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Can Nurses Teach Tomorrow's Doctors? A Nursing Perspective on Involvement in Community-Based Medical Education.

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Title: Can Nurses Teach Tomorrow's Doctors? A Nursing Perspective on Involvement in Community-Based Medical Education.
Language: English
Authors: Howe, Amanda, Crofts, Deborah, Billingham, Kate
Source: Medical Teacher. Nov 2000 22(6):576-581.
Peer Reviewed: Y
Page Count: 6
Publication Date: 2000
Document Type: Journal Articles
Reports - Research
Descriptors: Community Education, Educational Change, Higher Education, Interdisciplinary Approach, Medical Education, Nurses, Primary Health Care
ISSN: 0142-159X
Abstract: Points out the increasing importance of primary care which suggests an important role for the whole primary healthcare team in the education of 'tomorrow's doctors'. Uses a questionnaire survey to elicit the perspective of n=65 community-based nurses involved in a new undergraduate medical course. Reports a need for structural changes in the process of multidisciplinary medical education. Includes 24 references. (Author/YDS)
Journal Code: CIJOCT2002
Entry Date: 2002
Accession Number: EJ647841
Database: ERIC
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  Value: <anid>AN0003886348;MCH01NOV.00;2001Jan30.20:44;v4.1</anid> <title id="AN0003886348-1">CAN NURSES TEACH TOMORROW'S DOCTORS? A NURSING PERSPECTIVE ON INVOLVEMENT IN COMMUNITY-BASED MEDICAL EDUCATION </title> <p> <bold> SUMMARY </bold> The increasing importance of primary care suggests an important role for the whole primary healthcare team in the education of 'tomorrow' s doctors'. Few studies have evaluated the contribution and views of staff other than general practitioners. We used a questionnaire survey to elicit the perspective of 65 community-based nurses involved in a new undergraduate medical course. Some 67% of the cohort had already undertaken training to teach others, and were confident of their teaching skills but were overly reliant on the general practitioners for information, and on the goodwill of colleagues for time to teach. The findings suggest a need for structural changes in the process of multidisciplinary medical education, supporting the need for teaching commitments to be coordinated at practice rather than individual tutor level. The high level of professional development for teaching among community nurses suggests that there is a sound basis for encouraging such valuable professional input into medical education in the future. </p> <hd id="AN0003886348-2"> Introduction </hd> <p>Education for nursing and medicine has gone through rapid change in the last 15 years, as evidenced by Project 2000 (UKCC, 1986), and the General Medical Council report Tomorrow's Doctors (GMC, 1993). With falling inpatient numbers, shorter hospital stays and more specialized care being provided in the community, there is an increasing role for primary care in medical education, where much essential healthcare is offered by staff who are professionally qualified in fields other than medicine (Parsell & Bligh, 1998). Community-based teaching "has the major advantage of offering the students a relevant experience which will give them exposure to a wide variety of health conditions, an opportunity of working with different health professionals, and a greater awareness of the role of social factors in the causation and management of illness" (Habbick & Leeder, 1996, p.).This background appears to make medical student teaching by community nurses an essential development. </p> <p>However, there are potential barriers, both practical and political, teaching being an additional workload (Whitehouse, 1996), and teaching by nurses of medical students being a "shift in traditional roles which might be perceived as problematic" in its alteration of professional hierarchies (Dombeck, 1997). There are still structural divisions, in that midwives, health visitors and community nurses are usually Trust employees, while practice nurses are GP employed (Department of Health, 1997). The expertise of nurses as medical educators is also unclear: although a large part of primary care nursing' s daily role is patient education, this does not necessarily imply adequate training for tutoring other professionals. </p> <p>One example of new courses that seeks to utilize the skills of the whole primary care team (ASME, 1993) is Sheffield' s 'Medicine in the Community' (MITC), commenced for 1998 in the fourth year of the revised Sheffield MBChB curriculum. The module: </p> <ulist> <item> is integrated and multidisciplinary, focusing on midwifery, women' s health, child health, care of the elderly, and mental health to highlight the comprehensive care of individual patients through the work of the primary care team; </item> <item> emphasizes and demonstrates prevention, screening and health promotion; </item> <item> allows students to gain knowledge, skills and attitudes in the most relevant clinical setting for the learning objectives setting; </item> <item> highlights experience of teamwork (thus allowing team working to "be turned into a reality, not something to which lip service is paid in a frozen environment", Oswald, 1996). </item> </ulist> <p>The students are based for eight weeks with a single primary care team, supported by small-group and seminar teaching on a weekly basis. During the course, the four nursing disciplines in the primary healthcare team (midwife, health visitor, practice and community nurse) are asked to play a core role in the students' learning through specific contact during clinical work, and also through direct teaching. One example of a staff-specific objective is that, "as a result of midwife attachment, the student should be able to know in detail the routine procedures for ante- and post-natal care of pregnant women, and be able to perform a routine antenatal examination". </p> <p>'Medicine in the Community' is therefore intended to harness the skills of the primary care nurses to teach their roles, and to develop multiprofessional education. However, little has been published on this relatively new concept. Although the curricular rationale for this is excellent, as Pritchard points out (Pritchard, 1995) "we must first ensure that primary health care staff are prepared to accept the level of commitment that this implies. If team work does not enrich their work and personal development, why should they commit themselves?" It was therefore important to evaluate these placements