curriculum change Exploring frontline faculty perspectives after a curriculum change Shannon L Venance,1 Kori A LaDonna2 & Christopher J Watling1
CONTEXT Curriculum renewal is an essential and continual process for undergraduate medical education programmes. Although there is substantial literature on the critical role of leadership in successful curricular change, the voices of frontline faculty teachers implementing such change have not been explored. We aimed not only to examine and understand the perceptions of faculty members as they face curriculum change, but also to explore the influences on their engagement with change. METHODS We used a constructivist grounded approach in this exploratory study. Sixteen faculty members teaching in the pre-clinical years were interviewed on their perspectives on a recent curricular change in the undergraduate medical programme at a single Canadian medical school. Constant comparative analysis was conducted to identify recurring themes. RESULTS Faculty teachers’ engagement with curriculum change was influenced by three
critical tensions during three phases of the change: (i) tension between individual and institutional values, which was prominent as change was being introduced; (ii) tension between drivers of change and restrainers of change, which was prominent as change was being enacted, and (iii) tension between perceived gains and perceived losses, which was prominent as teachers reflected on change once implemented. CONCLUSIONS We propose a model of faculty engagement with curricular change that elucidates the need to consider individual experiences and motivations within the broader context of the institutional culture of medical schools. Importantly, if individual and institutional values are misaligned, barriers to change outweigh facilitators, or perceived losses prevail; subsequently faculty teachers’ engagement may be threatened, exposing the medical education programme to risk.
Medical Education 2014: 48: 998–1007 doi: 10.1111/medu.12529 Discuss ideas arising from the article at www.mededuc.com ‘discuss’
1 Department of Clinical Neurological Sciences, Schulich School of Medicine and Dentistry, Western University, London, Ontario, Canada 2 Faculty of Health and Rehabilitation Sciences, Western University, London, Ontario, Canada
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Correspondence: Shannon L Venance, Department of Clinical Neurological Sciences, Schulich School of Medicine and Dentistry, Western University, University Hospital, 339 Windermere Road, London, Ontario N6A 5A5, Canada. Tel: 00 1 519 663 3874; E-mail: [email protected]
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Faculty perspectives after a curriculum change
INTRODUCTION
Curriculum renewal is an essential and continual process for undergraduate medical education programmes. Curriculum change occurs in response to evolving societal requirements, changing health care needs and stakeholder influences. Bland et al.1 outlined a number of factors under the three broad domains of context, curriculum and process that guide successful curricular change in medical schools. These essential characteristics refer to the mission and goals, a history of organisational change, a cooperative climate and participation by stakeholders, communication, and human resource development.1 Creating effective change, whether incremental or transformational in scale, is complex; however, the business, social and psychology literatures feature models of behavioural and organisational change which can guide leaders who are contemplating change.2,3 Kotter’s eight steps for leading successful organisational change3 have been used to promote change when restructuring nursing4 and dental5 programmes, and to analyse the role of faculty development in effecting curricular change within a medical school.6 At a more theoretical level, Rogers’ notion of the diffusion of innovations addresses the rate of adoption of new ideas, behaviours or processes through communication by individuals and organisations within a social system.2 This theoretical construct has proved useful for exploring the effects of the introduction of an innovation in postgraduate medical education – workplacebased assessment – on the clinical workplace; the framework was of particular value in directing researchers’ attention to unanticipated, unintended and undesirable consequences of change.7
There is, in fact, a growing research literature addressing the role of leadership in achieving change in medical education.9,10 Twenty years ago, in a comparative case study of US medical schools, Cohen et al.11 stressed the central importance of strong, visionary leadership in facilitating medical education change. In a more recent exploration of how medical education leaders conceive of their work, Lieff and Albert10 found that, among the various lenses or frames through which leaders examine their work, that of human resources is of paramount importance. The human resource frame targets human needs with an underlying assumption that an organisation focused on the needs of its members will perform better.12 Leaders must therefore value, understand and engage with the unique needs of academic faculty members in order to create the conditions that will facilitate curriculum change. Notwithstanding the key role of leadership, however, it is faculty teachers who ultimately must create and implement innovations in order for change to be accomplished or for vision to become reality. The important perspectives of the teachers at the front line of curriculum change have not, to date, been fully explored. Although Cohen et al.11 identified teacher resistance as a critical barrier to change, their data sources were primarily individuals in key leadership positions rather than frontline teachers themselves. We reasoned that an exploration of these teachers’ perspectives would offer key insights that would deepen our understanding of curriculum change in the medical school setting. We aimed not only to examine and understand the perceptions of faculty teachers as they face curriculum change, but also to explore the influences on their engagement with change. Context of the study
Despite their usefulness in guiding and exploring some aspects of change in the realm of health professions education, these models were not developed from empiric work in a medical school context. Medical schools can be conceived of as distinct socio-cultural organisations by virtue of the individuals within them and the numerous roles in education, research, scholarship, management, administration and patient care that those individuals play, often simultaneously.8 There is a need, therefore, for context-specific research addressing curriculum change within this distinct setting in order to build a more sophisticated understanding of how and why curriculum change succeeds or struggles in medical schools.
The Schulich School of Medicine and Dentistry at Western University (‘the school’) is a mid-sized, publicly funded medical school in Ontario, Canada, jointly accredited by the Liaison Committee on Medical Education (LCME) and the Committee on Accreditation of Canadian Medical Schools (CACMS). The school is comprised of seven basic science and 14 clinical departments, all contributing to an academic mission founded on excellence in research, education and advancing health care. Frontline teaching faculty are frequently involved simultaneously in all three elements of this academic mission; increasingly, teaching and administrative contributions have been embedded
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S L Venance et al in the academic promotion process. The school’s 4-year undergraduate medical education programme is delivered in a traditional ‘2 + 2’ format so that the initial course-based pre-clerkship period (Years 1 and 2) is followed by primarily clinical learning experiences such as clerkships and clinical electives (Years 3 and 4). A curriculum renewal focused on the pre-clerkship years began in 2004/2005. The baseline curriculum, although emphasising patient-centred content and student-centred delivery, consisted of disciplinebased courses that were under the control of basic science departments in Year 1 and clinical departments in Year 2. Lectures were the dominant instructional technique in many courses, accounting for up to 85% of available course hours. The renewal process was motivated primarily by a desire to enhance students’ ability to integrate and apply material delivered across Years 1 and 2. The key changes that were implemented in the curriculum renewal process were: (i) integration of the basic and clinical sciences into 14 systems-based courses; (ii) delivery of course content using fewer committed teachers to enhance continuity; (iii) promotion of active learning opportunities for students; (iv) explicit blueprinting of assessment to learning objectives in all courses, and (v) centralisation of programme oversight and evaluation. The new weekly schedule included time dedicated to independent learning, clinical skills training, and small-group, case-based learning activities, and reduced lecture time. The renewed pre-clerkship curriculum was rolled out for the incoming class in September 2006. Concurrent with this curriculum renewal process, the school embarked on an expansion that involved opening a second, geographically distinct campus in Windsor, Ontario. This distribution of the school’s undergraduate programme added complexity to its curriculum renewal efforts; the delivery of an equivalent pre-clerkship curriculum at the new site demanded both the recruitment and development of new faculty members and the introduction of videoconferencing technology for large classroom sessions. The first class of 24 students entered Year 1 at the distributed campus in September 2008.
