really good stuff student obligations, and a series of interactive finalyear seminars focused on managing patient safety. Students were provided with clear guidance on pathways for raising concern and protocols for progression to a fitness-to-practise investigation. Throughout all activities, we emphasised the role of raising concern not only as it refers to the protection of patients, but also as it applies to supporting individual students and staff who are experiencing challenging circumstances so they may access professional and competent help in a timely fashion. Staff involved in these curriculum developments were aware of the potential conflict they might face as education providers, whereby they must support students by creating an environment of trust and openness, while also acting to police student behaviour and to rigorously assess and progress concerns raised. The school has a strong embedded ethos of community support and learning, recognised by the university internal subject review and the 2013 General Dental Council inspection, and we were confident that this curriculum development would not damage that ethos. What lessons were learned? Following implementation, and immediately after each lecture on raising concern, senior tutors experienced significant increases in the numbers of students raising concerns about themselves, colleagues and staff. Where possible, concerns were addressed at the point at which they were raised, but were otherwise passed as necessary to the Director of Progression, and the Professional Standards Review Committee (Dental). The volume of concerns raised was far greater than expected. In order to truly engender an ethos in which students are comfortable in raising concerns, genuine support and commitment are required in the form of prompt, sympathetic responses and the openness of tutors to engage in discussion. Investment in counselling and mentoring training, appropriate referral pathways to external student counselling and occupational health services, and robust processes for investigation and progression to fitnessto-practise assessments are needed. Actions must be visibly fair and effective or the student body will quickly become disenfranchised. Although we achieved the requirements of the Francis Report,1 our experience shows implications for other providers considering such a programme. Delivery of the changed curriculum need only have minor resource implications, but the processes involved in following up concerns raised constitute a significant outlay of staff resources. It is in this latter area that strategic investments in resources may be required to allow for a timely response to need.
In particular, pre-established pathways to agencies external to the school prove to be invaluable in providing visibly fair and effective means of dealing with many issues. REFERENCE 1 Francis R. Report of the Mid-Staffordshire NHS Foundation Trust Public Enquiry. London: Stationery Office 2013. Correspondence: Janice S Ellis, School of Dental Science, Newcastle University, Framlington Place, Newcastle upon Tyne NE2 4BW, UK. Tel: 00 44 191 222 8198; E-mail: [email protected] doi: 10.1111/medu.12715
Cultural competence lessons learned: the continuum model Gabriella Berger & Anita Peerson What problems were addressed? Cultural competence training enables health services to address health inequalities and improve health outcomes of culturally and linguistically diverse (CALD) populations in English-speaking parts of the world. ‘Health inequalities’ refer to differences in health status that can be measured, and are preventable and unjust. The greatest health inequalities have been found in comparisons of indigenous and non-indigenous populations, prompting Australia and New Zealand to implement ‘close the gap’ initiatives. A ‘culturally competent’ health care workforce is broadly defined as one that is capable of delivering a continuous and high level of care to all patients regardless of culture, ethnicity, gender, age or language. However, the goal of integrating culture into clinical care remains elusive. Our recent Australian study1 revealed that clinical supervisors were unable to define cultural competence and could not apply the concept to teach junior doctors to become culturally competent in the hospital setting. What was tried? For this study we developed the Continuum Model (of cultural competence training) by extending the focus of previous training approaches and administered it to about 300 junior doctors at the Darling Downs Hospital and Health Service in Queensland, Australia, from January 2011. The Continuum Model is comprised of three parts, visualised as a tree and designated: (i) ‘Roots of Knowledge’; (ii) ‘Leaves of Change’, and (iii) ‘Fruits of Wisdom’. In Part 1, we focused on exploring health and illness patterns in ethnic and marginalised groups, using 2011 census data for
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really good stuff national, regional and local CALD populations. Equity and access to health services, social determinants of health, and the relationship between culture and health were discussion topics. In Part 2, we explored cultural concepts in the context of change, including how culture shapes health beliefs, behaviours and values. Cultural labels were viewed as unhelpful when treating patients as they mask diversity and focus on similarity, thus giving rise to stereotyping. In Part 3, we offered strategies for clinicians to achieve optimal health care outcomes by suggesting methods of facilitating a patientcentred care approach. To engage the doctors in learning, we used a blended-delivery model which consists of an online course component (2 hours) followed by a face-to-face workshop (1 hour), thus providing