Professor Charlotte Rees

Critique has been levelled at the use of models for feedback practices that ignore context in health professions education. Models such as the 'feedback sandwich' are often adopted as rules to be followed regardless of the situation. In this chapter, we utilise an updated version of the Bronfenbrenner ecological framework of human development to unpack contextual influences on feedback practices at different levels. The framework seeks to integrate and conceptualise the environment and other influences on behaviour. The implication of the interplay of these networked systems on feedback practices and consequences for learners is that a one-size feedback intervention is not suitable for all situations. Promoting feedback by design involves taking context into account for each of the systems. A step forward in terms of scaling up effective feedback practices would be through using this contextual mapping to improve feedback literacy of students and staff. On the basis of our mapping, we highlight the usefulness of ecological models for research and practice in assessment for learning in higher education and propose recommendations for future research.

Introduction: Health professions education research has evolved as a discipline, yet chronological trends in topics and methodologies together have not been comprehensively explored previously. This study aimed to identify the trends in research topics and methodologies used in primary empirical studies published in reputable health professions education research journals at the turn of three decades (2000, 2010, and 2020). Methods: Underpinned by relativism and subjectivism, this review of trends included primary empirical studies published in five quartile 1 health professions education research journals, defined by Clarivate (Academic Medicine, Advances in Health Sciences Education, Medical Education, Medical Teacher, and Nurse Education Today) from three sample years at the start of three decades (2000, 2010, and 2020). Each study was coded for demographics (e.g., country of origin), topic area, and methodological approach, including philosophical positioning, study design, and methods. Data were analysed descriptively. Results: A total of 1126 empirical studies were published across the three time-points, with the majority from North American and European countries. More papers were published in recent years, with publications doubling in 2020 (n = 488) compared with 2000 (n = 223). Effective teaching methods were the most researched topic, whereas teaching and learning of Indigenous health received the least priority consistently across the three time-periods. Over half of the methodologies were quantitative, followed by qualitative, and mixed methods. The use of qualitative methodologies and the reporting of philosophical positioning (mostly in qualitative studies) have gradually increased over the three time-points. Many studies, however, still fail to report key markers of methodological quality. Discussion: Despite positive trends in health professions education research (more studies, multi-institutional research, and balanced methodological approaches), our review of trends identified notable issues (e.g., limited country diversity, missing criteria for methodological quality, and less-diverse research topics). We therefore encourage greater consideration of the role of journals in shaping the future, quality of output reporting, and gaps in the literature; thereby diversifying what and how we research health professions education.

Background: Delivering intensive care therapies concordant with patients' values and preferences is considered gold standard care. To achieve this, healthcare professionals must better understand decision-making processes and factors influencing them. Aim: The aim of this study was to explore factors influencing decision-making processes about implementing and limiting intensive care therapies. Design: Systematic integrative review, synthesising quantitative, qualitative, and mixed-methods studies. Methods: Five databases were searched (Medline, The Cochrane central register of controlled trials, Embase, PsycINFO, and CINAHL plus) for peer-reviewed, primary research published in English from 2010 to Oct 2022. Quantitative, qualitative, or mixed-methods studies focussing on intensive care decision-making were included for appraisal. Full-text review and quality screening included the Critical Appraisal Skills Program tool for qualitative and mixed methods and the Medical Education Research Quality Instrument for quantitative studies. Papers were reviewed by two authors independently, and a third author resolved disagreements. The primary author developed a thematic coding framework and performed coding and pattern identification using NVivo, with regular group discussions. Results: Of the 83 studies, 44 were qualitative, 32 quantitative, and seven mixed-methods studies. Seven key themes were identified: what the decision is about; who is making the decision; characteristics of the decision-maker; factors influencing medical prognostication; clinician-patient/surrogate communication; factors affecting decisional concordance; and how interactions affect decisional concordance. Substantial thematic overlaps existed. The most reported decision was whether to withhold therapies, and the most common decision-maker was the clinician. Whether a treatment recommendation was concordant was influenced by multiple factors including institutional cultures and clinician continuity. Conclusion: Decision-making relating to intensive care unit therapy goals is complicated. The current review identifies that breadth of decision-makers, and the complexity of intersecting factors has not previously been incorporated into interventions or considered within a single review. Its findings provide a basis for future research and training to improve decisional concordance between clinicians and patients/surrogates with regards to intensive care unit therapies.