to ensure that problems, concerns or any training needs of the nursing staff could be identified at an early stage, and improvements made for both staff and future students. </p> <hd id="AN0003886348-3"> Method </hd> <p>The aims of the study were to: </p> <ulist> <item> incorporate a nursing perspective into evaluation of community-based teaching of medical students, during the first year of a new course; </item> <item> identify the support and educational needs of the nurses involved; </item> <item> elucidate factors assisting or conflicting with achievement of course objectives. </item> </ulist> <p>A questionnaire survey method was chosen because it would minimize disruption to staff, whilst allowing exploration of the 'who, what, how and why' from the entire sample of nurses (<reflink idref="bib96" id="ref1">96</reflink>) involved in the teaching (Lydeard, 1991). The questionnaire content was drawn from concepts elsewhere in the literature, from authors' experience, and from the views of colleagues. It aimed to identify the following (Figure 1): </p> <ulist> <item> characteristics of the nurses involved in the medical students' placement; </item> <item> description of their input into the module; </item> <item> their views on the module; </item> <item> their needs as teachers. </item> </ulist> <p>The questionnaire was piloted on five nurses within a single teaching general practice. Core content was deemed appropriate, as was the overall length and level of the questionnaire, but there were some minor changes in wording and sequence. </p> <p>As is typical for most general-practice-based courses, contracts are placed with a named GP tutor who oversees and coordinates the attachment. The names and contact addresses of individual nursing colleagues involved in the course were not available to the research team, so the GP tutor at the participating practices was asked to forward these to the intended sample. The data collection involved: </p> <ulist> <item> four questionnaires to each practice (for midwife, health visitor, practice and community nurse); </item> <item> questionnaires attached to reply paid envelopes; </item> <item> deadline stipulated for return of questionnaires; </item> <item> general reminder sent to managers of the practices at time of first deadline, asking staff to return the questionnaires and extending the deadline for their return; </item> <item> questionnaire designed to allow qualitative comments to be made on most aspects of the placement. </item> </ulist> <p>The data analysis involved collation and analysis by one researcher (DC), grouping related themes within the free comment. Nurse descriptions of student contact and settings were verified for triangulation against student record of experience (by AH). </p> <p>Initially it was planned to use focus groups to address major concerns following completion of the questionnaire. However, only a minority of nurses expressed any need for further contact. It was therefore felt that the time commitment of extra meetings or interviews would be intrusive, and the qualitative comments recorded on the questionnaires were used instead for the evaluation. </p> <hd id="AN0003886348-4"> Results </hd> <hd id="AN0003886348-5"> Response </hd> <p>A total of 24 participating general practices were sent four copies of the questionnaire (96 in total); 65 questionnaires were returned (response rate 68%). A reasonably equal distribution of the different community nursing staff returned questionnaires (range 11-18, Figure 2): at least one was returned from all practices, with five practices returning all four. It was not possible to confirm which staff in each practice received the questionnaire, owing to the initial method of distribution. One practice nurse indicated that she had replied on behalf of all four colleagues. </p> <hd id="AN0003886348-6"> Time commitment </hd> <p>The mean time students spent with each nurse was 10 hours (range 2-48 hours, verified against number of sessions signed up in student record). This time was spent performing a multitude of tasks, such as clinics or home visits (Figure 3). </p> <p>More than 50% reported enjoying time spent with the students, but said that increasing workload by teaching could conflict with patient care. Both preparation and clinical teaching required additional time; respondents felt that students should continue to be placed with them during the module, but that they should be given more time: </p> <ulist> <item> to plan their teaching; </item> <item> to allow discussion of the nursing management with students and patients; </item> <item> to explain the reasoning behind their decisions. </item> </ulist> <p>Several nurses suggested that GPs and nurse managers would need to acknowledge that fewer patients or clients should be seen by nurses in sessions where students are present. Further illustrative participant comments are set out in Figure 4. </p> <hd id="AN0003886348-7"> Main perceived benefits and difficulties </hd> <p>The main perceived benefits of working with the medical students highlighted the positive impact on the team and staff themselves as well as the students (see Table 1). In addition to the impact on student understanding of health care and the nurses' role within it, the nurses felt that the placement demonstrated the various external and social pressures that affect the health of the population (seven nurses); made all staff more aware of the role of others within the primary health care team (five); and helped to enhance their own professional performance (five). </p> <p>Similarly, the data on disadvantages are set out in Table 2. The proportion of these was smaller than that for perceived benefits, and focused mainly on increased workload and time commitment. There was also an issue about potential conflict between student learning need and patient preference. </p> <hd id="AN0003886348-8"> Factors moderating effective teaching and learning </hd> <p>Respondents identified various factors: </p> <ulist> <item> Adequacy of information: 51 nurses (78%) requested a more detailed understanding of aims and objectives of the course: others wanted more information on the prior experience of the students, and more understanding of expectations of the nurses as educators. </item> <item> Communication within the practice: while many felt the new teaching had been a stimulus to teamwork (see Table 1), a minority (<reflink idref="bib10" id="ref2">10</reflink>, 15%) perceived a lack of involvement in the planning and structure of the placement, and felt the