METHODS
We utilised a constructivist grounded theory approach for this exploratory study.13 We undertook purposive sampling of faculty members with signifi-
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cant teaching roles in the pre-clinical courses of Years 1 and 2 of the 4-year undergraduate medical education programme. This sampling strategy was chosen because the curriculum change was centred on these first 2 years of undergraduate training. Initial recruitment was carried out via an e-mail sent to the 35 co-chairs of the Year 1 and 2 courses inviting their participation; we then asked those who agreed to participate to suggest other faculty members who might offer additional perspectives. Course chairs at our institution typically take on significant teaching duties and also attend to the organisation and logistics of their courses. We chose course co-chairs as our initial recruitment contacts because we anticipated that their organisational roles would give them reasonable knowledge of the changes that were expected, and their status as frequent frontline teachers would give them first-hand experience of implementing changes. A total of 16 faculty members participated in the study; the group included six basic science faculty teachers (PhD) and 10 clinicians (MD). Five participants taught in Year 1, six in Year 2 and five were involved in both Years 1 and 2. All participants had significant teaching responsibilities within the undergraduate programme; 11 had administrative roles in addition to their teaching duties, serving as course co-chairs. All had been actively engaged as teachers during the curriculum change process. One researcher (KAL) conducted semi-structured interviews of 45–60 minutes in duration; she was selected to conduct the interviews because she had no prior involvement in undergraduate medical education and no prior knowledge of the participants. Interviews were audiotaped and transcribed verbatim. The university’s research ethics board approved the study. Consistent with the iterative nature of grounded theory research, data analysis occurred alongside and informed data collection; interview probes were modified as analysis proceeded to explore more fully the emerging themes.14 Data collection continued until thematic sufficiency was achieved. The three authors initially analysed transcripts independently, and then met regularly to discuss the themes they were identifying, and to refine the process of categorising the data using codes. This process continued until a robust coding structure had been approved by consensus. Once all of the transcripts had been analysed using the finalised coding structure, we independently and then collectively used constant comparison to define categories, to examine the relationships among categories, and ultimately to raise the level of analysis toward the conceptual and theoretical.15
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Faculty perspectives after a curriculum change Three phases of curricular change
Re lecting on change Implementing change Setting the stage
Perceived gains versus perceived losses
Drivers of change versus restrainers of change
Individual values versus institutional values
Figure 1 The results of faculty members’ navigation of competing tensions during the phases of curricular change may determine their ongoing engagement. We propose that faculty teachers will be fully engaged when values are aligned, drivers outweigh restrainers and the change results in perceived gains
The constructivist grounded theory approach13 demands that researchers are reflexive and account for how their own backgrounds and experiences might influence their approaches to the subject. Two of the authors (SLV and CJW) were clinicians with involvement in undergraduate teaching, education administration and education research. SLV served as chair of a Year 2 course for 8 years. CJW was currently serving as associate dean for postgraduate medical education; although he had taught extensively in the undergraduate curriculum, he had never held an administrative or leadership role in the undergraduate realm. Neither of these authors was interviewed for the study, but their own recollections of experiencing curriculum change as teachers and of leading new curricular initiatives as education administrators influenced the perspectives from which data analysis was approached. As education leaders, the authors also had experience in preparing programmes for accreditation and thus brought insight into external forces that can influence curriculum change. KAL was a doctoral student using qualitative methodologies to study individuals with chronic health conditions; she had no teaching or administrative involvement with the medical school’s undergraduate programme. Her ‘outsider’ status provided a useful counterbalance to that of the two ‘insider’ authors.
RESULTS
In the data analysis, a number of factors impacting faculty members’ experiences of and engagement with curriculum change were identified. In the
presentation of results, these sometimes-competing influences are framed around three critical tensions, each of which appeared prominent at a particular phase of the change. These overarching tensions were: (i) tension between individual values and institutional values, which was prominent as change was being introduced; (ii) tension between drivers of change and restrainers of change, which was prominent as change was being enacted, and (iii) tension between perceived gains and perceived losses, which was prominent as teachers reflected on change once implemented (Fig. 1). The balance point between the opposing elements of these tensions varied across faculty members, and appeared to influence their engagement with curriculum change. Each of these tensions will be described and illustrated by representative quotations from participants. Individual values versus institutional values Individual values Faculty involvement in education was driven largely by individual values, including a love of teaching and a perception that teaching was a personally or professionally rewarding activity: I get a bit of a high whenever I’m able to teach a concept to a student. You know, when you see it in their eyes and they get it. And then when they apply it to patient care, for example, and it brings them a kind of a sense of accomplishment and that gives me a sense of accomplishment. So I think I love working with students and watching them grow. (Participant 16)
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S L Venance et al Participants valued student engagement and often viewed themselves not only as teachers, but also as role models who could use their interactions with students to link classroom teaching to students’ future professional roles: I see one of the big roles as a mentor/role model for some students. . . I bring my stories about my patients and my clinical practice to teaching. (Participant 6) Although curriculum change might be thought of as reflecting a collective educational vision, the faculty members interviewed tended to view teaching through individual lenses. Their teaching philosophies appeared to be shaped largely by their own past educational experiences: I was never trained as an educator, I was kind of thrown in as a lecturer. . . having been a student I know of different forms of teaching, and which lecturers were more effective than others. . . so I am not sure. . . but I think the teacher or the lecturer who is more engaging, willing to entertain questions and to try and explain concepts. . . that’s something to try and emulate. (Participant 7) Because individual teachers relied largely on their own experiences as learners and on their personal teaching role models for guidance, their approaches to teaching and learning varied considerably, despite their participation in the same process of institutional change. Institutional values Tensions existed between the individual values that guided faculty members in their approaches to teaching and the institutional values that underpinned the curriculum change process. Curriculum renewal brought explicit central oversight of the curriculum, for example, and carried clear expectations of and accountabilities for faculty that were sometimes at odds with their own values. One element of curriculum change was a mandated reduction in lecture hours. Although this change was made for sound pedagogical reasons, including an increased emphasis on active learning and problem solving, some faculty members regarded this mandated change as signalling reductions in the emphasis on and perceived value of their subject matter: I think we may have gone a little bit too far in tailoring things down and cutting out lectures
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and things. The students actually have a fair bit of free time I think. (Participant 9) The value that individuals placed on teaching as professionally rewarding was also, at times, at odds with the perceived institutional value of teaching: I mean certainly in our department at this particular time. . . research is always sort of seen as more important. . . there [are] a lot of teachers and educators within the department. . . most of those people would think they don’t get enough credit for it. (Participant 13) Despite perceptions that some gains had been made in valuing teaching in the promotion and tenure process, there was a call for senior leadership to go further to champion and reward teaching: A key goal. . . is to go out to speak to department chairs who are. . . team leaders of. . . [the] people who are responsible for most of the teaching and try to convince them that teaching matters. . . they don’t place a particularly compelling emphasis on teaching. They don’t particularly reward it. (Participant 4) This perceived misalignment of individual values and institutional values represented a potential threat to the maintenance of the engagement of faculty teachers through a process of change. As curriculum change requires a significant investment in time and effort from the teachers enacting it, doubts about the ultimate value the institution would place on these efforts might undermine the process. Drivers of change versus restrainers of change As change was being enacted, faculty members experienced both driving and restraining forces. Drivers could facilitate faculty participation and engagement, whereas restrainers could threaten that engagement. These drivers and restrainers included both internal and external elements. Drivers of change A key driver for change was a clear understanding on the part of faculty teachers of the rationale for change. Engaged faculty members tended to have internalised the imperative for change and could articulate how change might lead to a better product:
