Resilience Training in Healthcare to Meet the Needs of Learners and Practitioners

by Lori Emory, PharmD, PGY1 Pharmacy Practice Resident, Mississippi State Department of Health Pharmacy 

Resilience is the ability to “bounce back” from challenges — to learn and grow from setbacks. An individual’s resilience is built up over the course of their life and is shaped by their actions taken prior to, during, and after difficult and often stressful situations.^1,2  

Stress is a natural response by the body to physical and mental challenges. While stress can be a motivating factor that prompts us to try new things as we face new challenges, too much stress over a prolonged period of time is unhealthy and can lead to anxiety and burnout. Anxiety is an overreaction to stress experienced from performing “ordinary” daily activities which can lead to significant impairment. Burnout is a diminished ability to respond to stressors and can lead to anhedonia and depression.^1,3 

In healthcare, providers are responsible for the well-being of numerous patients. Chronic stress – often unavoidable in healthcare – puts health professionals at a higher risk for developing anxiety or burnout, which, in turn, results in less than optimal care and increases the risk of errors and poor patient outcomes.^1,3,4 Thus, resilience strategies, often techniques learned from previous stressful situations, help providers meet new challenges.⁵ 

There are conflicting feelings about resiliency training in healthcare.  Some have argued that resiliency training focuses too much on individuals by teaching them how to adapt to and cope with the ever-growing demands of the profession while letting institutions off the hook by failing to address poor working conditions, such as chronic understaffing and addressing hindrances.^2,4 While data supporting resilience training programs in healthcare are limited, results show participants generally appreciate learning about the tools they can use to become more resilient and like being part of a community where they can share experiences with fellow health professionals.^1,2 

Although self-care has been around for many years, resiliency training was introduced to me as a formal concept while applying for residency. Many residencies now offer resilience training as a required component of their program structure. Given that most pharmacy jobs provide little to no social support for new practitioners, I believe having resiliency training incorporated into the residency experience can be very beneficial. 

Several studies have examined the elements of resiliency training that participants generally believe are needed for it to be most beneficial:  

1. Focusing on the experience of health professionals and students is vital in a successful program. ^1,2,4,5,6  Healthcare workers are exposed to difficult human experiences while working with serious injuries, illnesses, and even death.^1,2,4,6 Participants in resiliency training programs discussed the need for training to be guided by another health professional with a shared understanding of the many challenges that come with working in healthcare.^1,2,6 

2. Sharing experiences in a positive and non-judgmental manner builds community among healthcare providers who often feel isolated.^1,2  Many providers report feeling isolated and a desire to participate in a community of peer support.¹ Program participants reported small group discussions allowed them to recognize their own behaviors better and learn from others’ real-world experiences.^1,6 Participants often report preferring voluntary attendance at these sessions as they felt it helped ensure that all participants would come in with an open mind about sharing experiences and learning to grow from difficult situations.^2,6  

3. Following up with participants helps turn new skills into daily practiced habits. While the initial training session(s) were often considered to be helpful by participants, programs that included follow-up reflection, allow participants to expand on the skills they learned and think about how they could use those skills in their daily lives. ^1,2,6 

4. All health professionals can benefit from these types of programs, regardless of their current level of experience. Even students at the beginning of their training are exposed to the difficult realities of a career working in healthcare, and serving people who are experiencing some of the greatest stress in their lives.^2,5 Promoting resiliency training programs during early didactic coursework or introductory practice experiences may provide key life-long skills that participants will benefit from long-term as they progress through training and into their professional lives.^2,6 Students particularly report benefits from training programs that are structured to provide insight into stressors that they may experience, during their training and in practice.^2,3,6  

Offering resiliency training led by experienced faculty members should be considered at all educational institutions that are preparing the next generation of health professionals. Resiliency training programs should be voluntary, such as course electives or extracurricular meetings, where all students can participate without feeling the need to give up other interests. Placing participants in small groups of 8-10 with a mix of learners at various levels and faculty with guided discussion prompts can foster natural mentorships and a sense of community within groups. Providing this kind of support early and often throughout the professional degree program can provide a safe space where genuine conversations can take place. Regularly obtaining feedback from participants is important to tailor these programs to meet the needs of students and faculty based on schedules and topics of interest.  

