Review question/objective
The objective of this systematic review is to synthesize the best available evidence regarding the effectiveness of various interventions on the self-efficacy of clinical teachers.
Consequently the specific review questions to be addressed are:
What interventions have been used to develop the self-efficacy of clinical teachers?
Is visualization or mental imagery an intervention that has been used to develop the self-efficacy of the clinical teacher?
What is the effect of visualization or mental imagery on the clinical teacher's self-efficacy?
How has self-efficacy been measured amongst clinical teachers?
Background
Increasingly, a general practitioner (GP) is involved in teaching and training undergraduate and postgraduate students in a clinical general practice. The GP clinical trainer/supervisor role is complex, demanding, and at times potentially conflicting, but underpins all the learning that occurs in a post graduate registrar's general practice training. The roles and qualities that make a GP supervisor a good teacher have only been superficially explored in the literature1-7, but go beyond the provision of medical knowledge, clinical and technical skills, and clinical reasoning. Excellent clinical teaching, although multi-factorial, transcends the ordinary, and is characterized by providing a positive supportive learning environment, actively involving, inspiring and communicating well with students.8 It cannot be assumed that all GPs possess the teaching skills and educational experience to perform quality teaching in general practice. Traditionally medical education followed an apprentice model, being based around the transfer of expert medical knowledge to the students identified learning objectives. With universal internet access to rapidly expanding medical knowledge, it is more difficult for the teacher to always be the expert. In the community general practice setting, clinical presentations can be ambiguous, patients' expectations unclear, and clinical placement students' learning objectives uncertain. With the additional responsibility of responding to the registrars/students presence, this leaves many clinical GP supervisors/trainers lacking confidence, perceiving lack of expertise and understanding of what they should teach.9 Literature identifies attributes of an excellent clinical teacher,5-9 with Azer highlighting the importance of non-cognitive attributes of the GP, like self-awareness and confidence.8
Self-efficacy can be defined as a person's belief about his/her ability and capacity to accomplish a task or deal with the challenges of life.10 The concept of self-efficacy lies at the heart of the psychologist Albert Bandura's social cognitive theory.11 He suggests that an individual's efficacy expectations (the belief in their ability to perform certain actions), combined with their outcome expectations (their conviction that such actions will lead to a particular outcome), are predictive of how successful that individual will be in performing the action in question and in achieving the desired outcome.11 Applying a psychological theory to the educational act of teaching leads to the compelling notion that a teacher's belief in their ability to impact student learning makes a difference in their teaching and in their students' learning.12 In the field of education, this construct of teacher self-efficacy has been correlated positively with a broad range of positive student outcomes, teaching practices and teacher classroom behaviors.13 Tschannen14 defines teachers' self-efficacy as the teacher's belief in his or her capability to organize and execute courses of action required to successfully accomplish a specific teaching task in a particular context. Thus teacher self-efficacy is "the confidence teachers hold about their individual and collective capability to influence student learning."15(p. 21)
Clinical teacher self-efficacy uses the above definition, applied to doctors who teach clinical, surgical or medical skills in undergraduate or postgraduate training.
By focusing on the self-efficacy of a clinical GP supervisor (GPS), there may be an improvement in the teaching and learning that is occurring in a clinical general practice setting. The existent literature has little to say about self-efficacy in clinical teaching, limited to an occasional article on asthma or epilepsy teaching.16 Most of the literature on self-efficacy relates to theoretical psychology models, and in educational fields with application to junior and high school teachers.17-21 Although teacher self-efficacy is an issue that has been studied for over 30 years,22 as the discipline of medical education is relatively new internationally, it is important to determine the place and effect of teacher self-efficacy in clinical teaching. Of particular interest are the GPs who teach in the community general practice setting, to postgraduate, vocational training or undergraduate students.
Some interventions have been used in the development of self-efficacy in clinical teachers, including peer reflection,23 train the trainer courses,24 interactive video scenarios25 and mental imagery.26 Mental imagery has successfully improved skills, confidence and enhanced performance in athletics,27 and been further applied in surgical training.28 Mental imagery is the conscious action of systematically and repeatedly imagining objects and movements without physically seeing or performing them, with the intention of improving performance.28 Other terms used to describe this technique include mental practice, motor rehearsal and visualization. Komesu et al. showed that a doctor learning the surgical procedure of cystoscopy found mental imagery to be a useful training preparation with a better surgical performance.29 Some tools have been developed to measure the self-efficacy of the learner,30 however few tools have been developed to measure the teacher's self-efficacy in clinical teaching, especially in a primary health or general practice setting.