students had been 'dropped on them'. </item> <item> Student motivation: student disinterest was mentioned by nine nurses (14%), though an equal proportion mentioned the effort students made to develop a good working relationship with the primary healthcare team. </item> <item> Practical constraints of the clinical setting as a learning environment (Packer, 1994): for example, some nurses found that the student timetable could not be made compatible with the routine timing of clinics. </item> </ulist> <hd id="AN0003886348-9"> Training for teaching </hd> <p>Of the 65 community nurses who returned the questionnaire, all felt able to teach the skills that they were performing on an everyday basis. Forty-four nurses had received some form of training to teach. Of these, 28 nurses reported formal education for teaching, with 22 nurses (34% of the total sample) having taken the ENB 997/998 'teaching and assessment' course, and the other six (9% of the total) being 'community practice teachers' (qualified to teach those undertaking a specialist community nursing training). One reported working as a nursing lecturer, and 11 reported training in management. Four reported 'in-service training' only. The remainder (21 staff, 32%) had received no specific training in teaching students, but some reported that general education was part of their training. Only 13 nurses (20%, none of whom had formal educational qualifications) perceived a need for further training, for example in methods of teaching and evaluation. This group also expressed a need for feedback on their teaching, to ensure that they achieved the aims and objectives: either by meeting with other nursing staff involved in the placements, or by a placement report from the university. </p> <hd id="AN0003886348-10"> Discussion </hd> <p>The findings raise several key issues for those designing and organizing community placements for medical students within primary care teams. The authors perceive two key areas requiring critical attention: first, the pivotal role of the GP tutor, which, mediated by personal and interprofessional relationships, has consequences for effective information flow and possibly for student learning. Related to this is the complex relationship between effective teamwork and effective delivery of interprofessional education. </p> <p>For historical and contractual reasons, the organizer of this course (AH) recruited practices via the existing and potential general practice tutors, who then took the role of placement coordinator. The effect of this was that all information and training was transmitted via the named GP tutor. The motivation of the GPs and their understanding of the nurse's role within learning thus becomes crucial in their decisions as to what information needs communicating. The data suggest that this worked admirably in some practices and less well in others; presumably dependent on the organizational ability of the GP, the working structures of the teams concerned, and the prior interprofessional relationships. What originally seemed a purely pragmatic decision may have unintentionally mirrored many gender- and power-related behaviours where "medicine continues to view the expanded role of the nurse in a hierarchical framework, in which nurses serve as physician extenders or helpers, under the authority of a physician team leader" (Campbell-Heider & Pollock, 1987). The method of questionnaire distribution may have compounded this, contributing to a somewhat modest response rate. </p> <p>An interesting finding was the high level of formal educational training among community nurses, and a low level of expressed need for assistance with teaching expertise. It is unlikely that such a high proportion of the GP tutors held similar formal qualifications. While this does not necessarily indicate a skills deficit in the general practitioners, many medical schools are setting up 'Teaching the Teachers' courses for doctors (Dennick, 1998) which suggest that they recognize the need for formal training of staff to ensure adequate skills for teaching. </p> <p>The criticism of an apparent lack in the course of specified aims and objectives for each staff encounter[<reflink idref="bib1" id="ref3">1</reflink>] ("to help tutors, particularly those who have not been involved in the design of a course, to know what is and what is not required", Whitehouse et al., 1997) is evidence of clear awareness of good educational practice among this nurse cohort. The fact that such a small number of nursing staff wished to be contacted again may also be a measure of teaching confidence, as evidenced by the qualifications held by the nurses involved. It could, however, reflect more problematic areas; for example, the difficulties of an increasing workload for nurses reducing motivation to undertake further training. Previous generic training also does not necessarily imply setting-specific skills for new teaching roles, or adequate application of teaching skill. It may therefore be important that quality assurance measures being developed for primary care (Howe, 1999) can be applied to all staff involved in teaching. The fact that some nurses identified a need for more training implies that 'teaching the teacher' provision could usefully extend to all disciplines actively involved in community-based teaching. </p> <p>The problem of student motivation is a universal one for educators; it may be affected by the prior assumptions of the student, the relationship of the module to the content and structure of the assessment, and in turn how these relate to student perceptions of graduation prospects (Baum, 1995). There may, however, be additional challenges facing primary care nurses assisting in the teaching of medical students. Community-based specialties such as general practice are themselves seeking to establish a level of professional respect within the medical hierarchy, and students may require a considerable change of world-view (Southgate & Randall, 1981) to accept the credibility of any primary care tuition. The possibility of ameliorating this will depend in part upon the confidence and skills of the teacher in motivating the student to learn, and, for both general practitioners and nursing, the previous issues of teaching skills and clarity of focus are pertinent. </p> <p>Finally, consideration must be given to the structural factors that are likely to allow this teaching input to continue. It was gratifying to find that in spite of some criticisms of the new course,[<reflink idref="bib2" id="ref4">2</reflink>] nurses