Impact of an Asynchronous Trainee-as-Teacher Curriculum on Teaching Self-Efficacy

A project submitted to the:
Division of Graduate Studies and Research of the University of Cincinnati
in partial fulfillment of the requirements for the degree of
MASTER OF EDUCATION (MEd)
From the Curriculum and Instruction program in the School of Education
In the College of Education Criminal Justice and Human Services (CECH)

By Kathleen Timme, MD
October 29, 2021
Committee:
Boyd Richards, PhD
Robert Harper, EdD

Abstract

Physicians are responsible for educating their patients, peers, and health professional learners.  Therefore, it is crucial for trainees to have opportunities to develop and hone teaching skills during training.  Resident-as-teacher curricula have developed in response to this need, but are largely classroom-based with limited opportunities to practice these valuable teaching skills.  In the midst of the COVID-19 pandemic and clinical demands that challenge the feasibility of live classroom-based learning experiences, there is a need for online asynchronous learning opportunities for trainees.  The aim of this study was to investigate the impact of an asynchronous online trainee-as-teacher curriculum on teaching performance and self-efficacy.  Resident physicians enrolled in an elective program featuring four online modules, real-life teaching experiences, and a reflective writing assignment. Participants completed a self-efficacy assessment before and after completion of the curriculum.  They also collected feedback forms from the individuals they taught during the teaching experiences.  We applied the qualitative methodology grounded theory in analyzing the written reflection.  Self-efficacy improved after program completion, with 100% of participants indicating that they felt comfortable teaching patients, colleagues/attendings at or above their level of training, and learners junior to themselves.  Teaching evaluations from patients and small group learners were also favorable.  Key themes from the qualitative portion of the study support that participants gained knowledge about health literacy, small group teaching, and clinical teaching.  This pilot study showed that an online asynchronous trainee-as-teacher program with opportunities for teaching practice and self-reflection fostered development of self-efficacy and improved teaching performance.

CHAPTER 1: INTRODUCTION

Problem

The ability to effectively teach is important for physicians to practice and master.  Physicians are not only responsible for educating their peers, the next generation of health care providers, and community members, but are also responsible for teaching patients.1,2  It has long been understood that physicians who are able to apply sound educational principles in practice can positively impact patient adherence to their treatment plans and outcomes.3  As a result, preparing residents and students (i.e. trainees) has increasingly become a goal of curricula across the medical education continuum.  Approaches to achieving this goal have evolved with changes in patient care demands and available teaching modalities. One of the most emergent modalities involves online asynchronous learning using internet-based platforms such as YouTube, social media, and learning management systems.  For these newer modalities to be optimally effective, which often lack face-to-face interactions, learners need to have opportunity to reflect during and after their teaching.4,5 The aim of this study is to assess the impact of an asynchronous online trainee-as-teacher curriculum featuring opportunities for reflection on teaching performance and self-efficacy.  The program is referred to as trainee-as-teacher, rather than the narrower resident-as-teacher, due to the goal of generalizing the curriculum to a broader audience of trainees, including health professional students, residents, and fellows.

Background and Review of Literature

The Accreditation Council for Graduate Medical Education recognizes the importance of developing teaching skills during post-graduate training and has made this a required activity within residency and fellowship training programs.6 Residency programs have included resident-as-teacher efforts as early as the 1960s, but the practice gained momentum after the 1990s.7 More recently, consensus guidelines have been developed indicating key components of these curricula.8,9

Traditional resident-as-teacher programs have largely taken place in the live classroom with varying degrees of experiential learning.10  The success of such programs have been made evident by resident satisfaction with curricula, improved resident attitudes towards teaching, and increased performance on objective measures of teaching, such as objective structured teaching examinations and evaluations by learners and faculty.11 Although these earliest efforts featured mostly synchronous learning, there has been a shift towards offering more asynchronous opportunities in recent years, certainly accelerated by the COVID-19 pandemic.12,13,14,15

