Africa found three criticisms from students. 1) The rural rotation was not structured efficiently; 2) compulsory written reports and additional projects prevented them from maximizing the rural experience; and 3) a time period of 2 weeks was felt to be too short for optimum benefit from the rotation.12

Medical education in nonmetropolitan clinical placements

The shortage of doctors in remote areas in Australia is a challenge for the health care system. Medical schools have addressed this need by developing rural-based teaching opportunities, with government funding allocated for rural clinical schools (RCSs) and rural placements.13 These placements aim to expose medical students to rural practice, encouraging them to work in geographical areas of need as graduates. It is thought that exposure to rural clinical practice in a doctor’s medical training is an important influence in determining whether they choose careers as rural health care providers.14 This philosophy also reduces the burden of clinical teaching in metropolitan health services, allowing for greater student–clinician and student–patient interaction. Allowing students to spend time in rural communities allows students to understand the role of a rural physician and to experience the unique opportunities available outside of metropolitan health care settings. Clinical Rotation Research Essay. A review of the literature regarding the impact of rural clinical experiences and future career choice found that the majority of studies showed they had a positive influence upon students to consider primary care specialities and choosing rural practice.14

Academic performance of rural students

Comparing the academic performance of rural and metropolitan medical students, a cohort study of medical students from Flinders University found the view that student academic performance in the tertiary hospital setting exceeding that of students in the regional hospital and community settings is not justified.15 In fact, the study’s results showed that students in the rural program outperformed metropolitan students academically. In contrast, a 1996 Western Australian study found that there was no statistically or clinically significant difference in the mean marks of rural students compared with metropolitan students.16 The study did, however, note that almost all rural students (25 out of 28) saw a wider variety of patients and more clinical problems and conditions than metropolitan students and they also participated in six times the number of procedures.

Assessments and impact on clinical learning

Students have reported frequent assessments in medical school mean that a lot of their time is spent preparing for the next examination rather than getting the most out of their clinical years in hospital-based learning environments. A study conducted by Newble and Jaeger17 in 1983 described a scenario where medical students reported that they spent too much time studying theoretical components of the course compared to the practical and clinical aspects of medicine. Clinical Rotation Research Essay. Action was taken by the faculty to develop a new examination regime that reflected more on aspects of clinical learning rather than just theory. Students surveyed after the course change found that the nature of clinical scenarios in the new examinations was a better assessment of their clinical competence and as such, they were able to get more out of their clinical learning environment, since an increase in ward-based learning activities was vital for success in such examinations. The new clinical examination had therefore influenced the students’ learning in a positive way and such positive influence may still be achieved if the current course takes the views of students on the frequency of assessments and the negative impact this can have on their learning.

Development of research project

The aim of this research was to identify strengths and weaknesses in current Australian medical student education. This was performed from the perceptions of the actual consumers, the students themselves. This study was conducted in the following two parts:

Focus groups to explore current students’ experiences and perception of educational value from their clinical placements.
An online questionnaire to quantify their responses and stratify differences between students who had completed at least 1 year in a rural clinical setting versus those that had completed most of their training in a metropolitan setting.

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Methods

Two focus groups were conducted, the first involving sixth-year University of Western Australia (UWA) medical students and the second involving medical students participating in the Australian Medical Students’ Association (AMSA) leadership council who were from various year groups and medical schools in Australia. The aim was to gather in depth information about students’ experiences and perspectives on teaching and learning in clinical placements and assessment in the medical course. Sixth-year medical students from UWA were invited to join the focus group via email. Sixth-year students who spent their fifth year participating in the RCS program were included, allowing for comparison between the experiences of these students and those who were metropolitan students in their fifth year. Clinical Rotation Research Essay. Three main questions were asked by the focus group facilitator and left open for discussion among the participants. These questions include the folllowing:

1. What were the placements that you found educationally useful?
2. Why did you find these placements useful?
1. A) What were the placements that you found enjoyable?
2. B) Why did you find these placements enjoyable?
1. A) What is your ideal learning environment?
2. B) What is the actual learning environment?

The common themes that arose from the focus groups helped define the different components of the questionnaire. The focus groups’ responses were recorded by three different scribes to make sure that all the discussion responses were noted. A debriefing session was conducted straight after to collate all the responses to the questions. Thematic analysis was used to capture the rich, detailed and complex account of the data. The analysis focused on a description of the whole data set.18 A theoretical thematic analysis was performed based on previous literature reviews.19 The main themes that were derived from the analysis were prior learning in medical program, clinical placements in metropolitan versus rural sites, maximizing value of interaction with clinicians and methods of interaction including assessment of performance. More details are provided in the “Results” section.

The study population consisted of final year (sixth-year) medical students from the UWA, who were recruited via email to fill in an online questionnaire.Clinical Rotation Research Essay. An initial recruitment email and three subsequent reminder emails were sent to the cohort’s university email accounts, inviting them to fill in a questionnaire on Survey Monkey, an online questionnaire website, by following a link contained in the email. The Questionnaire developed had the following four parts:

Part A – gathering background information including whether the respondent was in the undergraduate or graduate course and expected year of graduation.
Part B – determining the length of the respondent’s medical curriculum, including premedical, preclinical and clinical phases, the amount of integration of clinical and medical sciences in the course and ratings of different learning characteristics in the curriculum.
Part C – assessing clinical rotations, including participation in RCS, which rotations were most educationally useful and why they were useful.
Part D – determining which aspects of teaching were most useful and what type of assessments were commonly used during clinical rotations.

Respondents were also allowed to provide free text written comments on any other useful educational encounters they experienced.