felt that the benefits of the placement for students were considerable. The challenge of a multidisciplinary course had been an important exercise for practice teamwork in some instances, and had enhanced both perceived self-worth and professional development for those nurses sharing their expertise. Nevertheless, their strength of opinion around resourcing issues mirror findings among general practitioners about the need to allocate additional resources to allow dedicated time for effective teaching (Gray & Fine, 1997; Wilson et al., 1996). There may be a need for more formal recognition by employers of this new role for nurses, and some medical schools have already entered into dialogue on this (Seabrook et al., 1998). In addition, interprofessional training and enhancement of teamwork may reduce barriers, and thus indirectly improve delivery of joint teaching initiatives. </p> <p>The limitations of the method must be acknowledged. The problem of questionnaire distribution via the GP tutor has already been addressed. A semi-structured questionnaire is resource friendly, but is an inadequate measure of the outcomes of such new teaching, and will not reveal the subtle dynamics that may influence those outcomes. For example, there were no analyses of nurse and GP gender in the data, and it may be that an additional relevant dynamic pertains to issues of gender, power and authority (Witz, 1994).The level of confidence in anonymity of the data may have varied; frank identification of difficulties could have left them feeling vulnerable to reprisals from their employer, the GP practice, or the medical school (Long, 1996). Finally, the method would have been strengthened if parallel data had been collected from the general practitioners. </p> <p>In conclusion, community nursing staff both appreciated and enjoyed being teachers on the 'Medicine in the Community' programme. Teacher training for nurses did not appear to be a major issue amongst staff: most felt they had the skills as educators to adapt their skills to teach medical students, though a minority may require further input. Such placements benefit from a team approach to provision (Carter et al., 1998) and attention needs to be paid by both academic and GP tutors who coordinate placements to ensure that necessary information flows to colleagues. Quality assurance measures, such as feedback and training opportunities, need to be constructed for all staff not just named tutors, and issues of protected time for teaching may need to be addressed at the level of the community trust as well as that of practices. Further research is needed to explore the facilitating and inhibiting factors for effective nursing involvement in the undergraduate medical curriculum. </p> <p>'Medicine in the Community' is an example of an innovative primary-care-based training programme giving a wider experience to medical students, and giving nurses the opportunity to pass on their skills to the doctors of tomorrow. Such courses should contribute to improving the value and appreciation of the community nurse within the medical profession, developing better communication within the modern primary health care team and offering future doctors a deeper level of understanding of the different but important role of community nurses in the primary health care team of the future. This is only likely to be achieved within a professional and institutional culture of mutual respect and acknowledgement, with structures for involvement in teaching that reflect the key role of all team members. </p> <hd id="AN0003886348-11"> Acknowledgements </hd> <p>The authors would like to acknowledge Ms Kate Billingham, RN, RSCN, RHV, MA, for expertise and assistance as part of her work for the RCGP Prince of Wales Fellowship; Ms Debbie Crofts, RGN, for her role as field researcher; Dr Amanda Howe, for initiating the evaluation through her role as coordinator of community-based medical education in Sheffield, and main author; all the nurses and GP tutors who gave of their time and thinking, and who have made 'Medicine in the Community' such a successful course. </p> <hd id="AN0003886348-12"> Notes </hd> <p>[<reflink idref="bib1" id="ref5">1</reflink>] These were in the course book, but appear not to have been regularly communicated. As a consequence of this feedback, the course material now contains specific briefings for each category of staff involved. </p> <p>[<reflink idref="bib2" id="ref6">2</reflink>] Which were explicitly invited by the evaluation. </p> <p>Correspondence: Dr Amanda Howe MD FRCGP, Senior Lecturer in General Practice, University of Sheffield, Community Sciences Centre, Northern General Hospital, Sheffield S5 7AU, UK. Email a.howe@sheffield.ac.uk </p> <p> <bold> Table 1. </bold> Main perceived benefits of placing medical students with primary care nursing staff. </p> <p>(<reflink idref="bib1" id="ref7">1</reflink>) Gives students an insight into the multidisciplinary team, and the nurses' role within that team (40 respondents, 65%) </p> <p>(<reflink idref="bib2" id="ref8">2</reflink>) Gives medical students a wider view of medicine as it involves working with the healthy as well as the sick (28 staff, 43%) </p> <p>(<reflink idref="bib3" id="ref9">3</reflink>) Student placements stimulated staff to maintain their own professional knowledge and skills (16 staff, 24%) </p> <p>(<reflink idref="bib4" id="ref10">4</reflink>) Placement improved the communication within the primary health care team (14 staff, 21%) </p> <p> <bold> Table 2. </bold> Main perceived disadvantages of placing medical students with primary care nursing staff. </p> <p>(<reflink idref="bib1" id="ref11">1</reflink>) Increased time commitment (24 nurses, 37%) </p> <p>(<reflink idref="bib2" id="ref12">2</reflink>) Increased workload -- over stretched (11 nurses, 17%) </p> <p>(<reflink idref="bib3" id="ref13">3</reflink>) Patient inhibitions or customs present problems (9 nurses, 14%) </p> <p> <bold> Figure 1. </bold> Questionnaire for practice-based nursing staff. </p> <p>Medicine in the Community: Nursing Staff Questionnaire </p> <ct id="AN0003886348-13"> Practice Your post in the practice When did you complete your training? When did you join this particular practice? How long in total have you done this work? (years) Please circle the option that best applies to you Have you had medical students from Sheffield University on any previous course Y/N Have you had students from other disciplines attached to you in the practice Y/N</ct> <p>If yes, please describe those placements here: </p> <ulist> <item> Professional group? </item> <item> Length of the placements </item> <item> What you did for them? </item> <item> Comments </item> </ulist> <p>Have you had any formal training for teaching students (of any discipline)? Y/N </p> <p>If yes, please describe: </p> <ulist> <item> What training? </item> <item> How long for? </item> <item> How often? </item> </ulist> <p>Do you hold any specific qualifications for teaching? Y/N </p> <p>If yes, please describe what </p> <p>Approximately how much time did the student(s) spend with you over the first eight-week attachment? </p> <p>----- (days) -----(hours) </p> <p>Please circle any of the following activities you undertook with the student(s): </p> <ulist> <item> Students sitting in with you in clinic </item> <item> Students shadowing home visits </item> <item> Teaching them specific skills </item> <item> Supervising them seeing patients </item> <item> Tutorials </item> <item> Arranging patient contacts </item> <item> Arranging student timetables with the team </item> <item> Other (please describe) </item> </ulist> <p>What are the benefits you perceive of working with these students on the new course? </p> <p>(use space on reverse if necessary) </p> <p>What are the areas of difficulty? </p> <p>Can you make any suggestions that would help to improve areas of difficulty? </p> <p>Do you feel you need any of the following to improve your work with medical students? </p> <ct id="AN0003886348-14"> (1) More information Y/N If yes, please describe what (2) More teaching skills Y/N If yes, please describe what (3) Better communication within the team Y/N If yes, please describe how (4) What else? Please describe what!</ct> <p>Finally, it is likely that more students from all disciplines will increasingly be placed in primary care, since that is where most of the work is done. Do you have any suggestions on how you might like the teaching and training role to develop: </p> <ulist> <item> for you personally </item> <item> within your practice </item> <item> for medical students </item> <item> for other students </item> </ulist> <p> <bold> Figure 2. </bold> Response to questionnaire. </p> <ct id="AN0003886348-15"> Role Questionnaires returned District nurse 16 Practice nurse 18 Health visitor 17 Community midwife 11 Job title missing 3</ct> <p> <bold> Figure 3. </bold> Range and frequency of activities. </p> <ct id="AN0003886348-16"> Activities undertaken Frequency with student (episodes reported) Students sitting in on a clinic 56 Students shadowing home visits 46 Teaching specific skills 42 Supervising students seeing patients 14 Tutorials 6 Arranging patient contacts 15 Arranging student timetables with the team 14</ct> <p> <bold> Figure 4. </bold> Comments by nurses. </p> <p>Benefits </p> <ulist> <item> Medical students, i.e. future doctors, need to have a greater awareness and willingness to be part of a team of which nurses in all disciplines play a major role </item> <item> Improved our teamwork greatly </item> <item> I enjoy the intellectual stimulation of being asked by keen and interested students </item> <item> It encourages personal reflection and examination of one's own skills, values and knowledge, thereby enhancing professional development ... it gives a chance to swap views and knowledge with each other </item> <item> The student was perceived to be part of the team ... partly because he made the effort to fit in </item> </ulist> <p>Problems </p> <ulist> <item> We may need to look at my appointment times to allow more time for each patient when I have students with me </item> <item> I am almost always working at top speed to see the patients who make appointments or who are 'pushed in' for me. Introducing the students, teaching skills or explaining decisions or actions takes time -- makes me run late and increases my stress </item> <item> It has never been made clear what my role is and what level of input is required by me </item> <item> We are experimenting on a student's valuable learning curve, and usually prepare for new work </item> <item> Often find out on the morning of the day that students are expected to work with me that day </item> <item> (I prefer) being asked, not told, that medical students will be present in my clinic </item> </ulist> <hd id="AN0003886348-17"> References </hd> <p>ASME (1993) Medical Undergraduate Community Based Teaching: A Survey on Current and Proposed Teaching in the Community and General Practice in the UK, Occasional Paper No. 3 (Dundee, Association for the Study of Medical Education). </p> <p>BAUM, J.D (1995). Core knowledge, skills and attitudes for undergraduates: kindling curiosity, Archives of Disease in Childhood, 73, pp. 268-269. </p> <p>CAMPBELL-HEIDER, N. & POLLOCK, D. (1987) Barriers to physician-nurse collegiality: an anthropological perspective, Social Science & Medicine, 25(<reflink idref="bib5" id="ref14">5</reflink>), pp. 421-425. </p> <p>CARTER, Y., JACKSON, N. & BARNFIELD, A. (1998) The learning practice: a new model for primary health care teams, Education in General Practice, 9, pp.182-187. </p> <p>DENNICK, R. (1998) Teaching medical educators to teach: the structure and participant evaluation of the Teaching Improvement Project, Medical Teacher, 20(<reflink idref="bib6" id="ref15">6</reflink>), pp. 598-601. </p> <p>DEPARTMENT OF HEALTH (1997) The 'Red Book' (Attached Staff) (London, Department of Health). </p> <p>DOMBECK, M.T. (1997) Professional personhood: training, territoriality and tolerance, Journal of Interprofessional Care ,11(<reflink idref="bib1" id="ref16">1</reflink>), pp. 9-20. </p> <p>GENERAL MEDICAL COUNCIL (1993) Tomorrow' s Doctors. Recommendations on Undergraduate Medical Education (London, GMC). </p> <p>GRAY, J. & FINE, B. (1997) General practitioner teaching in the community: a study of their teaching experience and interest in undergraduate teaching in the future, British Journal of General Practice, 47, pp. 623-626. </p> <p>HABBICK, B.F. & LEEDER, S.R. (1996) Orienting medical education to community need: a review, Medical Education, 30, pp. 163-171. </p> <p>HOWE, A. (1999)Teaching in practice: a qualitative analysis of factors influencing community based teaching, submitted to Medical Education. </p> <p>LONG, S. (1996) Primary health care team workshop: team members' perspectives, Journal of Advanced Nursing, 23, pp. 935-941. </p> <p>LYDEARD, S. (1991) The questionnaire as a research tool, Family Practice, 8(<reflink idref="bib1" id="ref17">1</reflink>), pp. 84-91. </p> <p>OSWALD, N.T.A. (1996) Doctors for the 21st century: the