With increasing clinical demands, clinical training sites located away from the academic hub, and duty hour limitations, residency programs have made efforts to increase asynchronous learning opportunities.16,17  Furthermore, the technologically savvy generation Y and Z learners who are now entering and graduating medical school are accustomed to acquiring knowledge online and on demand.18,19  Medical students value online learning and are increasingly using this modality over traditional resources.20,21 Several health professional education programs have adjusted their teaching strategies to meet these needs and have moved towards asynchronous online trainee-as-teacher content delivery. The online modality has the advantage of flexibility and convenience, in that material can be accessed at any time, and works best when the content addresses a specific need for the learners.22 

Some studies suggest that learners are able to achieve the same educational outcomes in asynchronous online environments as they are in the traditional synchronous classroom.23,24  There have been resident-as-teacher programs that feature a blend of asynchronous and synchronous content delivery, such as a self-guided program in which trainees view videos on teaching at their own pace then later engage in discussion with facilitators.25 Another program took a completely asynchronous approach, reaching learners across different training sites in a dual-campus pharmacy resident teaching program.26  This pharmacy program featured self-paced distance learning with assigned readings, video recordings, and a discussion board.  Participants indicated satisfaction and increased confidence in teaching abilities after participation.

Online learning also has the advantage of tracking participation and engagement more easily than in a larger classroom setting with objective data such as discussion board comments.27  Effective online programs also have prompts for reflection, to increase learner engagement with the material.28 One concern about asynchronous online learning is limited interaction with instructors and peers, however use of virtual discussion can allow for rich asynchronous communication between learners and teachers at different sites.29 David Schon has also recognized the importance of reflection in professional development, and written reflection after engaging in certain activities provides a format for doing this.30 Schon invites professionals to take time to reflect both in-action and on-action as a way of solidifying learning. Reflection-in-action refers to thinking in the moment about the present situation and various ways to approach it, informed by prior learning and experience.  Reflection-on-action is a retrospective exploration of what happened and how we may approach the situation differently next time. With learning activities taking place outside the classroom, self-reflection becomes a prime way of engaging with curricular content, therefore we have chosen reflective practice as our conceptual framework.  Through reflection, individuals develop a self-concept in regards to their teaching abilities.  Teaching self-efficacy is one’s personal judgement about ability to teach effectively.  In addition to confidence in one’s ability to teach, trainees need to demonstrate competence.  Consensus guidelines for resident-as-teacher curricula recommend including direct observation of teaching with feedback.These expert guidelines also state that trainees should be evaluated on their teaching skills by core faculty, residents/fellows, and medical students.  Although asynchronous online curricula are designed with minimal instructor interaction, there are opportunities to capitalize on the real-life teaching that trainees perform in their clinical work environment, such as providing patient education and small group peer teaching.  In one resident-as-teacher program, residents received feedback from faculty after leading a morning report and noted that this was one of the most positive elements of the curriculum.31  Offering an asynchronous online trainee-as-teacher curriculum alongside a clinical rotation would allow for concurrent opportunities to practice the teaching skills gained through online learning.

Research Question

How will an asynchronous online trainee-as-teacher curriculum with feedback on real-world teaching practice and self-reflection impact trainees’ teaching performance and self-efficacy?

CHAPTER 2: METHODOLOGY

Study Design

This was a convergent design mixed-methods study in which investigators collected data in parallel, analyzed separately, and then merged.   We conducted both quantitative and qualitative assessments to allow for a more in-depth understanding of this impact.

Setting and Participants

K.T. developed an asynchronous online trainee-as-teacher (TAT) curriculum at the University of Utah School of Medicine for residents participating in rural clinical rotations as part of the Rural Underserved Utah Training Experience (RUUTE) program.  This elective opportunity was advertised via email to trainees that had signed up to participate in a rural clinical elective. A total of 3 residents, all in Pediatrics, completed 4-week long clinical rotations with community preceptors in rural settings in the state of Utah.  In addition to their clinical training at these sites, these trainees elected to complete this asynchronous online TAT curriculum. This rural training experience cohort offered a convenient sample for this study in that they were physically distant from the academic hub with time available for professional development activities.  We submitted this study to the University of Utah Institutional Review Board and it met criteria for exemption under non-human subjects research.