References: 

1. Epstein RM, Krasner MS. Physician Resilience: What It Means, Why It Matters, and How to Promote It. Academic Medicine 2013: 88(3):301-303.
2. Johnson J, Simms-Ellis R, Janes G, et al. Can we prepare healthcare professionals and students for involvement in stressful healthcare events? A mixed-methods evaluation of a resilience training intervention. BMC Health Serv Res 2020; 20: Article number 1094.
3. Fares J, Al Tabosh H, Stress AH, et al. Burnout and coping strategies in Preclinical Medical Students. N Am J Med Sci 2016; 8 (2):75-81.
4. Murthy VH. Confronting health worker burnout and well-being. N Eng J Med 2022;387(7):577–9.
5. Kunzler AM, Helmreich I, König J, et al. Psychological interventions to foster resilience in healthcare students. Cochrane Database of Systematic Reviews 2020, Issue 7. Art. No.: CD013684:7-43.
6. Bird A, Tomescu O, Oyola S, Houpy J, Anderson I, Pincavage A.A curriculum to teach resilience skills to medical students during clinical training. MedEdPORTAL 2020;16:10975.

Teaching Health Professional Students to Manage Patient Bias

by Allison Wadlow, PharmD, PGY1 Pharmacy Practice Resident, G.V. (Sonny) Montgomery VA Medical Center

Health disparities based on race have been a long-standing problem in the United States. Much light was shed on this matter in recent years prompted by numerous murders of minorities and the Black Lives Matter advocacy movement. It is well known that racial disparities exist within the healthcare system of this country. Even when patients have comparable incomes, similar education, and live in the same geographic location, minority populations sadly do not always receive the same standards of care as their white counterparts.¹

Many health professions programs offer training to learners on addressing bias and improving care delivery for all patients. Over the past decade, some popular training programs include Trauma Informed Care, Adverse Childhood Experiences training, and Multicultural Training. These programs have included materials to serve patients better, with the primary focus on patients, not the providers of care.

Bias towards healthcare professionals from underrepresented and marginalized groups is, unfortunately, commonplace. A recent study “Harassment and Discrimination in Medical Training” found that most health professional trainees have experienced bias at some point in their career, most often based on their race, gender, or sexuality.² 

To address this problem, medical students and faculty at multiple institutions in Northern Virginia and Washington, DC created a training program for medical students to manage patient bias.³ The goal of this program was to prepare students for the biases they may encounter in practice.  The investigators created a simulation exercise whereby participants learned, in a safe environment, to navigate these situations.³

The simulations involved encounters with standardized patients. During the encounter, the student was instructed to tell the patient about a follow-up appointment that had been scheduled with a provider who had a foreign-sounding name. The standardized patient was instructed to either accept this appointment or request an alternative provider. The student was then instructed to use motivational interviewing techniques to understand where the request to change providers stemmed from. The possible reasons for the patient’s request were:

• An untreated hearing loss made it difficult for the patient to understand accents
• A belief that “foreigners shouldn’t be taking American jobs”
• A preference to receive treatment from a physician who shares a similar cultural background due to the patient’s previous experiences of intolerance or disrespect

During the encounter, it was up to the student to determine the root cause of the request. In some instances, the request might lead to better patient care, and it should be honored. For example, in the case of a patient with hearing loss, switching to a provider without an accent, the patient might be able to better distinguish words spoken during the encounter. Of course, if the provider did not have an accent, the student should provide reassurance to the patient.  However, in some cases, the request to change providers was racially motivated. Of course, a surname does not always indicate the race of the provider. The point of this training experience was to allow students the opportunity, in a safe and controlled environment, to navigate through a patient request that, on the surface, may be motivated by racial bias. The goal is to develop the skills to uncover the root of these requests, rather than assuming that racism is the problem.