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Faculty perspectives after a curriculum change I think we are. . . we’re sort of producing. . . the more well-rounded physician. (Participant 8) Faculty teachers who had embraced and internalised a continuous quality improvement approach to education were also more apt to engage readily in curriculum change: One of my mantras is, there is nothing we do that can’t be improved. So things that were good, that’s not good enough – it can still get better. . . we can continue to evolve and improve and grow. (Participant 4) In addition to these internal attitudinal influences, we also identified external factors as drivers of change. Accreditation processes, for example, were widely recognised as key drivers of change, capable of creating a sense of urgency that was sometimes necessary to drive change forward: I’ve seen and been involved in accreditations in the past, several times, but this one had real teeth. . . (Participant 14) Faculty interviewees also identified administrative support for teachers as a key external facilitator of change. Speaking of the value of a key administrative staff member, one course chair noted: The administrative person that is involved in making sure that the entire year. . . and. . . for my 5-week block. . . she is kind of the go-to person if you have any questions about the process at all. . . so that is very helpful. . . (Participant 1) The availability of such administrative and logistical support was viewed as necessary for translating the engagement of individual teachers into meaningful and ongoing change. Restrainers of change Just as a clear, internalised sense of the rationale for change might drive change forward, internal doubts about the rationale for change might act to restrain the process. One faculty member’s ambivalence about change was apparent: I like [change] because I don’t like being bored. . . but I don’t like change just for the sake of change. So there are certain things, yeah, that I believe that you shouldn’t change. Or you shouldn’t change. . . just because new technologies come along. (Participant 15)
Although administrative support was a valued driver of change, the inescapable workload associated with large-scale curriculum change with which faculty teachers were burdened was daunting: Trying to find enough people to volunteer for the 3 hours of small-group sessions could be a bit of a problem, so. . . finding the manpower to do the work that needs to be done. . . there is a lot of work that goes into just trying to get together a team. (Participant 1) As this quotation also illustrates, frontline teachers often perceived themselves as volunteers whose job descriptions did not fully encompass their educational roles. One participant described the challenge of developing a core roster of teachers: . . .[it] is difficult because it is hard to get people to volunteer to teach big segments of the course. (Participant 2) The escalation of workload for ‘volunteer’ faculty appeared to diminish, for some, the pleasure and satisfaction they drew from teaching, further restraining their engagement in change processes: The administrative aspect of the undergraduate medical education. . . it’s necessary to ensure the smooth running of the course and making sure that everyone meets certain standards, but [it] takes a significant amount of time and it takes away from the initial joy of just being able to interact with students and teach students. . . (Participant 7) Even accreditation, although acknowledged as a key agent of change, might act to restrain faculty engagement in change if the standards it imposed failed to resonate with individual faculty members’ philosophies of education or with the perceived institutional culture: We know accreditation is coming. . . we’ve got to hurry up and put together our checklists. . . but we’ve not done them meaningfully. . . because after accreditation leaves, the change doesn’t necessarily lie very well with what we had intended it to be. And more importantly, it doesn’t really resonate with the stakeholders. It doesn’t resonate with the teachers. It doesn’t resonate with the physicians. It doesn’t resonate with the students. I am not sure who it resonates with. (Participant 10)
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S L Venance et al Gains versus losses As faculty members reflected on their experiences with change, they identified both gains and losses. Some perceived gains or losses were personal, whereas others related to learners or to the curriculum. We speculate that the point of balance between perceived gains and perceived losses might impact individual faculty members’ ongoing engagement with the curriculum.
develop new collaborative relationships through the process of reflection, redesign and delivery of the curriculum: I work much more closely now with clinicians. . . it’s been great because I think we each appreciate more of what the other does. And what it’s led to is collaborations in terms of research projects, in terms of teaching aids. . . (Participant 12)
Gains
In this case, the visibly better ‘product’ was an enhanced and more collaborative professional environment for the individual faculty member.
Reflecting on curriculum change, many faculty members could identify gains at an institutional level:
Losses
I think the big thing that came out of it was the central oversight that you absolutely needed. . . and so I think that that geared getting everyone back on the same page. It was important to say, yes, we know what we’re teaching in this medical school, we know what the students are getting. (Participant 6) Some faculty members were able to identify gains from the process of change itself, recognising the value associated with the reflection demanded by the curriculum change process: . . .it’s made us all sit back. . . and look at what does the undifferentiated medical student really need to know. . . (Participant 8) Moreover, gains were perceived when change was viewed as student-centred. One individual discussed how the integration of relevant basic and clinical sciences facilitated the application of knowledge within a clinical context for learners: I think it’s better. . . I think probably the graduating students these days see more of the significance of the basic sciences and its importance in the practice of medicine. (Participant 11) When faculty teachers could identify change as resulting in a visibly better product, they were more likely to frame their experiences in terms of gains for learners, teachers and the institution. Some faculty members also perceived personal gains from their experiences of curriculum change. For example, change provided opportunities for staff to
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Balancing the gains that many faculty members were able to identify were perceived losses, which ranged from the personal to the institutional. Personal losses included those that diminished the rewards or personal satisfaction associated with teaching. One individual described how increasing alternative learning strategies for learners reduced the opportunities available to engage in direct interaction with students: The number of hours. . . has decreased significantly over the last few years. . . some of that. . . has been replaced by independent learning modules, etc., but personally I miss the face-to-face contact. (Participant 12) Other faculty members identified change as constraining their creativity and ability to engage with students. One participant, discussing the introduction of videoconferencing, noted: You can’t be quite as animated, you can’t sort of pace around. I used to walk up the aisle and back down again. . . it’s eliminated the rhetorical question. . . now it slows things down. (Participant 14) Given that a love of teaching was identified as a key motivator for faculty engagement in the first place, these perceived losses represent potential threats to that engagement when curricula are changed. Losses were not entirely personal; some participants expressed concerns that changes to the educational process might result in losses to learners. For example, although the integration of basic and clinical sciences was perceived by many as constructive, interviewees voiced concerns with respect to whether important aspects of curricular content
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Faculty perspectives after a curriculum change critical to learners would be lost in this new integrated approach: The students need to learn to walk before they run. They need that foundation and the basics and they need that balance before they move on to the clinical part. And I think that [basic science] has been whittled down so there is a very, very minimum. (Participant 5)
DISCUSSION
The medical education literature, although it provides the perspectives of deans and many others who lead thinking in medical education on the challenges and successes of curricular reform and organisational change,1,9,16–18 has under-represented the important voices of frontline teachers. Successful curriculum reform demands the ongoing engagement of those frontline teachers; accordingly, their voices are critical.1,9,16,19,20 Similarly to other descriptions of organisational change2,3 and curricular reform,6,9,21 the present study has conceptualised curriculum change as a staged process. Our model describes a process by which individuals navigate three discrete phases of curricular change. Our study expands the understanding of these phases of curriculum change in the medical education setting by identifying competing tensions within each phase that may influence continuing faculty engagement with the curriculum. We have shown that as the stage is set for change, attention must be directed to the alignment of values. As change is implemented, attention must be directed to the promotion of drivers and the deflection of restrainers of change. Finally, as individuals and institutions reflect on change, attention must be directed to highlighting gains, and acknowledging and managing losses. The tensions we identified resonate with Rogers’ diffusion of innovation theory, which acknowledges that the effects of change represent a balance between the desirable and the undesirable, the direct and the indirect, the anticipated and the unanticipated.2 Our elaboration of competing tensions at each stage of change exposes potential points of vulnerability in the process of curricular change and we speculate that a failure to attend to these vulnerabilities may result, ultimately, in the loss of the engagement of the very faculty members on whom the curriculum depends. We propose that if the experience with curricular change is positive,