Curriculum Development

We selected educational topics based on consensus guidelines for resident-as-teacher programs.32,33  The TAT curriculum was divided into four modules: educating patients, clinical teaching, small group teaching, and giving effective feedback.  Each module consists of a video, article, and podcast episode to review.  K.T. created brief podcast episodes on teaching best practices for this curriculum using her established Teaching In Medicine podcast on Anchor FM.  We selected relevant videos and articles for each topic from peer-reviewed literature and media.  The curriculum also featured two experiential learning activities. One activity was to teach a patient on an aspect of their medical care, performed after completion of the module on educating patients.  The patient then fills out a feedback form on the trainee’s teaching ability and their level of understanding about their medical care after being taught by the trainee (Appendix A).  This form features 9 Likert-scale questions and 3 open-ended questions on teaching ability.  This form was then submitted to the course director to track completion.  The second activity was to give a brief presentation to the clinical team at their site on a topic of their choice and receive feedback forms from attendees of that session (Appendix B).  This was performed after completion of the module on small group teaching.  The form features 11 Likert-scale questions and 2 open-ended questions on teaching ability.  After completion of the four modules and two experiential learning activities, participants then completed a reflective writing assignment on their teaching experiences and future applications (Appendix C).  The trainee participants completed all modules and experiential learning activities at their convenience during their clinical rotation.  K.T. managed the trainee-as-teacher curriculum on the learning management system Canvas.

Analysis

The assessment strategy included collection of both quantitative and qualitative data in this convergent design mixed-methods study. Investigators collected the following quantitative measures:

  1. Participants completed a Trainee-as-Teacher Self-Efficacy Assessment before and after completion of the curriculum.  This is a 9-item Likert-scale questionnaire addressing comfortability with performing various teaching tasks to different audiences, providing a quantitative measure of confidence in one’s ability to teach (Appendix D).  K.T. created this assessment tool to specifically address the teaching skills that are targeted by this curriculum.  K.T. utilized descriptive statistics to assess difference between pre- and post-assessments.
  • K.T. also collected the feedback forms from patients and colleagues who were taught during the experiential learning activities and then quantified level of agreement on the trainee’s teaching abilities from the perspective of the learner using descriptive statistics. 

While the self-efficacy assessment and feedback forms provided objective information and opportunity to assess curriculum impact, we sought to better understand the effect of this novel asynchronous online teaching modality through qualitative investigation as well. K.T. and T.D. performed qualitative analysis of the written reflective assignment to better understand impact of the intervention that was not anticipated at the study outset.  We selected the written assignment for analysis as this was the prime modality of learner engagement with the course director and where the participant articulated the conclusions that they make after self-reflection.  Each prompt in the written assignment involved sharing thoughts and ideas after reflecting-on-action, aligning with Schon’s reflective practice.  K.T. and T.D analyzed the reflective assignments using principles of grounded theory.34 They reviewed and independently coded the text in a process of focused initial coding.  They performed initial coding line-by-line, labeling concepts that emerged from the data set and allowing for constant comparison throughout the analytic process.  Constant comparison is a process of continuously revising initial codes as one analyzes the data set.  This approach increases credibility and dependability in qualitative analysis.  The use of two investigators initially coding independently was a deliberate choice in order to obtain a more inclusive list of codes, as a single investigator is subject to their own lens and biases.  K.T and T.D resolved these issues and reached agreement on a final code book.  They then used this mutually agreed upon list to go back and re-code the data set.  They next linked the codes to identify themes and build a theory about the impact of an asynchronous trainee-as-teacher program in the theoretical coding phase.

CHAPTER 3: RESULTS

Trainees completed the Trainee-as-Teacher Self-Efficacy Assessment before and after completion of the TAT program (Table 1). After completion of the program, 100% of participants indicated that they felt comfortable teaching patients, colleagues/attendings at or above their level of training, and learners at a training level junior to themselves.  This was a change from pre-program, where only 67% felt comfortable teaching patients, 0% felt comfortable teaching learners above their level of training, and 33% felt comfortable teaching more junior learners even when they were knowledgeable on the clinical topic.  Self-reported comfortability with giving feedback to learners, providing quick clinical teaching, and teaching in small groups increased as well (33%, 0%, 0% pre-program respectively vs. 100%, 100%, 100% post-program respectively).

