Education for Health

ORIGINAL RESEARCH ARTICLE
Year
: 2019  |  Volume : 32  |  Issue : 1  |  Page : 3--10

Reflection and peer feedback for augmenting emotional intelligence among undergraduate students: A quasi-experimental study from a rural medical college in central India


Abhishek Vijaykumar Raut, Subodh Sharan Gupta 
 Department of Community Medicine, Mahatma Gandhi Institute of Medical Sciences, Wardha, Maharashtra, India

Correspondence Address:
Abhishek Vijaykumar Raut
Department of Community Medicine, Mahatma Gandhi Institute of Medical Sciences, Sewagram, Wardha - 442 102, Maharashtra
India

Abstract

Background: Professionalism is the foundation of the doctor–patient relationship with emotional competency at its core. This competency is based on emotional intelligence (EI), contributing to effective work performance. As EI is reasonably new in health professions education in India, this study was conducted to assess the effect of reflection and peer feedback on EI scores among undergraduate medical students and explore facilitating and hindering factors for augmenting EI. Methods: This pre- and post interventional study was conducted among 94 final-year (Part I) medical students from a rural medical college in Central India. Baseline assessment of EI scores was done using a self-reported validated EI scale, and then, a mini-workshop was conducted to sensitize students on EI and to train them in writing reflection and giving peer feedback. Between the pretest and posttest, students were asked to write weekly reflection and take monthly feedback from the “peer” of their choice. Posttest assessment was done at 1 week, 1 month, and 3 months. Force-field analysis was undertaken with 10 students each with highest and lowest EI scores to assess facilitating and hindering factors. Results: There was a significant improvement (P < 0.0001) in the EI scores at each subsequent time point from baseline. Students who were male, from nuclear families and considered themselves spiritual had significantly higher median EI scores. Students reported self-motivation, social support, and openness to learn new things as enabling forces for augmenting EI. Hindering factors were time constraint and lack of mutual trust in the relationship between students. Discussion: Based on the findings, it can be concluded that personal introspection methods such as self-reflection and peer feedback help to improve the EI of undergraduate students. Therefore, it is imperative that the students are trained in these skills for building their emotional competencies.



How to cite this article:
Raut AV, Gupta SS. Reflection and peer feedback for augmenting emotional intelligence among undergraduate students: A quasi-experimental study from a rural medical college in central India.Educ Health 2019;32:3-10


How to cite this URL:
Raut AV, Gupta SS. Reflection and peer feedback for augmenting emotional intelligence among undergraduate students: A quasi-experimental study from a rural medical college in central India. Educ Health [serial online] 2019 [cited 2019 Nov 11 ];32:3-10
Available from: http://www.educationforhealth.net/text.asp?2019/32/1/3/266185


Full Text



 Background



The Medical Council of India envisages producing an “Indian medical graduate” competent to perform the roles of clinician, professional, leader, communicator, and a life-long learner.[1] Producing such a professionally competent physician not only demands training of students in the medical competencies but also in the “soft” skills. Soft skills are the generic nontechnical skills that include interpersonal skills, communication skills, teamwork, social skills, professional attitudes, and ethical attitudes.[2],[3] In today's world, the importance of these soft skills cannot be understated.[4],[5]

Emotional intelligence (EI) is the capacity to recognize our own feelings and those of others, for motivating ourselves and for managing emotions effectively in others and us.[6],[7] The five elements that make up EI are self-awareness, self-regulation, motivation, empathy, and social skills.[8] EI in daily life empowers people to have superior self-control, ability to motivate them, manage and express emotions appropriately, and be assertive yet sympathetic and caring. There is evidence that individuals with high EI are excellent team players, cope better with emotional responses to work stressors, and have higher job satisfaction.[9]

Emotional competence is considered core to the professional competence of doctors, critical to their communication skills, and consequently, one of the hallmarks of patient-centered care and contributing to effective performance at work.[10] Doctors are expected to be kind, caring, affectionate, have unbiased empathetic approach, adequate self-control, and maintain cordial relation with their peers.[11] Higher EI in doctors is associated with better patients' trust, satisfaction with treatment, and better treatment outcomes. EI plays a momentous role in strengthening the doctor–patient relationship.[12],[13]