At the beginning and end of the course, students were surveyed to measure their growth. After completing the activities, students reported an increase in their confidence to explore intentions and beliefs, navigate a conversation with a patient exhibiting bias, and use nonverbal skills to demonstrate empathy.³

Addressing bias directed towards providers is not taught in most health professions' curricula or residency training programs. I think health-professional programs should begin to include this type of training so that students and residents are better equipped to manage patient bias.

The first step would be to give students exposure to patients who express a bias toward certain (commonly marginalized) groups. Nearly all students who participated in this simulation exercise stated they were very uncomfortable, but that it was a positive experience to be able to interact in a safe environment. The students stated they felt more prepared to manage these situations with real patients in practice.  Because learners should never be intentionally required to interact with people who have racial animus, they would learn how to assess patients’ requests, how to act in the face of bias, and how to move forward with patients who are explicitly or implicitly biased towards them or others. 

The next step would be to teach learners how to address patients who have explicit biases based on race, gender identity, and sexual preferences. Students must first be taught how to approach patients and uncover the rationale behind their biases. Once the student has uncovered the reasoning for the bias, there will be times when patients are explicitly racist, and students will need to be prepared (mentally) to manage the situation. Do they simply ignore and endure the bias? Do they refer the patient to alternative providers? Do they know when it is safe to speak up and say something to the patient? While there are no easy answers to these questions, the least we could do is provide students the opportunity to experience this type of conversation with patients before having to deal with it in the real world.

As with the implementation of any new training, cost becomes a factor to consider. The cost of hiring standardized patients may not be feasible for many programs. One workaround is to have volunteers serve as standardized patients, which could include faculty, upperclassmen, or alumni. Another way to mitigate the costs could be to have recordings of patient encounters, pausing the recording at various times to discuss with the class what they are observing. This option could open a rich class discussion on the negative consequences of bias toward marginalized patients as well as providers.

Bias in healthcare is not something we can eliminate, but we can build our skills to recognize and mitigate it.  We can prepare our students to uncover and address the biases they may encounter, including the bias that patients may express toward them or their professional colleagues. It is not ethical to know a problem exists, one that can mentally harm our learners, and do nothing to prepare them. It’s time to talk about patient bias and teach health professional students how to manage it.

References:

1. Williams DR, Rucker TD. Understanding and addressing racial disparities in health care. Health Care Financ Rev 2000;21(4):75-90.
2. Fnais N, Soobiah C, Chen MH, et al. Harassment and discrimination in medical training: a systematic review and meta-analysis. Acad Med 2014;89(5):817-27.
3. Zewdie M, Duval M, Liu C, et al. Virtual Communication Across Differences: Development of a Workshop on Managing Patient Bias. Acad Med 2023;98(2):209-213.

Professional Identity Formation (PIF) in Health Professions Education: Doing is Different from Being

by Lauren C. McConnell, PharmD, PGY1 Pharmacy Practice Resident, Baptist North Mississippi Hospital

Professional identity formation, or PIF, is the process through which a person becomes a professional — typically from student to practicing professional. The progression of PIF is uniquely individualized and superimposed on each student’s personal identity, values, morals, and beliefs.¹ The goal of forming a professional identity is to develop a resilient sense of belonging within a health profession.² PIF goes beyond students acquiring knowledge (‘thinking’) and demonstrating professionalism (‘acting’) to support one’s perception of self (‘feeling’).

Professionalism, as defined by The White Paper on Pharmacy Student Professionalism, is “the active demonstration of the traits of a professional”.³ Health professions students are intrinsically and extrinsically motivated to join a professional community and are willing to uphold certain professional expectations, such as wearing a white coat, communicating respectfully, and being accountable.^4,5 However, acting like a professional and being a professional are two different phenomena.