Introduction: While many studies have explored surgeons' personal and professional identities separately, our study is the first to examine intersecting female surgical identities. We explore intersecting surgical identities constructed by self and others (colleagues and patients) within two healthcare systems and their perceived impacts answering the research question: How do female surgeons' constructed identities intersect, and what influences do those intersections have on their surgical lives? Methods: We employed qualitative methodology drawing on semi-structured biographical narrative interviews underpinned by social constructionism. We employed intersectionality theory as an analytical lens. We adopted maximum variation sampling to identify diverse participants, including 38 surgeons (29 female; 9 male), 9 non-surgical colleagues (8 female, 1 male), and 13 patients of female surgeons (7 female, 6 male). Our 29 female surgeons also included six who had transitioned out of surgery. We analyzed the dataset using a five-step Framework Analysis approach. We captured talk about identities, as well as identity talk (constructions of identity through participants' talk). Findings: Multiple intersecting personal (not just gender) and professional identities were constructed and reported to have multiple impacts on female surgeons' lives (including their education, training, and success). We present intersecting identities and their impacts relating to gender through four primary intersections: (a) gender + ethnic identities; (b) gender + parenthood identities; (c) gender + age identities; and (d) gender + professional identities (namely carer, competent, mentor/mentee, role model and leader). Our findings particularly highlight the challenges experienced by female surgeons of color, who are mothers, who are younger and/or who are leaders, illustrating diversity in women's experiences beyond that of gender alone. Finally, we found unexpected insights into male surgeons and fatherhood. Discussion: Intersectionality theory offered a novel analytical lens to extend existing knowledge on female surgical identities. Further research is warranted exploring intersecting identities of female surgeons of color, younger female surgeons, and male surgeons who are fathers, as well as identities unexplored in this study (e.g., diverse sexualities). We need to raise awareness of intersecting identities and their impacts in surgery, as well as providing training, allyship, and policy revision that is sensitive to intersectionality.

Effective leadership is crucial to team performance within the intensive care unit. This novel study aimed to explore how staff members from an intensive care unit conceptualize leadership and what facilitators and barriers to leadership exist within a simulated workplace. It also aimed to identify factors that intersect with their perceptions of leadership. This study was underpinned by interpretivism, and video-reflexive ethnography was chosen as the methodology for the study. The use of both video recording (to capture the complex interactions occurring in the ICU) and team reflexivity allowed repeated analysis of those interactions by the research team. Purposive sampling was used to recruit participants from an ICU in a large tertiary and private hospital in Australia. Simulation groups were designed to replicate the typical clinical teams involved in airway management within the intensive care unit. Twenty staff participated in the four simulation activities (five staff per simulation group). Each group simulated the intubations of three patients with hypoxia and respiratory distress due to severe COVID-19. All 20 participants who completed the study simulations were invited to attend video-reflexivity sessions with their respective group. Twelve of the 20 participants (60%) from the simulations took part in the reflexive sessions. Video-reflexivity sessions (142 min) were transcribed verbatim. Transcripts were then imported into NVivo software for analysis. The five stages of framework analysis were used to conduct thematic analysis of the video-reflexivity focus group sessions, including the development of a coding framework. All transcripts were coded in NVivo. NVivo queries were conducted to explore patterns in the coding. The following key themes regarding participants' conceptualizations of leadership within the intensive care were identified: (1) leadership is both a group/shared process and individualistic/hierarchical; (2) leadership is communication; and (3) gender is a key leadership dimension. Key facilitators identified were: (1) role allocation; (2) trust, respect and staff familiarity; and (3) the use of checklists. Key barriers identified were: (1) noise and (2) personal protective equipment. The impact of socio-materiality on leadership within the intensive care unit is also identified.