contribution primary care could make, Education for Health, 9(<reflink idref="bib1" id="ref18">1</reflink>), pp. 37-44. </p> <p>PACKER, J.L. (1994) Education for clinical practice: an alternative approach, Journal of Nursing Education, 33, pp. 411-416. </p> <p>PARSELL, G. & BLIGH, J. (1998) Interprofessional learning, Postgraduate Medical Journal, 74(<reflink idref="bib868" id="ref19">868</reflink>), pp. 89-95. </p> <p>PRITCHARD, P. (1995) Learning to work effectively in teams, in: OWENS, CARRIER & HORDER (Eds) Interprofessional Issues in Community and Primary Health Care, Ch. 10 (London, Macmillan). </p> <p>SEABROOK, M., LEMPP, L. & WOODFIELD, S. (1998) Extending Community Involvement in Medical Education (London, Department of General Practice & Primary Care, Kings & St Thomas School of Medicine). </p> <p>SOUTHGATE, L. & RANDALL, S. (1981) in: P. REASON & J. ROWAN (Eds) Human Inquiry: A Source Book of New Paradigm Research, Ch. 5 (Chichester, Wiley). </p> <p>UNITED KINGDOM CENTRAL COUNCIL FOR NURSES, MIDWIVES AND HEALTH VISITORS (1986) Project 2000: A New Preparation for Practice (London, United Kingdom Central Council for Nurses, Midwives and Health Visitors). </p> <p>WHITEHOUSE, C.R. (1996) Planning for community-oriented medical education in Manchester, Education for Health, 9(<reflink idref="bib1" id="ref20">1</reflink>), pp. 45-59. </p> <p>WHITEHOUSE, C., ROLAND, M. & CAMPION, P. (Eds) (1997) Teaching Medicine in the Community: A Guide for Undergraduate Education (Oxford, Oxford University Press). </p> <p>WILSON, A., FRASER, R., MCKINLAY, R. et al. (1996) Undergraduate teaching in the community: can general practice deliver?, British Journal of General Practice, 46, pp. 457-460. </p> <p>WITZ, A. (1994) The challenge of nursing, in: J. GABE, D. KELLEHER & G. WILLIAMS (Eds) Challenging Medicine (London, Routledge). </p> <p> <bold> An analysis of cheating behaviours during training by medical students </bold> </p> <ct id="AN0003886348-18"> John H. Coverdale & Marcus A. Henning University of Auckland, New Zealand</ct> <p> <bold> SUMMARY </bold> The purpose of this study was to assess the acceptability of various behaviours including cheating behaviours and their prevalence during medical school training. Medical students from second- and fourth-year classes at one medical school anonymously completed a questionnaire (response rate 54%). Forty-nine students (39%) had altered or manipulated data and 37 students (29%) had falsified references or a bibliography even though these behaviours were considered unacceptable by the majority. Less commonly acknowledged behaviours included reporting an aspect of a physical examination as normal when inadvertently omitted, copying a report from a friend's paper or copying from a neighbour during an examination without the person realizing. The results are discussed in light of the novel selection process of the school and educational recommendations that the students themselves made. </p> <hd id="AN0003886348-19"> Introduction </hd> <p>In light of the high ethical behaviours required by the fiduciary relationship of medical practitioners with patients it would be expected that a culture of high ethical behaviours would be promoted during medical school. We have a new system in place at the University of Auckland, New Zealand which selects prospective students by individual interviews on the basis of attributes including sensitivity and empathy and by a group exercise which usually has an ethical component (Collins et al., 1995).This follows from a recognition of the importance of producing compassionate doctors with excellent interpersonal skills and ethical behaviours. </p> <p>Anderson & Obenshain (1994) found that many medical students perceive that some of their colleagues cheat. Such findings, however, do not define the prevalence of cheating behaviours. When students have been asked directly about their own behaviours, as many as 24% of fourth-year students reported having cheated in direct patient care, and 5% had cheated in basic science (Dans, 1996). The cheating in direct patient care included recording tasks not performed, reporting findings elicited by others, or lying about having ordered tests. The cheating in basic science included copying from someone else's paper or using crib notes. Sierles et al. (1980) found that 58% of fourth-year medical students at two American schools had cheated at least once during their training. </p> <p>Because of the dearth of studies and a few incidences of alleged or suspected cheating by medical students in our medical school (Nairn et al., 1995) and other occasions of alleged misconduct, we aimed to assess the acceptability of various behaviours that might be considered as problematic during medical school training. We also directly asked students whether they had engaged over the previous year in those behaviours that were viewed as unacceptable by the majority. Students were asked to recommend interventions that might address any of these issues in relation to the questions in the survey form. </p> <hd id="AN0003886348-20"> Method </hd> <p>Sixty-nine (59%) year two and 58 (49%) year four medical students completed a questionnaire addressing cheating behaviours.This provided a comparison between preclinical students (year two) and clinical students (year four). The overall response rate was 54%. This response rate was conservatively calculated using the total number of students who had enrolled in the courses rather than the number of students who had attended the seminar when this questionnaire was administered. </p> <p>A questionnaire investigating certain behaviours relevant to the practice of 'cheating' was developed by the present authors utilizing items that included those cited in related research (Anderson & Obenshain, 1994; Penington, 1996). We wanted to evaluate how medical students viewed such behaviours in terms of their acceptability and we therefore eliminated any pejorative language such as 'cheating' from the questionnaire. Students were asked whether or not they had participated in each category of behaviour and how often over the past year. Open-ended statements were used to prompt students' comments on whether they would benefit by further discussions concerning such behaviours, and whether they could suggest any educational intervention(s) that would address any of the issues raised by the questionnaire. Students were not asked specifically about the context within which these further discussions could take place (e.g. one-to-one discussion, small-group sessions or