Interrelationship Between Professional Identity and Professionalism

Professionalism and professional identity are distinct yet related concepts, which makes the fluid relationship between the two challenging to describe (see Figure 1). Professionalism is an outward display of the conduct of a professional, while a professional identity is the internal perception of one’s role as a professional.⁶ Professional traits and behaviors are crucial for PIF, as ‘acting’ like a professional encourages assimilation to that role.⁷ Similarly, self-awareness of a professional identity is essential for developing a professional demeanor. Several stepwise models exist that have attempted to describe this relationship. Acts of professionalism are observable signs which indicate the concurrent development of professional identity.⁶ Therefore, my professors at Auburn University and I recently proposed a model to illustrate the infinite and undirected interplay between PIF and professionalism, the Möbius Strip.⁷

Figure 1: Professionalism-Professional Identity Möbius Strip

According to Moseley et al., “as the internalization process of PIF occurs, outward professional behaviors are displayed, and as one chooses to behave as a professional, their sense of identity blossoms”.⁷ This model aligns with the proposal that the end goal of health professions education should not just focus on ‘doing’ but also on ‘being’.⁸ As with all educational goals, methods for teaching and evaluating progress are essential. The conundrum is how this fluid process can be measured and supported.

PIF-Friendly Pedagogy

Obtaining a professional identity is the desired outcome in health professions education, as it is the backbone of all decisions students will make as professionals.⁸ However, many students (and admittedly, myself included) fail to recognize themselves as professionals early in their health education journey. For this reason, PIF has long been an elusive target amongst health professions educators. Furthermore, PIF is a non-linear process, and each student progresses toward their professional identity at a different pace, which makes it challenging to foster and evaluate progress.⁹ For this reason, health professions educators should incorporate PIF-friendly teaching strategies into curricula.

PIF pedagogy is the practice of teaching, facilitating, and coaching students through their PIF journey — teaching methods that support the development of an identity that aligns with the values of their profession. Educators are a fundamental component of the student’s journey. The formation of a professional identity is influenced by external factors, such as curricula, learning environments, expectations, mentorship, and feedback.⁵ I distinctly remember key preceptors who created positive learning environments and served as role models that positively impacted how I perceived myself as a future pharmacist. Therefore, it is important for educators to foster relationships and create experiences that are meaningful to students, as PIF is facilitated, not taught.

Self-assessment and self-reflection are two PIF-friendly strategies that educators can use in curricula to help students become more aware of their professional strengths and weakness.¹⁰ The ability of the student to be self-aware of their presence and growth within a professional community increases PIF and creates a sense of belongingness.⁹ Other meaningful relationships outside the formal education environment (e.g., with preceptors, other health professionals, and patients) play a similar and equally important role. To me, there is no replacing the feeling you get the first time a patient mistakenly refers to you as a pharmacist or when a physician shows appreciation by stating ‘good catch.’ Through these interactions, students gain recognition for their place on the healthcare team. Situated learning theory suggests that “learning should take place in a setting the same as where the knowledge will be used”.¹¹ Therefore, it is no surprise that students report early introduction to their profession, direct interaction with patients, and frequent collaboration with other health professionals as key drivers of identity construction.¹²

Because educators are facilitators of PIF, structured evaluations (e.g., exams or performance-based assessments) are not helpful measures of student progression, particularly given that PIF does not occur at a single point in time. Experts recommend that assessments of PIF should occur longitudinally to ensure that the student’s professional identity is progressively developing over time.¹³ Unfortunately, there are no standardized methods for measuring PIF, and assessments rely on student understanding of who they are within a profession. I remember creating short- and long-term career goals as a first-year student pharmacist, thinking I knew exactly who I was and what pharmacy career path I wanted to pursue. But with each semester, I revisited these goals and was honestly embarrassed by what I thought I knew about who I wanted to be. 

In one study, investigators designed a Professional Self Identity Questionnaire (PSIQ) that attempts to measure the degree to which health professions students identify as a member of their profession.¹⁴ Building on this notion, faculty at Auburn University Harrison College of Pharmacy recently created a PIF instrument to encourage students to reflect on their professional identity. This instrument asks students to self-assess fourteen qualities/behaviors, such as confidence, knowledge, personality, professionalism, and communication.¹⁰ These PIF-friendly exercises, using a combination of self-assessment and self-reflection, attempt to measure what educators cannot see: how students see themselves in relation to their profession.