Table 1

Table 1: Teaching Self-Efficacy Pre-Program vs. Post-Program
Teaching Self-Efficacy Pre-Program vs. Post-Program

Trainees collected evaluation forms from patients after they were taught by the trainee (Table 2).  Each trainee taught one patient, therefore a total of 3 evaluation forms were received.  All patients either strongly agreed or agreed that the resident doctor taught on a relevant topic, covered the topic in appropriate detail, cared about their level of understanding, and spent the right amount of time teaching.  They also strongly agreed or agreed that the resident doctor was knowledgeable on the topic, confident and comfortable teaching, spoke at a volume and pace that was easy to understand, and gave opportunity for questions and answered them well.  Two patients (67%) indicated that the resident doctor stimulated their interest in the topic, whereas one patient (33%) selected neutral for this statement.

Table 2

Table 2: Patient Evaluation of Trainee Teaching
Patient Evaluation of Trainee Teaching

Trainees delivered small group teaching sessions and then collected evaluation forms from the learners in attendance (Table 3).  Learners included preceptors, health professional students, and staff at the clinical site.  The 3 trainees collected a total of 12 evaluation forms.  All learners strongly agreed or agreed that the session objectives were clear, the session was well-organized, appropriate amount of content was covered, and the topic was interesting. All learners also strongly agreed or agreed that the resident was knowledgeable, confident and comfortable presenting, spoke at a volume and pace that was easy to understand, and gave opportunities for questions and answered them well.  92% of learners strongly agreed or agreed that the resident stimulated their interested in the topic and that slides or teaching materials were helpful.  83% indicated that the resident encouraged their participation.

Table 3

Table 3: Learner Evaluation of Trainee Small Group Teaching
Learner Evaluation of Trainee Small Group Teaching

The reflective writing assignment was divided into three parts: insight gained from teaching patients, insight gained from small group clinical teaching, and future approaches to clinical teaching. For the lessons learned on teaching patients, 11 codes were identified across the three writing assignments.  7 of these codes were identified in more than one of the participants’ writing samples: cultural competency, framing the discussion, health literacy, previous exposure to the topic, reflective learning, teach-back method, and use of handouts while teaching patients.  A few themes emerged from the data set.  Participants felt that they gained knowledge and skills related to health literacy that allowed them to educate patients of varying health literacy levels and cultural backgrounds.  These tools included the teach-back method, use of handouts, and ways to frame the discussion.  There also was acknowledgement of previous exposure to the topic of health literacy in medical school, but that revisiting the concept in real-world experiences provided opportunities for application of what was learned.

For insight gained from small group teaching, 12 codes were identified across the three writing assignments.  6 of these codes were identified in more than one of the participants’ writing samples: challenges to effective teaching, future opportunities for application, qualities of a good presentation, relevance to audience, self-reflection, and teaching environment.  One of the themes that emerged was that learners were able to identify the challenges to effective small group teaching and the characteristics of high quality presentations and effective learning environments to avoid these challenges.  They were also able to utilize self-reflection to increase awareness of their own skill set and develop ideas for future use. Lastly, 14 codes were identified for the section on future approaches to clinical teaching.  8 of these codes were identified in more than one of the participants’ writing samples: communication with learner, educational tools, feedback, growth mindset, knowing your learner, reflection on past approaches, teaching pearls, and time constraint.  One key theme was that participants realized the importance of effective communication and feedback for learner growth and development.  They were also able to reflect on their past approaches, incorporate feedback, and identify ways to improve moving forward, thus showing a growth rather than fixed mindset.  Finally, they noted that time is the main barrier to effective clinical teaching and came up with strategies to mitigate this, such as educational tools and quick teaching pearls.

CHAPTER 4: CONCLUSIONS AND IMPLICATIONS

Physicians are responsible for the education of their patients, peers, learners, and community. Thus, effective and efficient teaching in the clinical learning environment is a crucial skill that should be honed in training. The current milieu calls for asynchronous opportunities in medical education. K.T. hypothesized that meaningful learning could occur in an asynchronous online trainee-as-teacher curriculum through independent review of curated resources, experiential learning opportunities, and deliberate self-reflection. By employing a mixed methods approach in this study, investigators hoped to better understand impact of this curricular approach on teaching self-efficacy and performance.

