Study design
This was a pre-post, quasi-experimental, single-group study. The study was performed at three university affiliated hospitals in Iran. The study was conducted in two phases: the instructional design and the implementation and evaluation of the intervention. During the design and implementation phase, the elements of Proctor’s model and workplace-based learning were taken into account. Below, you will find separate descriptions of these two phases. This study was approved by the Ethics Committee of the “Alzahra Research Center” have accepted this product article. Under the ethical code IR, Isfahan University of Medical Sciences The approval reference number is IR.ARI.MUI.REC.1400.081.
Study context
In Iran, the 18-month medical internship, the final practical training experience during medical education program, is comprised of clinical rotations across inpatient, emergency, and outpatient settings. Medical Interns spend their clinical rotations in different hospital wards. Core rotations include internal medicine, surgery, obstetrics/gynecology, and pediatrics. The pediatrics is a three-month rotation which is spended in university hospitals under faculty members’ supervision.
Instructional design
The Proctor model was used to create a clinical monitoring development program based on Ashour’s instructional design model. The purpose of this course was to familiarize faculty members with the practical application of Proctor’s model in clinical education and the successful implementation of clinical supervision. The department head and the head of clinical training for pediatric interns first met for an orientation session. This lecture covered the definition of clinical supervision, its meaning, the objectives, and the methodology of the research. After in-person and virtual meetings with the research team, a faculty development program focused on education was created that incorporated Proctor’s model.
One of the most popular frameworks for instructional design, especially regarding learner engagement, is the ASSURE model. ASSURE is a reliable model that describes the essential steps for effective teaching and learning and recommends appropriate measures for each step involved [36]. This model consists of six steps: (1) analyze learner characteristics, (2) state objectives, (3) select media and materials, (4) utilize media and materials, (5) require learner participation, and (6) evaluate and revise [37]. The instructional design process for this study was conducted as follows:
-
1.
Analyze learner characteristics: In this step, the pediatric department was consulted to assess the general characteristics of the learners, including demographic characteristics (number of learners, age, gender) and specific input characteristics of the learners (learners’ knowledge and attitudes toward the subject matter, their familiarity with the course topic, and their competencies and abilities). Information was collected on the number of faculty members who participated in training and were classified by gender, academic status, and teaching experience. The relevant literature has been examined to determine learning preferences and styles [38]. In addition, expert opinions were sought from specialists in clinical training and medical education.
-
2.
State objectives: Medical education experts and e-learning faculty were consulted to establish learning objectives based on expert opinion and a review of the literature in Step 1. The primary focus of this step was to establish objectives by focusing on the formative, restorative, and normative functions of Proctor’s model (Table 1).
-
3.
Select media and materials: The teaching sequence and content structure of the course were initially determined according to Proctor’s model. Owing to the limited availability of faculty and the wide geographical distribution of the selected hospital research sites, training was conducted online. This approach would allow faculty members to participate in both training sessions and work-based learning at their respective institutions. In addition, to audience analysis and state objectives, the methods, media, and teaching materials were tailored to support the formative, restorative, and normative functions of the Proctor’s model of clinical supervision. Specifically, the following approaches were used:
Instructional methods included lectures, discussions, group discussions, question-and-answer sessions, simulations, and workplace-based learning.
The media utilized for delivery were videos, written materials, cyberspace, and online learning platforms.
Instructional materials included films, scenarios, articles, books, and national and hospital guidelines and protocols.
-
4.
Utilize media and materials: In this step, the teaching materials and activities were reviewed. Learners have been prepared, and the necessary equipment and facilities, such as the online learning environment, the delivery of online section content, and the answers to questions during theoretical and practical training, have been prepared and verified. The training activities should enable learners to apply the learned content in real clinical supervision environments (selected teaching hospitals).
-
5.
Require learner participation: In this step, we determine how to utilize various methods, such as question-and-answer sessions, animations and scenario analyses, discussions, group discussions, and real actions in the workplace, to involve teachers in the teaching-learning process (Table 2).
-
6.
Evaluation and Revise: A self-report questionnaire, including an assessment of faculty members’ knowledge and attitudes toward clinical supervision, was developed to assess the impact of the faculty development program. In addition, a direct observation checklist was developed to evaluate the implementation of clinical supervision in real work settings.
Data collection tools
Knowledge and attitude self-reporting questionnaire
The questionnaire was a researcher-made instrument. Its content was developed based on library research and the results of a qualitative study conducted by two authors [19]. An expert panel consisting of 5 clinical experts from the pediatric department who did not participate in the study and 3 experts in medical education was assembled. To comply with ethical principles, the following statement was placed at the beginning of the questionnaire: Based on the stated objectives of the study and the oral explanations given by the project leader and colleagues, I am willing to take part in this study.
The questionnaire consisted of two parts. The first part included four demographic questions (gender, educational level, experience in medical education, and length of experience as academic staff) and ten knowledge questions about the provision of clinical supervision to medical interns. The respondents rated their knowledge on a scale from 1(no knowledge) to 10(complete mastery). This resulted in a minimum score of 10 and a maximum score of 100 for the knowledge area. The results were then averaged.