There are several other activities and instructional strategies that can be used to promote PIF, such as feedback, experiential education, co-curricular activities (e.g., health fairs), mentoring/role modeling, student well-being groups, and white coat ceremonies.^7,15 Of course, most professional curricula already incorporate many of these pedagogical methods, but require active effort by educators to intentionally foster PIF. Reflecting on my time as a student, I now know why I have always appreciated professors who were passionate about what they taught, preceptors who encouraged autonomous work, and mentors who led by example – they intentionally helped create my professional identity. Educators should continue to purposefully use and prioritize PIF-friendly pedagogical methods, particularly early in curricula, to support the process of professional identity formation amongst their students.

References

1. Cruess RL, Cruess SR, Steinert Y. Amending Miller's pyramid to include professional identity formation.Acad Med. 2016;91(2):180-5.
2. Kellar J and Austin Z. The only way round is through: Professional identity in pharmacy education and practice. Can Pharm J (Ott). 2022 Aug 13;155(5):238-240.
3. Roth MT and Zlatic TD. American College of Clinical Pharmacy. Development of student professionalism. Pharmacotherapy. 2009 Jun;29(6):749-756.
4. Holden M, Buck E, Clark M, Szauter K, Trumble J. Professional identity formation in medical education: The convergence of multiple domains. HEC Forum. 2012 Dec;24(4):245-255.
5. Findyartini A, Greviana N, Felaza E, et al. Professional identity formation of medical students: A mixed-methods study in a hierarchical and collectivist culture. BMC Med Educ. 2022 Jun 8;22(1):443.
6. Forouzadeh M, Kiani M, Bazmi S. Professionalism and its role in the formation of medical professional identity. Med J Islam Repub Iran. 2018;32(1):765-8.
7. Moseley LE, McConnell L, Garza KB, Ford CR. Exploring the evolution of professional identity formation in health professions education. New Dir Teach Learn. 2021 Dec 6;168:11-27.
8. Snell R, Fyfe S, Fyfe G, Blackwood D, Itsiopoulos C. Development of professional identity and professional socialisation in allied health students: A scoping review. Focus on Health Prof Educ. 2020 Apr 30;21(1):29-56.
9. Cruess SR, Cruess RL, Steinert Y. Supporting the development of a professional identity: General principles. Med Teach. 2019 Jun;41(6):641-9.
10. Ford CR, Astle KN, Kleppinger EL, Sewell J, Hutchison A, Garza KB.Developing a self-assessment instrument to evaluate practice-readiness among student pharmacists. New Dir Teach Learn. 2021 Dec 6;168:133-145.
11. Li LC, Grimshaw JM, Nielsen C, Judd M, Coyte PC, Graham, ID. Use of communities of practice in business and health care sectors: A systematic review. Implement Sci. 2009 May 17;4:27.
12. Wald HS. Professional identity (trans)formation in medical education: Reflection, relationship, resilience.Acad Med. 2015 Jun;90(6):701–6.
13. Garza KB,Moseley LE, Ford CR.Assessment of professional identity formation: Challenges and opportunities.New Dir Teach Learn. 2021 Dec 6;168:147-151.
14. Crossley J and Vivekananda-Schmidt P. The development and evaluation of a Professional Self Identity Questionnaire to measure evolving professional self-identity in health and social care students. Med Teach. 2021 Dec;31(12):e603-7.
15. Chandran L, Iuli RJ, Strano-Paul L, Post SG. Developing "a Way of Being": Deliberate approaches to professional identity formation in medical education.Acad Psychiatry. 2019 Oct;43(5):521–7.

Achieving the Promise of Authentic Workplace-Based Assessments

by Sophie Durham, PharmD, PGY1 Community Pharmacy Practice Resident, Mississippi State Department of Health Pharmacy

Workplace-based assessments (WBAs) can be intimidating and burdensome for students and evaluators alike; however, these assessments pose an opportunity to use real-time direct observation to provide feedback that supports a learner’s growth and development.¹ Unfortunately, students often fail to see the usefulness of feedback in clinical settings or feel that their grades might be negatively affected by observations reported through workplace-based assessments.