and if external influences such as departmental support are congruent with faculty members’ intrinsic motivations and values, faculty engagement will be enhanced. If, however, individual and institutional values are misaligned, if barriers to change outweigh facilitators or perceived losses dominate over perceived gains, there may be unwanted consequences. Faculty teachers may remain involved but be ambivalent about the process to a degree that limits their usefulness as champions of change, or may remove themselves from the process entirely, deciding instead to pursue other academic opportunities or roles. Our findings suggest that if we are to retain faculty engagement, we should consider the individual experiences and motivations of faculty teachers within the broader context of the institutional culture of the medical school. Lindberg, describing the process of curricular change at eight US medical schools, recognised the importance of attending to the individual and highlighted the imperative to understand that individual’s ‘perceptions of the change and their concerns about how it will affect them personally and professionally’.21 Our study adds another imperative: to understand the individual values that underlie faculty members’ involvement in teaching in the first place. Faculty teachers are motivated to become involved in medical education for a variety of reasons,20 some of which are largely internal; our participants spoke of teaching and the enjoyment they drew from engaging with students and promoting their development and success. This sentiment was also apparent in a phenomenology study that explored the perceptions of 14 clinicians of their roles in a curriculum that had incorporated problem-based learning (PBL) during the clinical years.22 These highly regarded teachers struggled with PBL, but valued the social aspects and opportunities it afforded to pass on their enthusiasm and mastery.22 Faculty engagement in curriculum change requires more than just a love of teaching, however. Engagement in change demands a commitment to advancing the educational programme that extends beyond simply teaching within it.19 Without careful management, curriculum change provides a stern test of the motivation of frontline teachers to remain committed to their teaching roles. What, then, are the key elements that promote the faculty engagement that is so essential to the success of the change process? Attention to promoting, among frontline teachers, an understanding and appreciation of the rationale for change is critical.1,9,17,21 This recommendation aligns with the
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S L Venance et al embedding of the need to create and communicate the vision as a key step in Kotter’s change model.3 Moving our institutions from a culture of episodic change to one of continuous change23 is also likely to be helpful. Accreditation is one tool for promoting such a cultural change. There is a dearth of evidence in the literature with respect to the influence of accreditation on education programme outcomes; Cohen et al.,11 for example, did not identify accreditation as a factor facilitating or inhibiting curriculum change. Although the intent of accreditation may be quality improvement, its actual impact on faculty members’ engagement appears complex. Our work shows that accreditation can serve as both a driver and a restrainer of change, depending on the extent to which faculty teachers embrace it as a useful and productive reflective process. Faculty members must also view their engagement as aligned with the values of the institution and as worthy of reward. Steinert24 argues that curriculum and organisational change is facilitated when academic promotion criteria are reassessed to ensure that excellence in teaching is recognised and rewarded. Indeed, the perception that teaching was not rewarded was identified as a factor that obstructed change in Cohen et al.’s study of six US medical schools whether the school had been identified as an innovator or as a stable school.11 Recognition for teaching must be embedded at both the medical school and the departmental level.20 Others have recognised that the support of departmental chairs is critical to the success of curriculum change,1,25 and our data reinforce the influence of home departments on the ability and motivation of faculty to continue in roles or accept greater responsibility. When enacting change, ensuring that departmental leaders remove barriers, encourage innovation and recognise and reward faculty successes aligns with Kotter’s guidance to empower others to act on the vision and to attend to the creation of short-term wins.3 We have also shown that support remains essential in later phases of change in which the consolidation and institutionalisation of the change occur.3 Lindberg’s21 caution about the risk to enduring faculty commitment as change is institutionalised resonates with our model. Our participants describe how teaching time competes with increasing clinical demands, other administrative roles and other academic work such as research, publication and grant application. Increases in faculty teaching time and workload that are not recognised, remunerated or rewarded have been identified as barriers to faculty participation.19,20
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Indeed, our participants described teaching in the medical school as a form of volunteerism. Although inadequate remuneration could certainly contribute to the perception of teaching as volunteer work, none of our participants explicitly pointed to remuneration as the problem; rather, teaching was perceived as inadequately valued – by colleagues, departments and the institution – and thus faculty members found it challenging to fully integrate teaching as a core facet of their professional work. It is therefore crucial that deans and departmental chairs find innovative ways to ensure the availability of interested faculty and to value the education work they do. Our academic environment offers too many opportunities for disengaged faculty to move on to other potentially more rewarding endeavours. Is it time for our leaders to consider Watson’s proposal26 for the development of a core group of teaching faculty – chosen according to their teaching excellence – who will be responsible for the education mandate? Our study is limited by its single-centre context, which necessarily reflects the particular culture and values of the medical school we studied. By their nature, however, constructivist grounded theory studies aim for situated knowledge and understanding.13 Thus, although we hope our analytic insights are useful to educators, we encourage readers to examine their own distinct contexts and settings when considering the transferability of our findings. In addition, many of our participants had administrative roles as course chairs, and thus may not fully represent the perspectives of frontline teachers who have no investment in the curriculum as a whole. Almost all of our participants remained very engaged in medical school teaching at the time they were interviewed; a fuller understanding of the potential threat to teacher engagement posed by curriculum change might have been gained if we had been able to represent the voices of those individuals who had stepped away from their teaching involvement. Even with this invested group of participants, however, we were able to highlight a number of threats to the maintenance of faculty engagement with curricular change. Future research could evaluate more deeply the perspectives of teachers who continue to have reservations about curriculum reform and those faculty members who disengage in order to further understanding of the challenges to faculty engagement with continual curriculum renewal. Contributors: SLV and CJW contributed to the conception and design of the study, and to data analysis through an
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Faculty perspectives after a curriculum change iterative process of discussion. SLV wrote the original draft of the manuscript and CJW contributed to revisions of subsequent drafts. KAL conducted all interviews, participated in data coding and analysis and offered suggestions after reviewing drafts of the manuscript. All authors approved the final manuscript for publication and are accountable for all aspects of the work and for ensuring that questions related to the integrity of any part of the work are appropriately investigated. Acknowledgements: the authors wish to thank all faculty participants for their contributions. Funding: this study was supported by a Schulich School of Medicine and Dentistry Faculty Support for Research in Education grant. Conflicts of interest: none. Ethical approval: this study was approved by the Health Research Ethics Board, Western University.
REFERENCES 1 Bland CJ, Starnaman S, Wersal L, MoorheadRosenberg L, Zonia S, Henry R. Curricular change in medical schools: how to succeed. Acad Med 2000;75: 575–94. 2 Rogers EM. Diffusions of Innovations, 5th edn. New York, NY: Free Press 2003. 3 Kotter JP. Leading Change. Boston, MA: Harvard Business Review Press 1996. 4 Beischel KP, Davis DS. A time for change: QSENizing the curriculum. Nurse Educ 2014;39:65–71. 5 Kadagad P, Tekian A, Pinto PX, Jirge VL. Restructuring an undergraduate dental curriculum to global standards – a case study in an Indian dental school. Eur J Dent Educ 2012;16:97–101. 6 Steinert Y, Cruess RL, Cruess SR, Boudreau JD, Fuks A. Faculty development as an instrument of change: a case study on teaching professionalism. Acad Med 2007;82:1057–64. 7 Fokkema JPI, Teunissen PW, Westerman M, van der Lee N, van der Vleuten CPM, Scherpbier AJJA, Dorr PJ, Scheele F. Exploration of perceived effects of innovations in postgraduate medical education. Med Educ 2013;47:271–81. 8 McLeod PJ, Steinert Y. The evolution of faculty development in Canada since the 1980s: coming of age or time for a change. Med Teach 2010;32:e31–5. 9 Loeser H, O’Sullivan P, Irby DM. Leadership lessons from curricular change at the University of California, San Francisco, School of Medicine. Acad Med 2007;82: 324–30.