Background: The transition from student to dietitian is an implicit expectation of dietetic education. Although there has been an expanding literature around elements of competency-based education, little attention has focused on sociocultural aspects of learning and professional identity formation in dietetic education. Objective: The aim of this study was to explore sociocultural factors in dietetics education influencing the transition into the profession from the perspective of dietetics students and educators. Design: An exploratory qualitative study underpinned by social constructionism. Participants/setting: From March 2018 until June 2019, interviews (individual and group) with final-year students (n = 22), dietetic preceptors (n = 27), and university faculty members (n = 51) from 17 of the 18 universities in Australia and New Zealand with accredited dietetic programs were undertaken and explored sociocultural factors in dietetic education. Analysis performed: Data were analyzed into key themes using framework analysis and applying the sociocultural theory of landscapes of practice. Results: Sociocultural factors are powerful influences on the student-professional transition. Dietetic cultures and minicultures of cohesion, conformity, competition, and conflict aversion exist. Boundaries exist within learning environments, which can limit or pose challenges to professional identity formation and transition into the profession. Conclusion: Stakeholders involved in dietetics education play pivotal roles in shaping the microcultures students learn and work within, which influence and impact socialization and transition into the profession. Opportunities exist to re-vision curriculum and foster positive learning cultures with a focus on sociocultural learning, including supporting boundary crossing and professional identity development.

Work-integrated learning (WIL) is increasingly common in higher education, with benefits and risks for students and supervisors' wellbeing. Central to wellbeing is dignity, often described as the respectful treatment of others. While studies have explored dignity for employees, it is yet to be examined in the WIL context. This qualitative study explores 46 student and 30 supervisors' understandings of WIL dignity. Using purposive sampling, supervisors and students from 6 disciplines participated in 7 groups and 58 individual semi-structured interviews. Participants were asked to describe their understandings of workplace dignity and data were analysed using team-based framework analysis. Four themes were identified: (1) participants' difficulties articulating dignity; (2) concepts used to define dignity; (3) the valence of conceptualisations; and (4) the levels to which dignity were conceptualised. Both students and supervisors need to work together to better understand what dignity is as the crucial first step toward maximising dignity during WIL.

Context: Research in health professions education (HPE) spans an array of topics and draws from a diversity of research domains, which brings richness to our understanding of complex phenomena and challenges us to appreciate different approaches to studying them. To fully appreciate and benefit from this diversity, scholars in HPE must be savvy to the hallmarks of rigour that differ across research approaches. In the absence of such recognition, the valuable contributions of many high-quality studies risk being undermined. Methods: In this article, we delve into two constructs---generalisability and bias--that are commonly invoked in discussions of rigour in health professions education research. We inspect the meaning and applicability of these constructs to research conducted from different paradigms (i.e., positivist and constructivist) and orientations (i.e., objectivist and subjectivist) and then describe how scholars can demonstrate rigour when these constructs do not align with the assumptions underpinning their research. Conclusions: A one-size-fits-all approach to evaluating the rigour of HPE research disadvantages some approaches and threatens to reduce the diversity of research in our field. Generalisability and bias are two examples of problematic constructs within paradigms that embrace subjectivity; others are equally problematic. As a way forward, we encourage HPE scholars to inspect their assumptions about the nature and purpose of research¿both to defend research rigour in their own studies and to ensure they apply standards of rigour that align with research they read and review.

Introduction: The OSCE is a sociomaterial assemblage¿a meshing together of human and material components producing multiple effects. Materials matter because they shape candidate performance, with potentially calamitous career consequences if materials influence performance unjustly. Although the OSCE literature refers to materials, few papers study the sociomateriality of OSCEs. Therefore, we explored OSCE stakeholders' talk about sociomaterial assemblages to better understand their importance for candidate performance. Methods: We conducted 15 focus groups with OSCE candidates (n¿=¿42), examiners (n¿=¿20) and simulated patients (n¿=¿17) after an Australian postgraduate nursing OSCE. Sociomateriality informed our team-based framework analysis of data. Results: Participants identified a multiplicity of OSCE materials (objects, technologies and spaces) thought to matter for candidate performance. Candidates' unfamiliarity with materials and missing or malfunctioning materials were reported to yield numerous negative impacts (eg cognitive overload, negative affect, time-wasting), thereby adversely affecting candidate performance. Both examiners and candidates made micro-adjustments to sociomaterial assemblages during the OSCE in order to make it work (eg candidates saying what they would do rather than doing it). Sometimes, such tinkering extended so far that sociomaterial assemblages were ruptured (eg examiners ignoring rubrics to help pass candidates), potentially influencing OSCE standardisation. Discussion: Our novel empirical study extends previous conceptual work by illustrating wide-ranging sociomaterial assemblages influencing OSCE candidate performance. Further research is now needed employing sociomaterial approaches to further elucidate sociomaterial entanglements in diverse OSCEs. We encourage OSCE stakeholders to become more attuned to the productive nature of materials within all stages of OSCE design and implementation.