Throughout my Advanced Pharmacy Practice Experiences (APPEs), I craved feedback so that I could develop as a clinician and ensure that I was providing optimal patient care. I valued the feedback that I received at the midpoint and final evaluations; however, these evaluations were used to determine my final grade. As a student, I benefitted from receiving more frequent, informal feedback to improve my performance in real time. By providing students with more timely formative assessments, preceptors allow students to reflect on their experiences and make necessary corrections to improve their practices without the stress of contributing to their grades.

WBAs are used to evaluate trainees’ performance in practice and can be used by learners as relevant feedback to engage in reflection. WBAs encompass a wide range of assessment strategies that require evaluators to move away from merely assigning numbers toward a more structured format of assessment. WBAs can be used to provide feedback on trainee-patient interactions, procedural skills, case-based discussions, and multi-source feedback.²

Lauren Phinney and colleagues at the University of California San Francisco used cultural historical activity theory (CHAT) to identify feedback system elements and tensions among these elements to explore workplace-based assessment used during medical clerkships. The school introduced a WBA tool in 2019 that includes drop-down items describing the clerkship specialty, skills observed, entrustment ratings adapted from the Ottawa scale, and space for narrative comments to encourage formative feedback. Students are required to gather two WBAs per week. The research interviewed first and second-year medical students participating in core clerkship rotations.¹

CHAT allows investigators to examine how tools mediate activities. An activity system is defined as the interaction between learners and tools to achieve an outcome. Tensions among these elements can promote change, create knowledge, and lead to new activity patterns.¹ After interviewing students in a series of focus groups, researchers identified five tensions:

1. Misinterpretation of WBA Feedback as Summative Assessment. Although WBAs were intended to serve formative purposes, first-year students perceived the object, or purpose, of the WBA to be for summative purposes. Formative assessments are intended to monitor student learning to provide ongoing feedback to improve teaching and learning. More specifically, formative assessments help students identify strengths and weaknesses. This allows students to target areas of improvement and help faculty pinpoint areas where students are struggling to provide assistance.³ On the other hand, the goal of summative assessments is to evaluate student learning at the end of a rotation and are often high stakes, resulting in the assignment of a grade or score. Even when second-year students correctly identified the purpose of WBAs as low-stakes feedback, students were still concerned that this feedback would be used to inform summative assessments and strategically chose to use WBAs when they anticipated positive feedback instead of opportunities for constructive feedback. Two ways to enhance the distinction between summative and formative evaluations in WBAs are to use two different platforms to complete WBAs and summative assessments and allow students to self-complete WBAs.¹
2. Cumbersome Tool Design that Delayed Feedback. WBA requests were sent via computer, so many of these requests were sent hours after feedback encounters. Students found that the distribution and completion of WBAs were delayed, which resulted in generic or untimely feedback. Utilizing QR codes on smart phones and improvements in technology facilitated supervisor engagement and rapid feedback.¹
3. Concern About Burdening Supervisors with WBA Tasks. While clerkship leaders encouraged students to seek feedback, students were concerned about interrupting workflow or interfering with patient care. Students found the assessments to be labor-intensive and redundant. Students employed strategies to streamline the process, such as recording and submitting comments that preceptors provided during the encounter with the WBA request form, which made it easier for preceptors to complete the assessments.¹
4. WBA Requirement as Checking Boxes vs. Learning Opportunity. The weekly quota of completion of two WBAs overshadowed the purpose of WBAs as a formative feedback mechanism. The authenticity and usefulness of the feedback could be jeopardized when students and supervisors focus on the rule instead of the opportunity to provide feedback. On the other hand, some students reframed this requirement to benefit them. One benefit of the requirement included the ability for students to direct their learning to meet self-identified goals and receive timely feedback to ensure that they were making progress toward achieving these goals. Another benefit of the rule was to initiate consistent feedback discussions with preceptors who did not volunteer to provide feedback.¹
5. WBA Within Clerkship-Specific Learning Culture. Supervisors’ promotion and acceptance of WBAs ultimately set the tone for WBA encounters. Students found that preceptors that actively facilitated WBA encounters provided more useful feedback, while preceptors that gave pushback created a barrier. In addition to using more convenient platforms to complete WBAs, students identified more convenient situations, logged feedback retrospectively, and bypassed tool discussion to minimize the burden on team members in settings that were not conducive to WBAs.¹