There has been considerable interest in EI in undergraduate medical education. EI of undergraduate medical students is associated with better health, life satisfaction, and stress mediation.[14],[15] Although the extent to which clinicians can learn these skills and how best to teach them remains unclear, available systematic reviews conclude that “emotional skills” are teachable and should be routinely included in medical education.[16],[17] Educational interventions that aim to improve EQ and patient care could include teaching empathy, communicating emotions, personal introspection, and mood management.[18],[19] As EI is a key competency for physician leaders, teaching EI is recommended to be a part of the medical training.[16],[20]

Despite its importance, presently, there is minimal formal training on emotional competencies in India. It is high time that a formal training for undergraduates on soft skills is initiated to produce professionally competent graduates. Therefore, this study was conducted with an objective to assess the effect of reflection and peer feedback on EI scores of undergraduate students and to further analyze the facilitating and hindering factors for augmenting EI.

 Methods



This quasi-experimental study was conducted using a pre- and postdesign. Study participants were final-year (Part I) medical students from a rural medical college in Central India. Students who were willing to comply with the study requirement of writing the reflections and providing and receiving feedback from their peers were included in the study. The sample size was estimated using G*power 3.1 software manufactured by the Heinrich-Heine-University Dusseldorf, Dusseldorf, Germany. To detect an effect size of 0.3 in median scores with 95% confidence level, 80% power, and 10% nonresponse/attrition, a sample of 100 students was needed. Therefore, universal sampling method was adopted, and the study was offered to all the 100 students in the final year (Part I). Ninety-four students who were present on the day when baseline assessment was done constituted the final sample size.

The data collection tool consisted of four subsections. Section 1 consisted of the sociodemographic details of the study participants. There were questions related to “locus of control,” being spiritual and religious. Section 2 consisted of the EI assessment scale. Sections 3 and 4 were the guide for reflection and peer assessment tool, respectively. The 25-item self-administered EI scale that has already been used in India to assess EI of medical students was used to calculate the EI scores.[21] There were five items for each of the five domains, namely self-awareness, managing emotions, motivating self, empathy, and social skill. For each of the 25 items, students had to rate themselves on a 5-point Likert scale with “1” – “completely disagree” to “5” – “completely agree.” A score above 100 meant that he/she had high EI. A score between 50 and 100 was interpreted to have a good platform of emotional competence on which they are capable to build their capacity. A score below 50 indicated an EI below average and needs to take more conscious efforts to improve their emotional competence.[21]

The intervention package included periodic self-assessment of EI scores, writing weekly reflection of their own behavior, and providing/receiving once a month peer feedback. After the baseline assessment, a 3-hour mini-workshop was conducted for sensitizing the students on EI and training them for writing reflection and peer feedback. The students were asked to write one reflection per week regarding their own emotional behavior. Reflection meant analyzing their own behavior over the last week, did they “react” or “respond” to the triggers that they were subjected to; were they in control of their behavior, emotions, and words or could they have managed the situation better; and what lessons do they have for themselves if they would be subjected to similar trigger again in future life. Students were asked to identify and pair with a “peer” of their choice whom they would observe closely wherever possible in the college, hospital, and hostel and would be comfortable to discuss the peer feedback. The reflection tool was semi-structured in nature with open-ended questions to trigger the thought process of the students. The peer feedback tool was in the form of a Likert scale with 20 questions related to the behavior of the students [Annexures 1 and 2]. Posttest assessment for EI scores was done with the same 94 students on day 7, 1 month, and 3 months from baseline.