Introduction: Although preparedness for practice (P4P) has been variously described, little shared understanding exists about what P4P is across the health professions. How P4P is conceptualised matters, because this shapes how stakeholders think, talk about and act towards it. Further, multiple understandings can result in diverse expectations for graduate performance. This study therefore explores health care learners' solicited and unsolicited conceptualisations of P4P over their early graduate transition. Methods: We conducted longitudinal qualitative research including individual and group entrance interviews (phase 1: n¿=¿35), longitudinal audio-diaries (phase 2: n¿=¿30), and individual and group exit interviews (phase 3: n¿=¿22) with learners from four disciplines (dietetics, medicine, nursing and pharmacy). We employed framework analysis to interrogate data cross-sectionally and longitudinally. Results: We found 13 conceptualisations of P4P (eg knowledge, confidence), broadly similar across the disciplines. We found some conceptualisations dominant in both solicited and unsolicited talk (eg skills), some dominant only in solicited talk (eg competence) and others dominant only in unsolicited talk (eg experience). Although most conceptualisations appeared relatively stable across time, some appeared to dominate at certain time points only (eg employability and skills in phases 1 and 2, and competence in phase 3). Discussion: This novel study extends previous uniprofessional work by illustrating a broader array of conceptualisations, differences between professions, solicited versus unsolicited talk and longitudinal cohort patterns. We encourage health care educators to discuss these different P4P understandings in graduate transition interventions. Further research is needed to explore other stakeholders' conceptualisations, and over a duration beyond the early graduate transition.

Tolerance of uncertainty, a construct describing individuals' responses to perceived uncertainty, has relevancy across healthcare systems, yet little work explores the impact of education on medical students' tolerance of uncertainty. While debate remains as to whether tolerance of uncertainty is changeable or static, the prevailing conceptual healthcare tolerance of uncertainty model (Hillen et al. in Soc Sci Med 180:62¿75, 2017) suggests that individuals' tolerance of uncertainty is influenced by so-called moderators. Evidence regarding education's role as a moderator of tolerance of uncertainty is, however, lacking. Preliminary work exploring medical students' professional identity formation within anatomy learning identified tolerance of uncertainty as a theme warranting further exploration. Extending from this work, our research question was: How does the anatomy education learning environment impact medical students' tolerance of uncertainty? To address this question, qualitative data were collected longitudinally across two successive cohorts through online discussion forums during semester and end of semester interviews. Framework analysis identified five stimuli of uncertainty, four moderators of uncertainty, and cognitive, emotional and behavioral responses to uncertainty with variable valency (positive and/or negative). Longitudinal data analyses indicated changes in stimuli, moderators and responses to uncertainty over time, suggesting that tolerance of uncertainty is changeable rather than static. While our findings support the Hillen et al. (Soc Sci Med 180:62¿75, 2017) model in parts, our data extend this model and¿the previous literature. Although further research is needed about students' development of tolerance of uncertainty in the clinical learning environment, we encourage medical educators to incorporate aspects of tolerance of uncertainty into curricular and learning environments.

Aim: Internal coherence in research refers to the alignment between ontology (nature of reality), epistemology (nature of knowledge), axiology (values), methodology and methods and is an important but often overlooked element of research quality. We therefore aimed to illustrate the concept of internal coherence in nutrition and dietetics research, and its importance beyond individual elements of study quality. Method: A targeted literature search in Nutrition and Dietetics was used to identify research illustrating one example of three main approaches to research (scientific, interpretive and critical inquiry) published between November 2017 and November 2020. Studies were included if they related to education research based on the expertise of the authors, and illustrated diverse points about internal coherence. The authors independently critiqued included studies for internal coherence and synthesised their findings. Results: From 76 manuscripts, 14 were identified as describing education research. Of the three selected studies that were critiqued, all had elements of internal coherence, in particular alignment between epistemology and methodology. However, each had elements of misalignment too, specifically between epistemology, axiology and method. The results point to the profession's historical groundings privileging the scientific approach, showing how this can yield misalignments, particularly when describing the limitations of interpretive and critical inquiry approaches. Conclusion: This review demonstrates the importance of internal coherence as a marker of quality, over and above existing quality assessment checklists for qualitative and quantitative methodologies. As such, it can help authors, reviewers and editors to improve the quality of nutrition and dietetics research and its reporting.