10 Lieff SJ, Albert MA. The mindsets of medical education leaders: how do they conceive of their work? Acad Med 2010;85:57–62. 11 Cohen J, Dannefer EF, Seidel HM, Weisman CS, Wexler P, Brown TM, Brieger GH, Margolis S, Ross LR, Kunitz SJ. Medical education change: a detailed study of six medical schools. Med Educ 1994;28:350– 60. 12 Bolman LG, Deal TE. Leadership and management effectiveness: a multi-frame, multi-sector analysis. Hum Resour Manage 1991;30:509–34. 13 Charmaz K. Constructing Grounded Theory: A Practical Guide Through Qualitative Analysis. Thousand Oaks, CA: Age Publications 2006. 14 Kennedy TJT, Lingard LA. Making sense of grounded theory in medical education. Med Educ 2006;40:101– 8. 15 Strauss A, Corbin J. Basics of Qualitative Research: Techniques and Procedures for Developing Grounded Theory, 2nd edn. Thousand Oaks, CA: Sage Publications 1998. 16 Watson RT, Suter E, Romrell LJ, Harman EM, Rooks LG, Neims AH. Moving a graveyard: how one school prepared the way for continuous curriculum renewal. Acad Med 1998;73:948–55. 17 Bernier GM Jr, Adler A, Kanter S, Meyer WJ III. On changing curricula: lessons learned at two dissimilar medical schools. Acad Med 2000;75:595–601. 18 MacCarrick G. Curriculum reform: a narrated journey. Med Educ 2009;43:979–88. 19 Rubeck RF, Witzke DB. Faculty development: a field of dreams. Acad Med 1998;73 (Suppl):32–7. 20 DaRosa DA, Skeff K, Friedland JA, Coburn M, Cox S, Pollart S, O’Connell M, Smith S. Barriers to effective teaching. Acad Med 2011;86:453–9. 21 Lindberg MA. The process of change: stories of the journey. Acad Med 1998;73 (Suppl):4–10. 22 Dornan T, Scherpbier A, King N, Boshuizen H. Clinical teachers and problem-based learning: a phenomenological study. Med Educ 2005;39:163–70. 23 Weick KE, Quinn RE. Organisational change and development. Annu Rev Psychol 1999;50:361–86. 24 Steinert Y. Faculty development: the road less travelled. Acad Med 2011;86:409–11. 25 Mennin SP, Krackov SK. Reflections on relevance, resistance, and reform in medical education. Acad Med 1998;73 (Suppl):60–4. 26 Watson RT. Rediscovering the medical school. Acad Med 2003;78:659–65. Received 27 October 2013; editorial comments to author 24 February 2014, accepted for publication 27 May 2014
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CONTEXT Curriculum renewal is an essential and continual process for undergraduate medical education programmes. Although there is substantial literature on the critical role of leadership in successful curricular change, the voices of frontline faculty teachers implementing such change have not been explored. We aimed not only to examine and understand the perceptions of faculty members as they face curriculum change, but also to explore the influences on their engagement with change. METHODS We used a constructivist grounded approach in this exploratory study. Sixteen faculty members teaching in the pre-clinical years were interviewed on their perspectives on a recent curricular change in the undergraduate medical programme at a single Canadian medical school. Constant comparative analysis was conducted to identify recurring themes. RESULTS Faculty teachers’ engagement with curriculum change was influenced by three
critical tensions during three phases of the change: (i) tension between individual and institutional values, which was prominent as change was being introduced; (ii) tension between drivers of change and restrainers of change, which was prominent as change was being enacted, and (iii) tension between perceived gains and perceived losses, which was prominent as teachers reflected on change once implemented. CONCLUSIONS We propose a model of faculty engagement with curricular change that elucidates the need to consider individual experiences and motivations within the broader context of the institutional culture of medical schools. Importantly, if individual and institutional values are misaligned, barriers to change outweigh facilitators, or perceived losses prevail; subsequently faculty teachers’ engagement may be threatened, exposing the medical education programme to risk.
Medical Education 2014: 48: 998–1007 doi: 10.1111/medu.12529 Discuss ideas arising from the article at www.mededuc.com ‘discuss’
1 Department of Clinical Neurological Sciences, Schulich School of Medicine and Dentistry, Western University, London, Ontario, Canada 2 Faculty of Health and Rehabilitation Sciences, Western University, London, Ontario, Canada
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Correspondence: Shannon L Venance, Department of Clinical Neurological Sciences, Schulich School of Medicine and Dentistry, Western University, University Hospital, 339 Windermere Road, London, Ontario N6A 5A5, Canada. Tel: 00 1 519 663 3874; E-mail: [email protected]
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Faculty perspectives after a curriculum change
INTRODUCTION
Curriculum renewal is an essential and continual process for undergraduate medical education programmes. Curriculum change occurs in response to evolving societal requirements, changing health care needs and stakeholder influences. Bland et al.1 outlined a number of factors under the three broad domains of context, curriculum and process that guide successful curricular change in medical schools. These essential characteristics refer to the mission and goals, a history of organisational change, a cooperative climate and participation by stakeholders, communication, and human resource development.1 Creating effective change, whether incremental or transformational in scale, is complex; however, the business, social and psychology literatures feature models of behavioural and organisational change which can guide leaders who are contemplating change.2,3 Kotter’s eight steps for leading successful organisational change3 have been used to promote change when restructuring nursing4 and dental5 programmes, and to analyse the role of faculty development in effecting curricular change within a medical school.6 At a more theoretical level, Rogers’ notion of the diffusion of innovations addresses the rate of adoption of new ideas, behaviours or processes through communication by individuals and organisations within a social system.2 This theoretical construct has proved useful for exploring the effects of the introduction of an innovation in postgraduate medical education – workplacebased assessment – on the clinical workplace; the framework was of particular value in directing researchers’ attention to unanticipated, unintended and undesirable consequences of change.7
There is, in fact, a growing research literature addressing the role of leadership in achieving change in medical education.9,10 Twenty years ago, in a comparative case study of US medical schools, Cohen et al.11 stressed the central importance of strong, visionary leadership in facilitating medical education change. In a more recent exploration of how medical education leaders conceive of their work, Lieff and Albert10 found that, among the various lenses or frames through which leaders examine their work, that of human resources is of paramount importance. The human resource frame targets human needs with an underlying assumption that an organisation focused on the needs of its members will perform better.12 Leaders must therefore value, understand and engage with the unique needs of academic faculty members in order to create the conditions that will facilitate curriculum change. Notwithstanding the key role of leadership, however, it is faculty teachers who ultimately must create and implement innovations in order for change to be accomplished or for vision to become reality. The important perspectives of the teachers at the front line of curriculum change have not, to date, been fully explored. Although Cohen et al.11 identified teacher resistance as a critical barrier to change, their data sources were primarily individuals in key leadership positions rather than frontline teachers themselves. We reasoned that an exploration of these teachers’ perspectives would offer key insights that would deepen our understanding of curriculum change in the medical school setting. We aimed not only to examine and understand the perceptions of faculty teachers as they face curriculum change, but also to explore the influences on their engagement with change. Context of the study
Despite their usefulness in guiding and exploring some aspects of change in the realm of health professions education, these models were not developed from empiric work in a medical school context. Medical schools can be conceived of as distinct socio-cultural organisations by virtue of the individuals within them and the numerous roles in education, research, scholarship, management, administration and patient care that those individuals play, often simultaneously.8 There is a need, therefore, for context-specific research addressing curriculum change within this distinct setting in order to build a more sophisticated understanding of how and why curriculum change succeeds or struggles in medical schools.