The purpose of this systematic review is to robustly explore and determine whether interventions are known to impact on clinical teacher self-efficacy. Prior to the commencement of this systematic review, the Joanna Briggs Institute Database of Systematic Reviews and Implementation Reports, Cochrane Database of Systematic Reviews and Database of Abstracts of Reviews and Effects were searched, and no previous systematic reviews on this specific topic were identified.
Inclusion criteria
Types of participants
The quantitative component of this review will consider studies that include clinical teachers, defined as doctors who teach clinical, surgical or medical skills in undergraduate or postgraduate training.
Types of interventions
This review will consider quantitative studies that evaluate the use and effectiveness of any interventions, where the stated outcome involves the clinical teacher's self-efficacy. Included studies may describe the effectiveness of various techniques for improving self-efficacy, including teaching/training programs or mental imagery and visualization for clinical teachers. The term mental imagery broadly covers and will include other terminology like mental rehearsal, mental practice, visualization, visual, guided and motor imagery.
Types of outcomes
This review will consider studies that include any outcome that involves the clinical teacher's self-efficacy, self-confidence or self-efficacy beliefs. Additional information around the performance of a professional, clinical, medical or teaching task maybe identified. Any tool or scale used to measure self-efficacy will be included. Quantitative tools used to measure effectiveness may include methods such as surveys, questionnaires, or self-efficacy scales. Studies that look at preparedness of the teacher, the self-efficacy of the student or learner will be excluded.
Types of studies
This review seeks to determine effectiveness of interventions on clinical teacher self-efficacy, so will consider the international literature and studies that focus on quantitative data. The studies will include those of an experimental study design including randomized controlled trials, quasi-experimental studies and before and after studies. Observational studies including cohort and case control studies and descriptive studies such as case series or case reports will be included.
This review will exclude opinions, editorials, letters and peer group recommendations.
Search strategy
The search strategy aims to find both published and unpublished studies. A three-step search strategy will be utilized in this review. An initial limited search of MEDLINE and PsycINFO will be undertaken followed by analysis of the text words contained in the title and abstract, and of the index terms used to describe article. A second search using all identified keywords and index terms will then be undertaken, with counsel of University of Adelaide medical librarian across all included databases. Thirdly, the reference list of all identified reports and articles will be searched for additional studies.
Studies published in English will be considered for inclusion in this review.
Studies published from 1995 to 2014 will be considered for inclusion in this review, due to medical education being a new discipline internationally.
The databases to be searched include:
PubMed
The Cochrane Central Trials Register
Embase
Scopus
ScienceDirect
PsycINFO
The search for unpublished studies will include:
ProQuest Dissertations & Theses Database (PQDT)
Dissertation Abstracts Online (DIALOG)
Association of Medical Educators Europe (AMEE)
Summary of research logic grid:
Assessment of methodological quality
Quantitative papers selected for retrieval will be assessed for methodological validity prior to inclusion in the review using the appropriate and standardized critical appraisal instruments from the Joanna Briggs Institute Meta-Analysis of Statistics Assessment and Review Instrument (MAStARI) (Appendix I). Any disagreements that arise between the reviewers will be resolved through discussion and counsel with a third reviewer.
Data extraction
Quantitative data will be extracted from papers included in the review using the appropriate data extraction tool from MAStARI (Appendix II). The data extracted will include specific details about the interventions, populations, study methods and outcomes of significance to the review question and specific objectives.
Data synthesis
Quantitative research findings will, where possible be pooled using JBI-MAStARI. Quantitative papers will be, where possible, pooled with statistical meta-analysis using JBI-MAStARI. Effect sizes will be expressed as weighted or standardized mean differences (for continuous data) or relative risks or odds ratios for dichotomous data and their 95% confidence intervals calculated. Heterogeneity will be assessed statistically using the standard chi-square, with significance set at P = 0.05. Where statistical pooling is not possible, the findings will be presented in narrative form including tables and figures to aid in data presentation where appropriate. Subgroup analysis is planned in different populations (for example GPs) if enough data is available.
Conflicts of interest
No potential conflict of interest is anticipated.
Acknowledgements
Thank you to my supervisors Professor Justin Beilby and Professor Nigel Stocks for their guidance and support.
As this review forms partial submission for a Doctorate of Philosophy studies at the University of Adelaide, a secondary reviewer will only be used for critical appraisal.
References