In competitive cultures like medicine, it can be difficult to facilitate formative assessments. The author concluded that by incorporating learner input to make intentional changes, perceptions and utilization of WBAs can be enhanced.¹

The authors provided potential solutions to the perceived problems with WBAs. There is often a disconnect between the intention and interpretation of workplace-based assessments.  Thus, we need to consider structuring their format and delivery by gathering student feedback. Through this collaboration with students, we can strive to achieve authentic workplace-based assessments that accurately reflect learners’ progress and are used to improve future performance.

While this study focused on the benefits of WBAs in student-preceptor interactions at one medical school, WBAs can be used in several ways. WBAs can be applied across multiple settings and can be separated into three different categories: observation of clinical performance, discussion of clinical cases, and feedback from peers, coworkers, and patients. These assessment tools provide insight to the trainee, assessor, and academics alike.²

In addition to getting student feedback, I believe we need to gather feedback from preceptors to determine their perceptions of WBAs. Thus, WBAs could be further improved to meet the needs of both students and preceptors. To ensure that we are providing useful and timely feedback to learners, its important to reduce the barriers to WBA use. By using QR codes, separate platforms to differentiate summative and formative assessments, and platforms that are compatible with smartphones when computers are not available, schools can establish user-friendly and time-efficient processes and ensure that WBAs that are valuable without adding substantial burden that jeopardize feedback quality.¹

References:

1. Phinney, LB, Fluet A, O’Brien BC, Seligman L, Hauer KE. Beyond checking boxes: Exploring tensions with use of a workplace-based assessment tool for formative assessment in clerkships. Acad Med 2022; 97: 1511-1520.
2. Guraya, SY. Workplace-based assessment; Applications and educational impact. Malays J Med Sci 2015; 22: 5-10.
3. Formative vs. Summative Assessment [Internet]. Pittsburgh: Carnegie Mellon University; [cited 2022 Nov 18].

Failure to Fail: Why Teachers Are Reluctant to Fail Learners and What We Can Do About It

by Katelyn Miller, PharmD, PGY1 Pharmacy Practice Resident, St. Dominic Hospital

Failure is success in progress. – Albert Einstein

The word “failure” often evokes a negative connotation, but it is a necessary part of learning and growing. However, when it comes time to address an underperforming trainee, student, or resident, many educators and preceptors find it hard to address and document the poor performance of trainees. Reports in medical literature across multiple healthcare disciplines have raised concern about this “failure to fail” phenomenon and its prevalence.¹ In one survey, 18% of 1,790 nursing mentors admitted to passing an underachieving student that should have failed.² Another survey of ten American medical schools found that 74.5% of clinical preceptors indicated it was difficult to accurately assess poorly performing students because they were unwilling to record negative evaluations.³ As health professionals and educators, we have a responsibility to our patients and our professions to accurately evaluate trainees and ensure they become competent members of healthcare teams. To determine if a learner is sufficiently prepared, here is the critical question: Would I let this person take care of my family member? If the answer is no, why is it so hard to act and deliver an accurate evaluation of an underperforming trainee’s performance?