Aim: This integrative review aims to explore the relationship between feedback and evaluative judgement in undergraduate nursing and midwifery education. Background: Research in higher education has shown that feedback practices can lead to students' developing evaluative judgement; thought critical for performance improvement and life-long learning. While literature in nursing and midwifery education has not yet employed the term 'evaluative judgement' explicitly, there might be similar concepts and practices that seek to develop students' judgement of performance that sustain learning beyond the immediate task. Design: An integrative review of the nursing and midwifery feedback literature. Methods: In February 2020, six online databases (CINAHL, ProQuest, Scopus, ERIC, PsycINFO, Ovid MEDLINE) were systematically searched for literature published between January 1989-February 2020. Synonyms for feedback and evaluative judgement were used to inform our search. This review included a rigorous team-based, five-stage approach: (1) identifying the problem; (2) conducting the search; (3) evaluating the data; (4) analysing the data; and (5) presenting the integrative review. Results: A total of 1408 studies were initially retrieved with 543 duplicates. 865 abstracts were screened using eligibility criteria, resulting in the exclusion of 835 studies. Thirty full-text studies were appraised for quality. Eighteen studies with diverse methodologies achieved a medium-high quality score for inclusion in data analysis. Conceptions of feedback and evaluative judgement were identified in all studies; despite none using the term 'evaluative judgement' explicitly. Thematic analysis of the studies resulted in seven themes: conceptions of feedback, purposes of feedback, sources of feedback, modes of feedback, conceptions of evaluative judgement, purposes of evaluative judgement and relationships between feedback and evaluative judgement. Conclusions: While our findings supported contemporary higher education research, the feedback-evaluative judgement relationship is novel in nursing education. We encourage educators to design feedback activities privileging students' active engagement through dialogic feedback, reflection and self-assessment, to develop their evaluative judgement of practice.

An integrative review of the literature specific to leadership within the intensive care unit was planned to guide future research. Four databases were searched. Study selection was based on predetermined inclusion and exclusion criteria and a quality check was done. Data extraction and synthesis involved developing a preliminary thematic coding framework based on a sample of papers. The coding framework and all selected papers were entered into NVivo software. All papers were then coded to the previously identified themes. Themes were summarised and presented with illustrative quotes highlighting key findings. In total, 1102 relevant quotations were coded across the 28 included papers. Four themes pertaining to leadership were described and analysed: (a) leadership dimensions and discourses; (b) leadership experiences; (c) facilitators and/or barriers to leadership; and (d) leadership outcomes. The literature was found to focus on leader behaviours, as well as the leader dimensions of role allocation, clinical and communication skills and traditional hierarchies. Positive behaviours mentioned included good decision-making, staying calm under pressure and being approachable. Leadership experiences (and outcomes) are typically reported to be positive. Personal individual factors seem the biggest enablers and barriers to leadership within the intensive care unit. Training is considered to be a facilitator of leadership within the intensive care unit. This study highlights the current literature on leadership in intensive care medicine and provides a basis for future research on interventions to improve leadership in the intensive care unit.

Medicine is a gendered discipline, in which women, both as patients and practitioners, have often held subordinate positions. The reproduction of dominant gender biases in the medical setting can negatively impact the professional development of medical students and the wellbeing of patients. In this analysis of medical students' narratives of professionalism dilemmas, we explore students' experiences of gender bias in hospital settings. Seventy-one students participated in 12 group interviews, where they discussed witnessing or participating in various activities that they thought were professionalism lapses. Within the dataset, 21 narratives had a distinctly gendered component broadly pertaining to patient dignity and safety dilemmas, informed consent issues, and female student abuse. Interestingly, perpetrators of such acts were commonly female healthcare professionals and educators. Although students recognized such acts as professionalism lapses and often expressed concern for patient wellbeing, students did not intervene or report such acts due to hierarchical cultural contexts, and at times even reproduced the discriminatory behavior they were criticizing. This raises concerns about medical students' professionalism development and the extent to which gender bias is ingrained within particular medical systems. The normalization of disrespectful and abusive treatment of female patients poses immediate and future consequences to the wellbeing and safety of women. Furthermore, the same socio-cultural values that sustain these acts may account for perpetrators often being women themselves as they strive to overcome their subordinate position within medicine.