lecture format. (A copy of this questionnaire may be obtained from the first author.) Demographic information on the questionnaire was very limited in order to protect students' anonymity. </p> <p>Following University Ethics approval the student year representatives of years two and four of the Faculty of Medicine and Health Science were approached. After some discussion with one of the authors and the student representative it was decided that the best probability of response from students would occur if the questionnaire was administered to the relevant years at one sitting. The students received the questionnaires and were asked to complete and return them to an anonymous post box in the lecture room, or alternatively to an administrative secretary. </p> <hd id="AN0003886348-21"> Results </hd> <p>Five behaviours were viewed neutrally or as possibly acceptable by the majority of respondents, e.g. allowing own course to be copied, citing papers without having read the original, writing up a biochemistry laboratory exercise without having done the work and observing a student copying in an examination while doing nothing. Table 1 illustrates those behaviours which the majority of students viewed as unacceptable. As can be seen from Table 1 the two behaviours most commonly considered as unacceptable were copying from a neighbour during an examination without the person realizing and taking unauthorized material into an examination. </p> <p>Table 2 describes students' self-reported frequencies of behaviours during the academic year for those behaviours that were viewed as unacceptable by the majority. Students most commonly had altered or manipulated data (e.g. adjusted data to obtain a significant result) or falsified references. Five students acknowledged altering or manipulating data five or more times during the preceding year; none had falsified references this often. Other frequently reported behaviours included reporting an aspect of a physical examination as 'normal' when it was inadvertently omitted, copying a report for a preclinical or clinical paper from a friend's paper from a prior year, and copying from a neighbour during an examination without the person realizing. </p> <p>Forty-six students (36%) commented on whether they wanted further discussion on the issues raised by the survey. Of these respondents, 31 (67% were in favour of further discussion while 13 (28%) were against and two students were neutral. Students' recommendations for educational interventions to address the issues raised by the questionnaire are provided in Table 3. </p> <hd id="AN0003886348-22"> Discussion </hd> <p>These data should be considered in the light of several limitations. Only 55%of students responded, which perhaps reflected the sensitivity of the questionnaire even with the precautions we had set in place in order to protect anonymity. Other factors may also be significant in the low response rate such as questionnaire fatigue or simply not being bothered.There may have been a bias towards socially desirable responses and those who did not respond might have reported quite different attitudes and behaviours. These results are also not necessarily generalizable. </p> <p>With every behaviour there was at least a minority of students, of 6% or greater, who viewed it as acceptable or who were neutral about it. Furthermore, behaviours viewed as unacceptable were engaged in by at least a small minority of students. For example, 13% of respondents acknowledged copying from a neighbour during an examination. The behaviour most commonly engaged in which was viewed as unacceptable by a majority was altering or manipulating data (e.g. adjusting data to obtain a significant result). Other behaviours such as taking unauthorized material into an examination or taking an examination for someone else were rarely acknowledged. This may have reflected the perceived strength of opposition by others to these behaviours, or that specific instruction was given prohibiting them. Alternatively, this may have reflected students' concerns about the likelihood of detection and the possible implications of detection. </p> <p>These results are concerning in light of the ethical behaviours required of physicians. However, we do not know that the people who engage in such unethical or problematic behaviours during medical training will continue to do so. As far as we are aware, a direct link between medical students and doctors who engage in illegal or unethical behaviours has not been established. Nevertheless, the behaviours reported by some of the respondents, e.g. falsifying individual patient records, laboratory information, or X-ray data clearly have immediate serious clinical consequences. A worrying precedence is also set when students alter or manipulate data (Lock, 1988; Drummond & Gunsalus, 1993). </p> <p>These results are also particularly surprising in light of the selection process of this medical school. All participating students had been selected for medical school by the new system that emphasized positive attributes including excellent interpersonal skills and ethical behaviour. Didactic teaching is provided on ethics at all years in this school and in some cases students signed an ethical declaration before initiating a research project (Nairn et al., 1995). University regulations also explicitly prohibited copying during examinations from another candidate's answers. However, as far as we are aware there had been no formal didactic teaching on issues around plagiarism or falsifying data during clinical rotations. </p> <p>We cannot ascertain to what extent, however, the selection process might have made a difference. We did not include a sample of students from before the implementation of the new system that selected the most positive attitudinal and behavioural aspects of students. Alternatively, the high educational demands placed on the students may have led some to behave less ethically. </p> <p>Our data suggest a priority for educational interventions to address these ethical concerns, which might include some of those interventions recommended by the students such as reducing course requirements, encouraging integrity and providing clear and relevant guidelines. The dearth of studies that inquire about students' own reported ethical behaviours and a lack of evaluation of educational programmes on ethical behaviour during medical school are priorities for further research. One challenge will be to delineate what kinds of teaching and educational experiences will effect attitudinal