The Schulich School of Medicine and Dentistry at Western University (‘the school’) is a mid-sized, publicly funded medical school in Ontario, Canada, jointly accredited by the Liaison Committee on Medical Education (LCME) and the Committee on Accreditation of Canadian Medical Schools (CACMS). The school is comprised of seven basic science and 14 clinical departments, all contributing to an academic mission founded on excellence in research, education and advancing health care. Frontline teaching faculty are frequently involved simultaneously in all three elements of this academic mission; increasingly, teaching and administrative contributions have been embedded
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S L Venance et al in the academic promotion process. The school’s 4-year undergraduate medical education programme is delivered in a traditional ‘2 + 2’ format so that the initial course-based pre-clerkship period (Years 1 and 2) is followed by primarily clinical learning experiences such as clerkships and clinical electives (Years 3 and 4). A curriculum renewal focused on the pre-clerkship years began in 2004/2005. The baseline curriculum, although emphasising patient-centred content and student-centred delivery, consisted of disciplinebased courses that were under the control of basic science departments in Year 1 and clinical departments in Year 2. Lectures were the dominant instructional technique in many courses, accounting for up to 85% of available course hours. The renewal process was motivated primarily by a desire to enhance students’ ability to integrate and apply material delivered across Years 1 and 2. The key changes that were implemented in the curriculum renewal process were: (i) integration of the basic and clinical sciences into 14 systems-based courses; (ii) delivery of course content using fewer committed teachers to enhance continuity; (iii) promotion of active learning opportunities for students; (iv) explicit blueprinting of assessment to learning objectives in all courses, and (v) centralisation of programme oversight and evaluation. The new weekly schedule included time dedicated to independent learning, clinical skills training, and small-group, case-based learning activities, and reduced lecture time. The renewed pre-clerkship curriculum was rolled out for the incoming class in September 2006. Concurrent with this curriculum renewal process, the school embarked on an expansion that involved opening a second, geographically distinct campus in Windsor, Ontario. This distribution of the school’s undergraduate programme added complexity to its curriculum renewal efforts; the delivery of an equivalent pre-clerkship curriculum at the new site demanded both the recruitment and development of new faculty members and the introduction of videoconferencing technology for large classroom sessions. The first class of 24 students entered Year 1 at the distributed campus in September 2008.
METHODS
We utilised a constructivist grounded theory approach for this exploratory study.13 We undertook purposive sampling of faculty members with signifi-
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cant teaching roles in the pre-clinical courses of Years 1 and 2 of the 4-year undergraduate medical education programme. This sampling strategy was chosen because the curriculum change was centred on these first 2 years of undergraduate training. Initial recruitment was carried out via an e-mail sent to the 35 co-chairs of the Year 1 and 2 courses inviting their participation; we then asked those who agreed to participate to suggest other faculty members who might offer additional perspectives. Course chairs at our institution typically take on significant teaching duties and also attend to the organisation and logistics of their courses. We chose course co-chairs as our initial recruitment contacts because we anticipated that their organisational roles would give them reasonable knowledge of the changes that were expected, and their status as frequent frontline teachers would give them first-hand experience of implementing changes. A total of 16 faculty members participated in the study; the group included six basic science faculty teachers (PhD) and 10 clinicians (MD). Five participants taught in Year 1, six in Year 2 and five were involved in both Years 1 and 2. All participants had significant teaching responsibilities within the undergraduate programme; 11 had administrative roles in addition to their teaching duties, serving as course co-chairs. All had been actively engaged as teachers during the curriculum change process. One researcher (KAL) conducted semi-structured interviews of 45–60 minutes in duration; she was selected to conduct the interviews because she had no prior involvement in undergraduate medical education and no prior knowledge of the participants. Interviews were audiotaped and transcribed verbatim. The university’s research ethics board approved the study. Consistent with the iterative nature of grounded theory research, data analysis occurred alongside and informed data collection; interview probes were modified as analysis proceeded to explore more fully the emerging themes.14 Data collection continued until thematic sufficiency was achieved. The three authors initially analysed transcripts independently, and then met regularly to discuss the themes they were identifying, and to refine the process of categorising the data using codes. This process continued until a robust coding structure had been approved by consensus. Once all of the transcripts had been analysed using the finalised coding structure, we independently and then collectively used constant comparison to define categories, to examine the relationships among categories, and ultimately to raise the level of analysis toward the conceptual and theoretical.15
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Faculty perspectives after a curriculum change Three phases of curricular change
Re lecting on change Implementing change Setting the stage
Perceived gains versus perceived losses
Drivers of change versus restrainers of change
Individual values versus institutional values
Figure 1 The results of faculty members’ navigation of competing tensions during the phases of curricular change may determine their ongoing engagement. We propose that faculty teachers will be fully engaged when values are aligned, drivers outweigh restrainers and the change results in perceived gains
The constructivist grounded theory approach13 demands that researchers are reflexive and account for how their own backgrounds and experiences might influence their approaches to the subject. Two of the authors (SLV and CJW) were clinicians with involvement in undergraduate teaching, education administration and education research. SLV served as chair of a Year 2 course for 8 years. CJW was currently serving as associate dean for postgraduate medical education; although he had taught extensively in the undergraduate curriculum, he had never held an administrative or leadership role in the undergraduate realm. Neither of these authors was interviewed for the study, but their own recollections of experiencing curriculum change as teachers and of leading new curricular initiatives as education administrators influenced the perspectives from which data analysis was approached. As education leaders, the authors also had experience in preparing programmes for accreditation and thus brought insight into external forces that can influence curriculum change. KAL was a doctoral student using qualitative methodologies to study individuals with chronic health conditions; she had no teaching or administrative involvement with the medical school’s undergraduate programme. Her ‘outsider’ status provided a useful counterbalance to that of the two ‘insider’ authors.
RESULTS
In the data analysis, a number of factors impacting faculty members’ experiences of and engagement with curriculum change were identified. In the
presentation of results, these sometimes-competing influences are framed around three critical tensions, each of which appeared prominent at a particular phase of the change. These overarching tensions were: (i) tension between individual values and institutional values, which was prominent as change was being introduced; (ii) tension between drivers of change and restrainers of change, which was prominent as change was being enacted, and (iii) tension between perceived gains and perceived losses, which was prominent as teachers reflected on change once implemented (Fig. 1). The balance point between the opposing elements of these tensions varied across faculty members, and appeared to influence their engagement with curriculum change. Each of these tensions will be described and illustrated by representative quotations from participants. Individual values versus institutional values Individual values Faculty involvement in education was driven largely by individual values, including a love of teaching and a perception that teaching was a personally or professionally rewarding activity: I get a bit of a high whenever I’m able to teach a concept to a student. You know, when you see it in their eyes and they get it. And then when they apply it to patient care, for example, and it brings them a kind of a sense of accomplishment and that gives me a sense of accomplishment. So I think I love working with students and watching them grow. (Participant 16)
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S L Venance et al Participants valued student engagement and often viewed themselves not only as teachers, but also as role models who could use their interactions with students to link classroom teaching to students’ future professional roles: I see one of the big roles as a mentor/role model for some students. . . I bring my stories about my patients and my clinical practice to teaching. (Participant 6) Although curriculum change might be thought of as reflecting a collective educational vision, the faculty members interviewed tended to view teaching through individual lenses. Their teaching philosophies appeared to be shaped largely by their own past educational experiences: I was never trained as an educator, I was kind of thrown in as a lecturer. . . having been a student I know of different forms of teaching, and which lecturers were more effective than others. . . so I am not sure. . . but I think the teacher or the lecturer who is more engaging, willing to entertain questions and to try and explain concepts. . . that’s something to try and emulate. (Participant 7) Because individual teachers relied largely on their own experiences as learners and on their personal teaching role models for guidance, their approaches to teaching and learning varied considerably, despite their participation in the same process of institutional change. Institutional values Tensions existed between the individual values that guided faculty members in their approaches to teaching and the institutional values that underpinned the curriculum change process. Curriculum renewal brought explicit central oversight of the curriculum, for example, and carried clear expectations of and accountabilities for faculty that were sometimes at odds with their own values. One element of curriculum change was a mandated reduction in lecture hours. Although this change was made for sound pedagogical reasons, including an increased emphasis on active learning and problem solving, some faculty members regarded this mandated change as signalling reductions in the emphasis on and perceived value of their subject matter: I think we may have gone a little bit too far in tailoring things down and cutting out lectures