Questions in Parts C and D asked respondents to rate clinical attachments and aspects of teaching and learning using 5-point Likert scale. The allocated ratings were

Not useful at all
Rarely useful (<10% of the time)
Minimally useful (10%–30% of the time)
Moderately useful (40%–80% of the time)
Very useful (>80% of the time)
Not applicable

Participants were recruited through a total of four emails. The initial recruitment email raised 22 responses. Three subsequent reminder emails raised ~10 additional students each time. This generated a total response from 54 students out of an eligible cohort of 160 students. This represented 33.8% of all registered final year medical students in this cohort. Clinical Rotation Research Essay.

Recruitment emails were sent together with an information form pertaining to the study aims, the ethics approval and the contact details for the research supervisor of the study. As the study was anonymous, participants provided informed consent for their data to be used in the study according to the Ethics approval, by completion of the questionnaire. The Faculty Information Technology Officer matched the emails to the questionnaires to confirm that no student completed this more than once. Neither incentives nor financial rewards were offered or given to students who completed the questionnaire.

The pattern of response rate was very similar following each recruitment email. The responses generated from each email all came within the first few days after the email.

Both descriptive and inferential statistical analysis was performed on the relevant questionnaire responses. Rating averages were generated for questions for which they would provide meaningful results. The rating averages had to be adjusted using a simple algorithm, for the questions in which participants could answer not applicable (NA), so that they were a true reflection of the responses.

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Ethics

The project had already gained ethics approval from Scientific Research and Ethics committee of the Medical Deans of Australia and New Zealand, which also supported this project. The AMSA has also supported this research and one of the focus groups was conducted at their Annual Congress in 2013. Ethics approval was given by the UWA Human Research Ethics Committee . Clinical Rotation Research Essay.(RA/4/1/5326).

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Results and analysis

Focus group reports

UWA focus group

The initial focus group conducted involved four sixth-year UWA medical students, three of whom participated in the RCS placement during their fifth year of study.

Students who took part in RCS found it an enjoyable experience that had advantages over teaching in metropolitan tertiary hospitals. Aspects of RCS, which were favorable, included being able to interact with doctors on a closer basis professionally and socially, the smaller student–teacher ratio, the presence of doctors that were more invested in students’ learning, the ability to develop a long-term relationship with doctors (metropolitan students change rotation every 8 weeks, while RCS students have an 11-month continuous contact with the same doctors) and the ability to generate a greater rapport with patients and be involved in their follow-up.

Students felt that participation in outpatient clinics and bedside tutorials were valuable to their learning. Clinics and bedside tutorials allow for students to receive feedback from senior doctors on their examination technique and then be questioned about clinical findings, diagnoses and management.

Students found that business ward rounds were of little benefit, as they were often only able to observe and not actively participate. Ward rounds are important in the organization of patient care in hospitals but are often not the ideal environment to develop practical skills or clinical reasoning due to time constraints faced by consultants and senior doctors.

Aspects of teaching that were found to be most useful revolve around student participation in patient care.Clinical Rotation Research Essay. The ideal learning environment involved students being included as a part of a team and able to contribute to management plans, allowing them to gain confidence and develop skills to be prepared to work as an intern. The best approach seemed to be when students were able to see a patient and conduct an appropriate history and clinical examination, then present to a senior doctor and receive feedback, discuss a management plan and be asked questions. This was felt to increase student’s medical competency and communication skills. Being able to follow-up patients to discharge was the ideal ending to these scenarios where the student would be able to see how effective the management plan was, its implementation and the results.

Students identified that assessments should be relevant to teaching. Assessments functioned as a useful learning tool if they were designed to solidify knowledge and point out gaps in their learning. Assessing knowledge that was too specific or not commonly encountered on rotations placed pressure on students in their study and would frustrate and hamper their confidence. Too many written assessments also caused students to reduce the amount of patient contact they experience while on placements as they spend time completing these.

AMSA Leadership Council focus group

Thirteen students participated in this focus group voluntarily, comprised of a mix of graduate and undergraduate students throughout Australia from the Universities of New South Wales, Newcastle, Adelaide, Wollongong, Queensland, Tasmania, Monash and Deakin Universities, and a postgraduate doctor in an Obstetrics-Gynecology training program.

The participants agreed that clinical rotations were more effective when they were “hands on”. This correlated with smaller team sizes and when students were included in the team, often doing jobs that the intern would normally do. Overall the more engaged the student was, the more beneficial they felt that particular rotation was. The most favored rotation was the emergency room as students were able to perform the job of an intern and were not dependent on the medical team to provide them with educational experiences as they are constantly exposed to learning opportunities. Clinical Rotation Research Essay.

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Outpatient clinics were thought to be less educationally useful as there would often be less patient exposure, as only a few patients may be seen in a session. They were useful when the students were allowed to see the patient one-on-one, formulate their own diagnosis and management plan and then discuss with the treating doctor. Allied health clinics were thought to be too specialized a placement. Students felt that placements should be more general instead of being too specialized as this allows for development of a wider range of skills and observing a broad range of clinical problems and diseases.

However, allied health exposure was seen to be important as it allows students to understand their roles better and increase confidence in communication. Students were able to see how a multidisciplinary team works and were made aware of the services that are available for doctors to refer patients to. Students felt that they would benefit from completing these placements early on in their medical education, as they would serve as an appropriate introduction into the clinical teaching environment. This would require an appropriate educational structure and encourage the students to become involved.

The ideal learning environment would be when students are held accountable (e.g., allocated patients to clerk when their team is on take) and have some responsibility in the team, as they were more encouraged and motivated to be involved and found that learning is generally more effective. The ability to give feedback is important for students so that they are able to effect change in the structure of placements when problems arise. Students noted that the placements which accepted constructive feedback were more beneficial learning environments. Clinical Rotation Research Essay.