and behavioural change and facilitate ethical behaviours by medical students. </p> <hd id="AN0003886348-23"> Notes on contributors </hd> <p>John H. Coverdale is associate professor in the Department of Psychiatry and Behavioural Science, Faculty of Medicine and Health Science, The University of Auckland. </p> <p>Marcus A. Henning MA is a Tutor and Psychologist in the Student Learning Centre, Auckland Institute of Technology, Auckland, New Zealand. </p> <p>Correspondence: Dr John Coverdale, MB CLB FRANZCP, Department of Psychiatry and Behavioural Science, Faculty of Medicine and Health Science, The University of Auckland, Private Bag 92019, Auckland, New Zealand. </p> <p> <bold> Table 1. </bold> Number and percentage of students (years two and four) perceiving described behaviours as unacceptable (vs. neutral or acceptable). </p> <ct id="AN0003886348-24"> Rank Item n % (1) Copying from a neighbour during an examination without the person realizing 120 94 (2) Taking unauthorized material into an examination 119 94 (3) Removing an assigned reference from a shelf in the library and thereby preventing others from gaining access to the information in it 113 89 (4) A student taking an examination for someone else or having someone else taking an examination for him or her 112 88 (5) Permitting another student to copy from another student during an examination 112 88 (6) Reporting an aspect of a physical examination as 'normal' when it was inadvertently omitted from the examination 107 84 (7) Reporting a lab test or X-ray as 'normal' during ward rounds when in actual fact there had been no attempt to obtain the information 103 81 (8) Falsifying references or a bibliography 95 75 (9) Copying a report for a preclinical or clinical paper from a friend's paper from a prior year 88 69 (10) Altering or manipulating data (e.g. adjusting data to obtain a significant result) 69 54</ct> <p> <bold> Table 2. </bold> Ranked self-reported (years two and four) frequencies of students' behaviours (n = 127) for those behaviours viewed as unacceptable. </p> <ct id="AN0003886348-25"> Rank Item n % (1) Altering or manipulating data (e.g. adjusting data to obtain a significant result) 49 39 (2) Falsifying references or a bibliography 37 29 (3) Reporting an aspect of a physical examination as 'normal' when it was inadvertently omitted from the examination (4) Copying a report for a preclinical or clinical paper from a friend's paper from a prior year 22 17 (5) Copying from a neighbour during an examination without the person realizing 16 13 (6) Permitting another student to copy from another student during an examination 6 5 (7) Removing an assigned reference from a shelf in the library and thereby preventing others from gaining access to the information in it 3 2 (8) Reporting a lab test or X-ray as 'normal' during ward rounds when in actual fact there had been no attempt to obtain the information 3 2 (9) Taking unauthorized material into an examination 2 2 (10) A student taking an examination for someone else or having someone else taking an examination for him or her 2 2</ct> <p> <bold> Table 3. </bold> Medical students' recommendations for educational interventions. </p> <ulist> <item> Encourage integrity in students as a crucial factor for future doctors </item> <item> Allow adequate time for students to do laboratory exercises and completion of reports </item> <item> Clear guidelines on how to use references </item> <item> Extra tuition for laboratory projects </item> <item> Courses on how to organize notes and study skills </item> <item> Lecturers and junior staff opposing such behaviour rather than being neutral or encouraging </item> <item> Previous exam papers should be available to all students </item> <item> Accept that these things happen </item> <item> Reduce course requirements </item> <item> Enhance team bonding </item> <item> Place all important references on desk copy and fine students who are late in returning such articles </item> <item> Discussion on other issues, e.g. confidentiality when making complaints, time management, academic ranking and consequences of falsifying records </item> </ulist> <hd id="AN0003886348-26"> References </hd> <p>ANDERSON, R.E. & OBENSHAIN, S.S. (1994) Cheating by students: findings, reflections and remedies, Academic Medicine, 69(<reflink idref="bib5" id="ref21">5</reflink>), pp. 323-331. </p> <p>COLLINS, J., WHITE, G., PETRIE, K. & WILLOUGHBY, E. (1995) A structured panel interview and group exercise in the selection of medical students, Medical Education, 29, pp. 332-336. </p> <p>DANS, P. (1996) Qualities of medical students: self reported cheating by students at one medical school, Academic Medicine, 71(Jan. Suppl), pp. s70-s72. </p> <p>DRUMMOND, R. & GUNSALUS, C. (1993) Scientific misconduct: new definition, procedures, and office -- perhaps a new leaf, Journal of the American Medical Association, 269(<reflink idref="bib7" id="ref22">7</reflink>) pp. 915-917. </p> <p>LOCK, S. (1988) Misconduct in medical research: does it exist in Britain?, British Medical Journal, 297, pp. 1531-1535. </p> <p>NAIRN, R.G., COVERDALE, J.H. & ELKIND, G.S. (1995) Teaching the principles of behaviour change to medical students: evaluation of a programme, Medical Education, 29, pp. 443-448. </p> <p>PENINGTON, H. (1996) Cheating among NZ university students, Paper presented at NZ Psychological Conference, Christchurch, 28 August. </p> <p>SIERLES, F., HENDRICKSX, I. & CIRCLE, S. (1980) Cheating in medical school, Journal of Medical Education, 55, pp. 124-125. </p> <p>SIMPSON, D.E., YINDRA, K.J., TOWNE, J.B. & ROSENFIELD, P.S. (1989) Medical students' perceptions of cheating, Academic Medicine, 64, pp. 221-222. </p> <p>STIMMEL, B. & YENS, D. (1982) Cheating by medical students on examinations, American Journal of Medicine, 73, pp. 160-164. </p> <aug> <p>By Amanda Howe; Deborah Crofts and Kate Billingham, University of Sheffield, UK </p> </aug> <nolink nlid="nl1" bibid="bib96" firstref="ref1"></nolink> <nolink nlid="nl2" bibid="bib10" firstref="ref2"></nolink> <nolink nlid="nl3" bibid="bib1" firstref="ref3"></nolink> <nolink nlid="nl4" bibid="bib2" firstref="ref4"></nolink> <nolink nlid="nl5" bibid="bib3" firstref="ref9"></nolink> <nolink nlid="nl6" bibid="bib4" firstref="ref10"></nolink> <nolink nlid="nl7" bibid="bib5" firstref="ref14"></nolink> <nolink nlid="nl8" bibid="bib6" firstref="ref15"></nolink> <nolink nlid="nl9" bibid="bib868" firstref="ref19"></nolink> <nolink nlid="nl10" bibid="bib7" firstref="ref22"></nolink>
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