greater flexibility and enhancing participation. What lessons were learned? Feedback from evaluations attested to the effectiveness of the model in fostering a greater understanding of cultural competence and providing clinicians with practical strategies to enhance health outcomes of vulnerable CALD patients. Certain challenges remain, largely related to the mismatch between patients’ needs (complex presentations in busy clinics and hospital departments) and the actual time and resources available. Improvements in communication, such as the development of active listening skills, the benefits of using qualified interpreters and ensuring patient participation in health care decision making were flagged as valuable lessons in providing patient-centred care. REFERENCE 1 Berger G, Conroy S, Peerson A, Brazil V. Clinical supervisors and cultural competence. Clin Teach 2014;11:370–4. Correspondence: Gabriella Berger, Darling Downs Hospital and Health Service, PMB 2, Toowoomba Qld 4350, Australia. Tel: 00 61 746 166681; E-mail: [email protected] doi: 10.1111/medu.12685
Medical student nutrition and culinary training David M Levine, Scott Vasher, Jared Beller, Lisa Sasson & Rob Caldwell What problem was addressed? Health care providers are expected to educate patients in nutrition
516
and weight management, yet formal medical student training is deficient. What was tried? Our interdisciplinary group of faculty, staff and trainees in medicine, nutrition and the culinary arts developed, piloted and assessed the impact of a pre-clinical medical student seminar designated ‘CHEF’ (Cook Healthy Eat Fresh) aimed at improving health promotion, dietary practices, food preparation and knowledge of nutrition. CHEF comprised four 3-hour cooking sessions in a teaching kitchen and four 50-minute didactic sessions in a classroom. Cooking session themes included the Mediterranean and DASH diets, which were linked to classroom topics including the socio-cultural aspects of nutrition, barriers to dietary change and making informed food decisions. Health promotion and dietary practices were assessed pre- and post-intervention using the Nutrition in Patient Care Survey (NIPS) and the Automated Self-Administered 24-Hour Diet Recall (ASA24), respectively. Food preparation was evaluated through a self-efficacy questionnaire and kitchen skills observation rubric. Knowledge on nutrition was determined via exit surveys. What lessons were learned? CHEF demonstrated an improvement in participant behaviours and perspectives toward promoting healthy eating and cooking. Scores on the NIPS significantly improved on three of five scales (p < 0.05), demonstrating increased ownership of health promotion activities. Results on the ASA24 revealed reduced weekday calorie intake (p = 0.01). Self-efficacy scores improved in culinary skills, time efficiency and budget-appropriate meal preparation (p < 0.05). Exit surveys demonstrated > 80% mean mastery of content objectives. This suggests a more robust change in perspective and a less potent change in behaviour. Given that providers who are more health-conscious may better counsel their patients,1 CHEF was successful in laying the foundation for the development of practitioners more dedicated to their own health and that of their patients. We believe our multidisciplinary and hands-on approach was important for effective student learning. Our choice of multiple assessment modalities, two of which are well validated (the NIPS and ASA24), also facilitated a multifaceted picture of the participant experience. Although this intervention served as a pilot exercise, we struggled with study enrolment and consequently with achieving a sample size sufficient to entirely assess impact. Although it was not difficult to attract students to the CHEF seminar (we had an extensive waiting list), the consent process deterred
ª 2015 John Wiley & Sons Ltd. MEDICAL EDUCATION 2015; 49: 513–541
Copyright of Medical Education is the property of Wiley-Blackwell and its content may not be copied or emailed to multiple sites or posted to a listserv without the copyright holder's express written permission. However, users may print, download, or email articles for individual use.
In particular, pre-established pathways to agencies external to the school prove to be invaluable in providing visibly fair and effective means of dealing with many issues. REFERENCE 1 Francis R. Report of the Mid-Staffordshire NHS Foundation Trust Public Enquiry. London: Stationery Office 2013. Correspondence: Janice S Ellis, School of Dental Science, Newcastle University, Framlington Place, Newcastle upon Tyne NE2 4BW, UK. Tel: 00 44 191 222 8198; E-mail: [email protected] doi: 10.1111/medu.12715
Cultural competence lessons learned: the continuum model Gabriella Berger & Anita Peerson What problems were addressed? Cultural competence training enables health services to address health inequalities and improve health outcomes of culturally and linguistically diverse (CALD) populations in English-speaking parts of the world. ‘Health inequalities’ refer to differences in health status that can be measured, and are preventable and unjust. The greatest health inequalities have been found in comparisons of indigenous and non-indigenous populations, prompting Australia and New Zealand to implement ‘close the gap’ initiatives. A ‘culturally competent’ health care workforce is broadly defined as one that is capable of delivering a continuous and high level of care to all patients regardless of culture, ethnicity, gender, age or language. However, the goal of integrating culture into clinical care remains elusive. Our recent Australian study1 revealed that clinical supervisors were unable to define cultural competence and could not apply the concept to teach junior doctors to become culturally competent in the hospital setting. What was tried? For this study we developed the Continuum Model (of cultural competence training) by extending the focus of previous training approaches and administered it to about 300 junior doctors at the Darling Downs Hospital and Health Service in Queensland, Australia, from January 2011. The Continuum Model is comprised of three parts, visualised as a tree and designated: (i) ‘Roots of Knowledge’; (ii) ‘Leaves of Change’, and (iii) ‘Fruits of Wisdom’. In Part 1, we focused on exploring health and illness patterns in ethnic and marginalised groups, using 2011 census data for