One of the distinguishing features of this program is that the participants had minimal interaction with the course director.  They were provided with module resources and reviewed those independently.  They received brief written feedback from the course director after submitting learner evaluations and the written reflection, but did not have synchronous experiences with an instructor as is more typical in curricula for trainees.  Despite this, participants were able to increase teaching self-efficacy.  Most impressive was the impact on comfortability with teaching colleagues above their level of training, teaching under time constraints, and teaching in small group settings.  Perhaps the opportunities to teach their preceptors in the real-life clinical setting contributed to comfortability with these more advanced teaching skills.

Another strength of this program was the opportunity to teach patients and learners in real, rather than simulated, encounters.  These activities were performed after participants reviewed modules on teaching patients and teaching in small groups.  The modules equipped the participants with the necessary skills and the experiential activities gave them timely opportunities to practice.  Patient and learner evaluations forms were overwhelmingly positive.  The high teaching self-efficacy ratings were triangulated by learner agreement with the trainee’s knowledgeability and confidence in the topic.  One limitation is that the patient and learner feedback forms are subject to acquiescence or agreement bias, in that learners may have responded more positively than they truly felt.  This may have been influenced by the assumption that responses would eventually be reviewed by the participant.

The convergent mixed methods design allowed for simultaneous collection of qualitative data, to also address the question of curriculum impact.  Grounded theory, the qualitative methodology employed, is inductive in that the process is theory generating.  We utilized this approach as we were unsure of what the impact of this novel curriculum would be at the outset.  Qualitative analysis of the reflective writing assignment provided a closer look at impact on the trainee after they were given the opportunity to self-reflect on what they learned through independent study of the modules and performance of teaching activities. It was surprising to learn that participants already had learned about health literacy in medical school, but that they still found value in real-life opportunities to practice providing education to patients.  Their depth of understanding of the challenges to effective teaching and insight on tools to mitigate this challenge was also noteworthy.  Finally, the participants saw the value of self-reflection and how this promotes a growth mindset as they develop as clinician-educators.  These themes complement the quantitative data set in supporting the overall positive impact of this curriculum on teaching performance and self-efficacy.

Strengths of this study include the convergent mixed methods design to investigate curriculum impact from multiple angles.  Qualitative methodology was particularly rigorous through applying principles of grounded theory and having two investigators independently code the data set.  The curriculum design also differed from more traditional classroom-based approaches, in that it was online and asynchronous, but with opportunities to practice the skill set in real-life scenarios.  The main limitation was the small number of participants, certainly impacted by limited rural rotations during the COVID-19 pandemic.  The participants were also all pediatric residents, raising the question of generalizability to other specialties.  With the small number of participants, we were unable to demonstrate significance of impact in the quantitative portion of the study or reach saturation in the qualitative portion.

This study suggests that trainees can gain valuable teaching skills in an online format with minimal instructor contact.  This approach may be of use for program directors who would like to provide advanced training on education-skills, but lack the time for synchronous activities.  The program takes advantage of concurrent clinical activities as opportunities to practice teaching, rather than the time-intensive creation of standardized teaching encounters.  Asynchronous online curricula could be advantageous for trainees who are interested in professional development, but are on rotations away from the academic hub.  It is also a timely approach given the limited in-person experiences due to the COVID-19 pandemic.

This study will be ongoing to increase the number and diversity of participants.  We plan to include participants from other specialties, health professional students, and fellow trainees rather than only residents.  With more participants, we hope to reach saturation in the qualitative data set.  It would also be interesting to assess durability of impact, through assessment of participants at later time points after completion of the curriculum. Overall, an online asynchronous trainee-as-teacher program is a novel way to equip medical trainees with important teaching skills.  Providing resources for self-study, opportunities for real-life practice, and prompts for self-reflection led to trainees who felt confident in their teaching abilities and learners who were positively impacted by the trainees’ teaching performance. Ongoing implementation of this pilot study will allow for more thorough evaluation of the impact of this unique approach.

Appendices

Appendix A:  Trainee Feedback Form – Patient Teaching

Appendix B: Trainee Feedback Form – Educational Session to Clinical Team

Appendix C: Reflective Writing Assignment

Appendix D: Trainee-as-Teacher Self-Efficacy Assessment


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Impact of an Asynchronous Trainee-as-Teacher Curriculum on Teaching Self-Efficacy by Kathleen Timme, MD