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and things. The students actually have a fair bit of free time I think. (Participant 9) The value that individuals placed on teaching as professionally rewarding was also, at times, at odds with the perceived institutional value of teaching: I mean certainly in our department at this particular time. . . research is always sort of seen as more important. . . there [are] a lot of teachers and educators within the department. . . most of those people would think they don’t get enough credit for it. (Participant 13) Despite perceptions that some gains had been made in valuing teaching in the promotion and tenure process, there was a call for senior leadership to go further to champion and reward teaching: A key goal. . . is to go out to speak to department chairs who are. . . team leaders of. . . [the] people who are responsible for most of the teaching and try to convince them that teaching matters. . . they don’t place a particularly compelling emphasis on teaching. They don’t particularly reward it. (Participant 4) This perceived misalignment of individual values and institutional values represented a potential threat to the maintenance of the engagement of faculty teachers through a process of change. As curriculum change requires a significant investment in time and effort from the teachers enacting it, doubts about the ultimate value the institution would place on these efforts might undermine the process. Drivers of change versus restrainers of change As change was being enacted, faculty members experienced both driving and restraining forces. Drivers could facilitate faculty participation and engagement, whereas restrainers could threaten that engagement. These drivers and restrainers included both internal and external elements. Drivers of change A key driver for change was a clear understanding on the part of faculty teachers of the rationale for change. Engaged faculty members tended to have internalised the imperative for change and could articulate how change might lead to a better product:
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Faculty perspectives after a curriculum change I think we are. . . we’re sort of producing. . . the more well-rounded physician. (Participant 8) Faculty teachers who had embraced and internalised a continuous quality improvement approach to education were also more apt to engage readily in curriculum change: One of my mantras is, there is nothing we do that can’t be improved. So things that were good, that’s not good enough – it can still get better. . . we can continue to evolve and improve and grow. (Participant 4) In addition to these internal attitudinal influences, we also identified external factors as drivers of change. Accreditation processes, for example, were widely recognised as key drivers of change, capable of creating a sense of urgency that was sometimes necessary to drive change forward: I’ve seen and been involved in accreditations in the past, several times, but this one had real teeth. . . (Participant 14) Faculty interviewees also identified administrative support for teachers as a key external facilitator of change. Speaking of the value of a key administrative staff member, one course chair noted: The administrative person that is involved in making sure that the entire year. . . and. . . for my 5-week block. . . she is kind of the go-to person if you have any questions about the process at all. . . so that is very helpful. . . (Participant 1) The availability of such administrative and logistical support was viewed as necessary for translating the engagement of individual teachers into meaningful and ongoing change. Restrainers of change Just as a clear, internalised sense of the rationale for change might drive change forward, internal doubts about the rationale for change might act to restrain the process. One faculty member’s ambivalence about change was apparent: I like [change] because I don’t like being bored. . . but I don’t like change just for the sake of change. So there are certain things, yeah, that I believe that you shouldn’t change. Or you shouldn’t change. . . just because new technologies come along. (Participant 15)
Although administrative support was a valued driver of change, the inescapable workload associated with large-scale curriculum change with which faculty teachers were burdened was daunting: Trying to find enough people to volunteer for the 3 hours of small-group sessions could be a bit of a problem, so. . . finding the manpower to do the work that needs to be done. . . there is a lot of work that goes into just trying to get together a team. (Participant 1) As this quotation also illustrates, frontline teachers often perceived themselves as volunteers whose job descriptions did not fully encompass their educational roles. One participant described the challenge of developing a core roster of teachers: . . .[it] is difficult because it is hard to get people to volunteer to teach big segments of the course. (Participant 2) The escalation of workload for ‘volunteer’ faculty appeared to diminish, for some, the pleasure and satisfaction they drew from teaching, further restraining their engagement in change processes: The administrative aspect of the undergraduate medical education. . . it’s necessary to ensure the smooth running of the course and making sure that everyone meets certain standards, but [it] takes a significant amount of time and it takes away from the initial joy of just being able to interact with students and teach students. . . (Participant 7) Even accreditation, although acknowledged as a key agent of change, might act to restrain faculty engagement in change if the standards it imposed failed to resonate with individual faculty members’ philosophies of education or with the perceived institutional culture: We know accreditation is coming. . . we’ve got to hurry up and put together our checklists. . . but we’ve not done them meaningfully. . . because after accreditation leaves, the change doesn’t necessarily lie very well with what we had intended it to be. And more importantly, it doesn’t really resonate with the stakeholders. It doesn’t resonate with the teachers. It doesn’t resonate with the physicians. It doesn’t resonate with the students. I am not sure who it resonates with. (Participant 10)
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S L Venance et al Gains versus losses As faculty members reflected on their experiences with change, they identified both gains and losses. Some perceived gains or losses were personal, whereas others related to learners or to the curriculum. We speculate that the point of balance between perceived gains and perceived losses might impact individual faculty members’ ongoing engagement with the curriculum.
develop new collaborative relationships through the process of reflection, redesign and delivery of the curriculum: I work much more closely now with clinicians. . . it’s been great because I think we each appreciate more of what the other does. And what it’s led to is collaborations in terms of research projects, in terms of teaching aids. . . (Participant 12)
Gains
In this case, the visibly better ‘product’ was an enhanced and more collaborative professional environment for the individual faculty member.
Reflecting on curriculum change, many faculty members could identify gains at an institutional level:
Losses
I think the big thing that came out of it was the central oversight that you absolutely needed. . . and so I think that that geared getting everyone back on the same page. It was important to say, yes, we know what we’re teaching in this medical school, we know what the students are getting. (Participant 6) Some faculty members were able to identify gains from the process of change itself, recognising the value associated with the reflection demanded by the curriculum change process: . . .it’s made us all sit back. . . and look at what does the undifferentiated medical student really need to know. . . (Participant 8) Moreover, gains were perceived when change was viewed as student-centred. One individual discussed how the integration of relevant basic and clinical sciences facilitated the application of knowledge within a clinical context for learners: I think it’s better. . . I think probably the graduating students these days see more of the significance of the basic sciences and its importance in the practice of medicine. (Participant 11) When faculty teachers could identify change as resulting in a visibly better product, they were more likely to frame their experiences in terms of gains for learners, teachers and the institution. Some faculty members also perceived personal gains from their experiences of curriculum change. For example, change provided opportunities for staff to
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Balancing the gains that many faculty members were able to identify were perceived losses, which ranged from the personal to the institutional. Personal losses included those that diminished the rewards or personal satisfaction associated with teaching. One individual described how increasing alternative learning strategies for learners reduced the opportunities available to engage in direct interaction with students: The number of hours. . . has decreased significantly over the last few years. . . some of that. . . has been replaced by independent learning modules, etc., but personally I miss the face-to-face contact. (Participant 12) Other faculty members identified change as constraining their creativity and ability to engage with students. One participant, discussing the introduction of videoconferencing, noted: You can’t be quite as animated, you can’t sort of pace around. I used to walk up the aisle and back down again. . . it’s eliminated the rhetorical question. . . now it slows things down. (Participant 14) Given that a love of teaching was identified as a key motivator for faculty engagement in the first place, these perceived losses represent potential threats to that engagement when curricula are changed. Losses were not entirely personal; some participants expressed concerns that changes to the educational process might result in losses to learners. For example, although the integration of basic and clinical sciences was perceived by many as constructive, interviewees voiced concerns with respect to whether important aspects of curricular content