A systematic review article recently published in the Medical Teacher examined both qualitative and quantitative studies relating to evaluators’ willingness and perceived ability to report unsatisfactory performance in health professions education.¹ The authors identified six barriers that assessors face when addressing an underperforming trainee:

1. The Burden and Risks of Failing Someone. Assessors reported that the amount of time and paperwork required to fail a trainee is a deterrent. In the health professions, preceptors and educators often have multiple responsibilities, and student evaluations are often given lower priority. Assessors also express a hesitancy to fail underperforming trainees due to fear of litigation or worries that it would negatively affect the professional reputation of the assessor.¹
2. Guilt and Self-Blame: Assessors reported an emotional toll, including feelings of guilt and self-blame, connected to failing a trainee. These feelings are increased if the assessor has developed a close relationship with the trainee. Assessors often want to avoid conflict with the trainee and feel that failing the trainee could be perceived as uncaring behavior, which is difficult in a profession dedicated to caring for others like healthcare.¹
3. Trainee Considerations. Assessors were reluctant to fail someone based on the trainee’s stage within the program. With trainees who are in the earliest stages in the curriculum, assessors indicated they were reluctant because they believed the learner could improve with time. Ironically, assessors were equally reluctant to fail trainees that were advanced in their training because they had already invested much time and money. Assessors also worried about the negative effect that failing would have on the trainee’s emotional stability, career goals, and self-esteem.¹
4. Questionable Assessments. Assessors reported a lack of confidence in their ability to accurately evaluate trainees due to feeling unprepared, a lack of training, or a lack of experience. As a result, they questioned their judgment and were willing to give underperforming trainees “the benefit of the doubt.” Assessors also reported a lack of confidence in the tools they used to assess trainees. They expressed uncertainty about what the expectations should be for trainees at different stages of training and questioned whether the evaluation tools being used were appropriate or objective.¹
5. Institutional Support. Assessors reported feeling pressured to pass students and feared they would not be supported by the institution if they failed a student. Assessors also considered the loss of financial support for the institution that would result from failing a student.¹
6. Unsatisfactory Remediation. Assessors were reluctant to fail a trainee if there was no remediation available or if they deemed the available remediation unsatisfactory. Assessors also expressed angst about the timeliness of remediation and whether remediation would be long enough to adequately address the performance problems.¹

Conversely, the authors also identified three factors that enabled assessors to fail a failing trainee. These include the assessor’s sense of responsibility and duty to the profession, support from the institution, and the availability of remediation for the trainee.¹

While this review of literature helps us to understand the “failure to fail” phenomenon, no quick or easy solution exists. Some experts suggest a narrative-based approach is needed in order to help assessors overcome barriers to providing corrective feedback and delivering unsatisfactory evaluations.³ Providing feedback that clearly indicates the specific areas of improvement can help guide underperforming students to address poor skills or knowledge and “shift the focus from evaluating to understanding and teaching” the learner.³ Even with a shift from quantitative to qualitative evaluation methods, several barriers will persist.

To ensure patient safety and the quality of care delivered by future health professionals, I believe all schools should institute standardized, formal training of preceptors, educators, and anyone who will be evaluating trainees. Institutions should require new assessors to complete training that teaches them how to accurately use evaluation tools, how to articulate concerns, and how to deliver difficult messages. The training program should make clear the remediation opportunities available to address performance problems and emphasize a competency-based approach to teaching and learning. Institutions should make it explicitly clear what resources are available, including the support systems available to address the assessor’s negative emotions and the mental toll that comes with failing a trainee.

I believe a mental shift in healthcare education is needed. We should acknowledge that competency is the primary goal and that everyone progresses at different paces. Not everyone will graduate at the same time, and that is okay! It is important for educators to accept their responsibility to future patients and the potential harm that could result from failing to fail underperforming trainees. 

References:

1. Yepes-Rios M, Dudek N, Duboyce R, Curtis J, Allard RJ, Varpio L. The failure to fail underperforming trainees in health professions education: A BEME systematic review: BEME Guide No. 42. Medical Teacher. 2016;38(11):1092-1099.
2. Brown L, Douglas V, Garrity J, Shepard CK. What influences mentors to pass or fail students. Nursing Management. 2012;19(5)16–21.
3. McConnell M, Harms S, Saperson K. Meaningful Feedback in Medical Education: Challenging the “Failure to Fail” Using Narrative Methodology. Acad Psychiatry. 2016;40(2):377-379.