ª 2015 John Wiley & Sons Ltd. MEDICAL EDUCATION 2015; 49: 513–541
515
really good stuff national, regional and local CALD populations. Equity and access to health services, social determinants of health, and the relationship between culture and health were discussion topics. In Part 2, we explored cultural concepts in the context of change, including how culture shapes health beliefs, behaviours and values. Cultural labels were viewed as unhelpful when treating patients as they mask diversity and focus on similarity, thus giving rise to stereotyping. In Part 3, we offered strategies for clinicians to achieve optimal health care outcomes by suggesting methods of facilitating a patientcentred care approach. To engage the doctors in learning, we used a blended-delivery model which consists of an online course component (2 hours) followed by a face-to-face workshop (1 hour), thus providing greater flexibility and enhancing participation. What lessons were learned? Feedback from evaluations attested to the effectiveness of the model in fostering a greater understanding of cultural competence and providing clinicians with practical strategies to enhance health outcomes of vulnerable CALD patients. Certain challenges remain, largely related to the mismatch between patients’ needs (complex presentations in busy clinics and hospital departments) and the actual time and resources available. Improvements in communication, such as the development of active listening skills, the benefits of using qualified interpreters and ensuring patient participation in health care decision making were flagged as valuable lessons in providing patient-centred care. REFERENCE 1 Berger G, Conroy S, Peerson A, Brazil V. Clinical supervisors and cultural competence. Clin Teach 2014;11:370–4. Correspondence: Gabriella Berger, Darling Downs Hospital and Health Service, PMB 2, Toowoomba Qld 4350, Australia. Tel: 00 61 746 166681; E-mail: [email protected] doi: 10.1111/medu.12685
Medical student nutrition and culinary training David M Levine, Scott Vasher, Jared Beller, Lisa Sasson & Rob Caldwell What problem was addressed? Health care providers are expected to educate patients in nutrition
516
and weight management, yet formal medical student training is deficient. What was tried? Our interdisciplinary group of faculty, staff and trainees in medicine, nutrition and the culinary arts developed, piloted and assessed the impact of a pre-clinical medical student seminar designated ‘CHEF’ (Cook Healthy Eat Fresh) aimed at improving health promotion, dietary practices, food preparation and knowledge of nutrition. CHEF comprised four 3-hour cooking sessions in a teaching kitchen and four 50-minute didactic sessions in a classroom. Cooking session themes included the Mediterranean and DASH diets, which were linked to classroom topics including the socio-cultural aspects of nutrition, barriers to dietary change and making informed food decisions. Health promotion and dietary practices were assessed pre- and post-intervention using the Nutrition in Patient Care Survey (NIPS) and the Automated Self-Administered 24-Hour Diet Recall (ASA24), respectively. Food preparation was evaluated through a self-efficacy questionnaire and kitchen skills observation rubric. Knowledge on nutrition was determined via exit surveys. What lessons were learned? CHEF demonstrated an improvement in participant behaviours and perspectives toward promoting healthy eating and cooking. Scores on the NIPS significantly improved on three of five scales (p < 0.05), demonstrating increased ownership of health promotion activities. Results on the ASA24 revealed reduced weekday calorie intake (p = 0.01). Self-efficacy scores improved in culinary skills, time efficiency and budget-appropriate meal preparation (p < 0.05). Exit surveys demonstrated > 80% mean mastery of content objectives. This suggests a more robust change in perspective and a less potent change in behaviour. Given that providers who are more health-conscious may better counsel their patients,1 CHEF was successful in laying the foundation for the development of practitioners more dedicated to their own health and that of their patients. We believe our multidisciplinary and hands-on approach was important for effective student learning. Our choice of multiple assessment modalities, two of which are well validated (the NIPS and ASA24), also facilitated a multifaceted picture of the participant experience. Although this intervention served as a pilot exercise, we struggled with study enrolment and consequently with achieving a sample size sufficient to entirely assess impact. Although it was not difficult to attract students to the CHEF seminar (we had an extensive waiting list), the consent process deterred
ª 2015 John Wiley & Sons Ltd. MEDICAL EDUCATION 2015; 49: 513–541
Copyright of Medical Education is the property of Wiley-Blackwell and its content may not be copied or emailed to multiple sites or posted to a listserv without the copyright holder's express written permission. However, users may print, download, or email articles for individual use.