The second part, which was designed based on Proctor’s model, examined faculty attitudes toward clinical supervision during training. This section included 24 phrases in three functions: Restorative(5 phrases), Normative(9 phrases), and Formative(10 phrases). A 5-point Likert scale was used for the rating (strongly disagree = 1, completely agree = 5). To ensure data accuracy, four reverse-scored statements were included. Scores in the restorative domains ranged from highest [25] to lowest [5]. Similarly, the values of the normative and formative functions were between 45 and 9 and between 50 and 10, respectively. The overall attitude score was between 24(minimum) and 120(maximum). The values were then averaged to produce a more meaningful result, with the highest and lowest average values being 5 and 1, respectively. Participants who had more than 50% of the questions in a section left unanswered were excluded. However, all the questionnaires met this criterion. Scores above 3 indicated a positive attitude toward clinical supervision, whereas scores below 2.99 indicated a negative attitude. Content validity (CVI = 0.93) and relative content validity (CVR = 0.85) were determined. Furthermore, the internal consistency reliability was high (α = 0.96). To determine validity, eight medical education experts assessed the degree of association of each statement with clinical faculty members’ knowledge or attitudes toward clinical supervision in training. They used scales of ‘totally related,’ ‘related,’ ‘slightly related,’ and ‘unrelated.’ The CVI and CVR were calculated based on these assessments.
Direct observation performance checklist
The direct performance observation checklist included 26 statements in three functions: restorative (6 statements), normative (7 statements), and formative (13 statements) developed by the researcher. The terms of the checklist were compiled based on Proctor’s model and the content presented in the online sections. A 3-point Likert scale (Yes, No, not applicable) was used for the rating. To ensure content validity, the prepared checklist was provided to five medical education experts. The experts’ correction comments were included in the checklist. Cronbach’s alpha was used for reliability (α = 0.86). The evaluation of the checklist included awarding full marks (100) to all statements implemented by faculty during the observed clinical rounds. A score of zero was given for statements that were not implemented. The sentences marked ‘does not apply’ indicated situations where the statement was irrelevant due to the specific clinical case or ward conditions. Finally, the implementation of each statement was reported as a percentage based on the observed clinical rounds.
Intervention implementation and evaluation
This study involved 20 faculty members from the Department of Pediatrics at Isfahan Medical University. The inclusion criterion was at least one year of clinical teaching experience with medical trainees. The study used a convenience sampling method in which all faculty members teaching medical interns in the specified departments of the selected hospitals were invited to participate in the study. The director of the Center for Educational Studies and Development extended a written invitation to the faculty members, who invited them to participate in the Faculty Development Program. The program’s timetable was coordinated with the lecturers. A written invitation was personally delivered to participants two days before the commencement of the faculty development program. The study aims were comprehensively elucidated, and participants were assured of their right to withdraw at any time and the confidentiality of their data. Following the acquisition of initial verbal consent, a detailed explanation was provided regarding completing the written informed consent form within the pre-test questionnaire. In addition, faculty members received text messages the day before and the morning of the sessions to remind them of the start time and provide them with the link to join the online session.
At the beginning of the faculty development program, faculty members received a link via text messages to a self-report questionnaire designed to assess their knowledge and attitudes toward clinical supervision. The procedure for responding to the statement regarding informed consent in the questionnaire was re-explained to ensure that all participants fully understood their rights. The participants had 15 min to answer the questionnaire. The training program’s content, which included effective observation, feedback, reflection, and implementation of the Proctor model of clinical supervision in clinical training, was subsequently delivered online over 9 h over three days (19, 20, and 22 December 2022) by the study team. Various teaching methods were used to present the content, including lectures, group discussions, presentations, handouts, multimedia, and animations. Throughout the program, participants received guidance and support through the virtual platform and were provided access to training materials.
After completing the online training, the participating faculty members were asked to apply their newly acquired clinical supervision skills in their clinical rotations for one month (23 December– 23 January). During the clinical rounds, independent clinical supervision experts evaluated the performance of faculty members. Two nurses, both holding Master of Science in Nursing degrees and selected in consultation with district nurse supervisors, underwent training in relevant medical modules. They received a two-hour training session focused on clinical supervision, feedback, reflection, and the use of observation checklists.
A pilot test during three clinical rounds validated training understanding and checklist reliability. In each round, the first author and trained nurses independently completed the checklist, then compared the completed checklists and reconciled any discrepancies. Data from these pilot rounds were excluded from the final analysis. A randomized schedule for daily observations was created using a lottery system, with the involvement of the pediatric internship training coordinator. Before participation in the clinical rounds, the consent was obtained from the relevant faculty member. Each faculty member’s clinical rounds were observed for at least one day.
During the observations, the observers positioned themselves so as not to interfere with the clinical examinations or procedures. Furthermore, all observations were conducted without any explanation to the faculty member to ensure that the clinical monitoring process occurred naturally. During the clinical supervision process, an observation checklist was completed by the observer. At the end of the clinical rotation, faculty members received feedback on the strengths and weaknesses of implementing the clinical supervision model. Inquiries from faculty members regarding the procedural aspects of the Proctor model of clinical supervision were answered. In addition, academic staff asked questions in a virtual group and received answers from medical education experts. To ensure the completeness, accuracy, and reliability of the data recorded in the observation checklist, the completed checklist was reviewed by the observer within 10 min of the end of the clinical round. Any incomplete items were subsequently completed.
Following the faculty development program, a text message was sent to all the participating faculty members with a link to an electronic self-report questionnaire assessing their knowledge and attitudes toward clinical supervision. Faculty members were given 15 min to complete the questionnaire. One week after the study was completed, a summary report on faculty performance in clinical supervision was provided to all participants by the Center for Medical Education Studies and Development of Isfahan University of Medical Sciences. Data analysis was performed via SPSS 27.
link