Introduction Prescribing antibiotics is an error-prone activity and one of the more challenging responsibilities for doctors in training. The nature and extent of challenges experienced by them at different stages of the antibiotic prescribing process are not well described, meaning that interventions may not target the most problematic areas. Objectives Our aim was to explore doctors in training experiences of common problems in the antibiotic prescribing process using cultural-historical activity theory (CHAT). Our research questions were as follows: What are the intended stages in the antibiotic prescribing process? What are the challenges and where in the prescribing process do these occur? Methods We developed a process model based on how antibiotic prescribing is intended to occur in a 'typical' National Health Service hospital in the UK. The model was first informed by literature and refined through consultation with practising healthcare professionals and medical educators. Then, drawing on CHAT, we analysed 33 doctors in training narratives of their antibiotic prescribing experiences to identify and interpret common problems in the process. Results Our analysis revealed five main disturbances commonly occurring during the antibiotic prescribing process: consultation challenges, lack of continuity, process variation, challenges in patient handover and partial loss of object. Our process model, with 31 stages and multiple practitioners, captures the complexity, inconsistency and unpredictability of the process. The model also highlights 'hot spots' in the process, which are the stages that doctors in training are most likely to have difficulty navigating. Conclusions Our study widens the understanding of doctors in training prescribing experiences and development needs regarding the prescribing process. Our process model, identifying the common disturbances and hot spots in the process, can facilitate the development of antibiotic prescribing activities and the optimal design of interventions to support doctors in training.

Context: The inclusion of interprofessional education opportunities in clinical placements for pre-registration learners has recently been proposed as a strategy to enhance graduates' skills in collaborative practice. Objectives: A realist review was undertaken to ascertain the contexts, mechanisms and outcomes of formal interprofessional clinical workplace learning. Methods: Initial scoping was carried out, after which Ovid MEDLINE, CINAHL and EMBASE were searched from 2005 to April 2016 to identify formal interprofessional workplace educational interventions involving pre-registration learners. Papers reporting studies conducted in dedicated training wards were excluded, leaving a total of 30 papers to be included in the review. Results: Several educational formats that combined students from medicine, nursing, pharmacy and allied health professions were identified. These included: the use of engagement by student teams with a real patient through interview as the basis for discussion and reflection; the use of case studies through which student teams work to promote discussion; structured workshops; ward rounds, and shadowing. Meaningful interprofessional student discussion and reflection comprised the mechanism by which the outcome of learners acquiring knowledge of the roles of other professions and teamwork skills was achieved. The mechanism of dialogue during an interaction with a real patient allowed the patient to provide his or her perspective and contributed to an awareness of the patient's perspective in health care practice. Medication- or safety-focused interprofessional tasks contributed to improved safety awareness. In the absence of trained facilitators or in the context of negative role-modelling, programmes were less successful. Conclusions: In the design of workplace education initiatives, curriculum decisions should take into consideration the contexts of the initiatives and the mechanisms for achieving the education-related outcomes of interest.

Medical students often experience professionalism dilemmas (which differ from ethical dilemmas) wherein students sometimes witness and/or participate in patient safety, dignity, and consent lapses. When faced with such dilemmas, students make moral decisions. If students' action (or inaction) runs counter to their perceived moral values-often due to organizational constraints or power hierarchies-they can suffer moral distress, burnout, or a desire to leave the profession. If moral transgressions are rationalized as being for the greater good, moral distress can decrease as dilemmas are experienced more frequently (habituation); if no learner benefit is seen, distress can increase with greater exposure to dilemmas (disturbance). We suggest how medical educators can support students' understandings of ethical dilemmas and facilitate their habits of enacting professionalism: by modeling appropriate resistance behaviors.