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Faculty perspectives after a curriculum change critical to learners would be lost in this new integrated approach: The students need to learn to walk before they run. They need that foundation and the basics and they need that balance before they move on to the clinical part. And I think that [basic science] has been whittled down so there is a very, very minimum. (Participant 5)
DISCUSSION
The medical education literature, although it provides the perspectives of deans and many others who lead thinking in medical education on the challenges and successes of curricular reform and organisational change,1,9,16–18 has under-represented the important voices of frontline teachers. Successful curriculum reform demands the ongoing engagement of those frontline teachers; accordingly, their voices are critical.1,9,16,19,20 Similarly to other descriptions of organisational change2,3 and curricular reform,6,9,21 the present study has conceptualised curriculum change as a staged process. Our model describes a process by which individuals navigate three discrete phases of curricular change. Our study expands the understanding of these phases of curriculum change in the medical education setting by identifying competing tensions within each phase that may influence continuing faculty engagement with the curriculum. We have shown that as the stage is set for change, attention must be directed to the alignment of values. As change is implemented, attention must be directed to the promotion of drivers and the deflection of restrainers of change. Finally, as individuals and institutions reflect on change, attention must be directed to highlighting gains, and acknowledging and managing losses. The tensions we identified resonate with Rogers’ diffusion of innovation theory, which acknowledges that the effects of change represent a balance between the desirable and the undesirable, the direct and the indirect, the anticipated and the unanticipated.2 Our elaboration of competing tensions at each stage of change exposes potential points of vulnerability in the process of curricular change and we speculate that a failure to attend to these vulnerabilities may result, ultimately, in the loss of the engagement of the very faculty members on whom the curriculum depends. We propose that if the experience with curricular change is positive,
and if external influences such as departmental support are congruent with faculty members’ intrinsic motivations and values, faculty engagement will be enhanced. If, however, individual and institutional values are misaligned, if barriers to change outweigh facilitators or perceived losses dominate over perceived gains, there may be unwanted consequences. Faculty teachers may remain involved but be ambivalent about the process to a degree that limits their usefulness as champions of change, or may remove themselves from the process entirely, deciding instead to pursue other academic opportunities or roles. Our findings suggest that if we are to retain faculty engagement, we should consider the individual experiences and motivations of faculty teachers within the broader context of the institutional culture of the medical school. Lindberg, describing the process of curricular change at eight US medical schools, recognised the importance of attending to the individual and highlighted the imperative to understand that individual’s ‘perceptions of the change and their concerns about how it will affect them personally and professionally’.21 Our study adds another imperative: to understand the individual values that underlie faculty members’ involvement in teaching in the first place. Faculty teachers are motivated to become involved in medical education for a variety of reasons,20 some of which are largely internal; our participants spoke of teaching and the enjoyment they drew from engaging with students and promoting their development and success. This sentiment was also apparent in a phenomenology study that explored the perceptions of 14 clinicians of their roles in a curriculum that had incorporated problem-based learning (PBL) during the clinical years.22 These highly regarded teachers struggled with PBL, but valued the social aspects and opportunities it afforded to pass on their enthusiasm and mastery.22 Faculty engagement in curriculum change requires more than just a love of teaching, however. Engagement in change demands a commitment to advancing the educational programme that extends beyond simply teaching within it.19 Without careful management, curriculum change provides a stern test of the motivation of frontline teachers to remain committed to their teaching roles. What, then, are the key elements that promote the faculty engagement that is so essential to the success of the change process? Attention to promoting, among frontline teachers, an understanding and appreciation of the rationale for change is critical.1,9,17,21 This recommendation aligns with the
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S L Venance et al embedding of the need to create and communicate the vision as a key step in Kotter’s change model.3 Moving our institutions from a culture of episodic change to one of continuous change23 is also likely to be helpful. Accreditation is one tool for promoting such a cultural change. There is a dearth of evidence in the literature with respect to the influence of accreditation on education programme outcomes; Cohen et al.,11 for example, did not identify accreditation as a factor facilitating or inhibiting curriculum change. Although the intent of accreditation may be quality improvement, its actual impact on faculty members’ engagement appears complex. Our work shows that accreditation can serve as both a driver and a restrainer of change, depending on the extent to which faculty teachers embrace it as a useful and productive reflective process. Faculty members must also view their engagement as aligned with the values of the institution and as worthy of reward. Steinert24 argues that curriculum and organisational change is facilitated when academic promotion criteria are reassessed to ensure that excellence in teaching is recognised and rewarded. Indeed, the perception that teaching was not rewarded was identified as a factor that obstructed change in Cohen et al.’s study of six US medical schools whether the school had been identified as an innovator or as a stable school.11 Recognition for teaching must be embedded at both the medical school and the departmental level.20 Others have recognised that the support of departmental chairs is critical to the success of curriculum change,1,25 and our data reinforce the influence of home departments on the ability and motivation of faculty to continue in roles or accept greater responsibility. When enacting change, ensuring that departmental leaders remove barriers, encourage innovation and recognise and reward faculty successes aligns with Kotter’s guidance to empower others to act on the vision and to attend to the creation of short-term wins.3 We have also shown that support remains essential in later phases of change in which the consolidation and institutionalisation of the change occur.3 Lindberg’s21 caution about the risk to enduring faculty commitment as change is institutionalised resonates with our model. Our participants describe how teaching time competes with increasing clinical demands, other administrative roles and other academic work such as research, publication and grant application. Increases in faculty teaching time and workload that are not recognised, remunerated or rewarded have been identified as barriers to faculty participation.19,20
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Indeed, our participants described teaching in the medical school as a form of volunteerism. Although inadequate remuneration could certainly contribute to the perception of teaching as volunteer work, none of our participants explicitly pointed to remuneration as the problem; rather, teaching was perceived as inadequately valued – by colleagues, departments and the institution – and thus faculty members found it challenging to fully integrate teaching as a core facet of their professional work. It is therefore crucial that deans and departmental chairs find innovative ways to ensure the availability of interested faculty and to value the education work they do. Our academic environment offers too many opportunities for disengaged faculty to move on to other potentially more rewarding endeavours. Is it time for our leaders to consider Watson’s proposal26 for the development of a core group of teaching faculty – chosen according to their teaching excellence – who will be responsible for the education mandate? Our study is limited by its single-centre context, which necessarily reflects the particular culture and values of the medical school we studied. By their nature, however, constructivist grounded theory studies aim for situated knowledge and understanding.13 Thus, although we hope our analytic insights are useful to educators, we encourage readers to examine their own distinct contexts and settings when considering the transferability of our findings. In addition, many of our participants had administrative roles as course chairs, and thus may not fully represent the perspectives of frontline teachers who have no investment in the curriculum as a whole. Almost all of our participants remained very engaged in medical school teaching at the time they were interviewed; a fuller understanding of the potential threat to teacher engagement posed by curriculum change might have been gained if we had been able to represent the voices of those individuals who had stepped away from their teaching involvement. Even with this invested group of participants, however, we were able to highlight a number of threats to the maintenance of faculty engagement with curricular change. Future research could evaluate more deeply the perspectives of teachers who continue to have reservations about curriculum reform and those faculty members who disengage in order to further understanding of the challenges to faculty engagement with continual curriculum renewal. Contributors: SLV and CJW contributed to the conception and design of the study, and to data analysis through an
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Faculty perspectives after a curriculum change iterative process of discussion. SLV wrote the original draft of the manuscript and CJW contributed to revisions of subsequent drafts. KAL conducted all interviews, participated in data coding and analysis and offered suggestions after reviewing drafts of the manuscript. All authors approved the final manuscript for publication and are accountable for all aspects of the work and for ensuring that questions related to the integrity of any part of the work are appropriately investigated. Acknowledgements: the authors wish to thank all faculty participants for their contributions. Funding: this study was supported by a Schulich School of Medicine and Dentistry Faculty Support for Research in Education grant. Conflicts of interest: none. Ethical approval: this study was approved by the Health Research Ethics Board, Western University.
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