Force-field analysis (FFA) was done with 10 students each with highest and lowest EI scores. Students were asked to list the enabling forces that positively helped and negative forces that were a barrier for practicing self-reflection and peer feedback. In the second step of FFA, students were asked to give weights to the enlisted factors considering the relative contribution of that factor in enabling or preventing practice of self-reflection and peer feedback.[22]

Descriptive analysis was done using mean, median, and interquartile range. As EI scale was an ordinal scale, the Mann–Whitney test was used to assess variables having significant association with median EI scores at baseline. Comparison of median pre- and posttest scores for EI was done using Friedman's two-way ANOVA test for k-related samples. Kendall's coefficient of concordance was calculated to see the degree of association of ordinal assessments made during multiple assessments. Post hoc analysis using Wilcoxon signed-rank test was done to find out exactly which two scores significantly differ from each other. Post hoc “P” values were interpreted after adjusting for Bonferroni correction.

This study was initiated after approval from the Institutional Ethics Committee. Written informed consent was taken from the students before their inclusion in the study.

 Results



[Table 1] gives the scores for the 94 participants at different time points. There was a consistent improvement in the mean and median EI scores at each of the time points. Mean and Median EI scores increased by 13 and 8 points, respectively, between baseline and end line at day 90. [Figure 1] depicts the density curves for distribution of EI scores over the different time points. The density curve for end line EI scores has lesser spread and increased peak as compared to the baseline EI scores. The density curve for end line scores is shifted to the right indicating that as compared to the baseline scores the median EI scores have improved. Also, the end line scores have a shorter tail to the left, indicating that the proportion of students with EI scores <50 have decreased. The improvement of scores was more for students with lesser EI scores at baseline as compared with those with high EI scores. [Table 2] shows the association of median EI scores with different variables at baseline. Male students, students coming from nuclear families, and students who considered themselves spiritual had significantly higher median EI scores. The difference in median EI scores for any of the other variables was not found to be statistically significant. As shown in [Table 3], the improvement in the median EI scores over time was found to be statistically highly significant (Friedman's test statistic was 259.04 at df = 3 and exact P < 0.0001). Kendall's coefficient of concordance (W) was 0.91 indicating the high degree of association across multiple assessments. Post hoc analysis using Wilcoxon signed-rank test was done to find out exactly which two scores significantly differ from each other. Post hoc “P” values were interpreted after adjusting for Bonferroni correction, and the difference was considered significant only if P < 0.0083. As shown in [Table 4], the difference in median scores was highly significant across all-time points with P < 0.0001. [Table 5] gives the facilitating and hindering factors for augmenting EI as identified by the students during FFA. Factors that were identified by students to have enabling influence for the development of EI were personal interest, self-motivation, support from friends, support from family, guidance from teachers, openness to learn new things, reinforcement by teachers, flexibility for reflection, and flexibility in choosing the peers. The hindering factors identified by students were packed schedule of classes with little or no flexibility, lack of time for doing anything that is extra-curricular, lack of mutual trust relationship between students, fear of being judged by peers, nonacceptance of feedback given to them by their peers, limited communication skills, and inability to reflect back on their own behavior.{Table 1}{Figure 1}{Table 2}{Table 3}{Table 4}{Table 5}

Informal feedback was obtained from the students who participated in the FFA on the two tools at the end of 3 months. Students found both the tools for reflection and peer feedback simple and easy to use. The reflection tool helped them to identify their best and worst managed moments and also helped them to analyze those moments to draw lessons for the future. The students appreciated thinking about both the good and bad moments, as it made them feel good about themselves as well as made it easy to accept their shortcomings. Students reported that the peer feedback tool was too structured being a Likert scale and they would have preferred some open-ended questions in the peer feedback tool.

Based on the feedback from students during posttest discussions, initially, the reflection from students was much superficial and it was more of “ I did this right/wrong” without much analysis or deep thought to what made them behave in a particular way or what lessons do they derive for themselves for not repeating the same regrettable behaviors again in the future. However, their ability to reflect back on their own behavior deepened with practice. The difficulties expressed by students were that although they are able to reflect back on their own behavior and draw lessons from it to improve their behavior, they find a time constraint to actually sit and pen down the reflections.

Regarding peer feedback, the students initially had apprehension about accepting the critical observations regarding their own behavior from their peers, but when explained that it is not a fault-finding activity but an opportunity for self-improvement, then the acceptance improved. Some of the students also expressed concern that it is not very easy to convey the mistakes of your own peers especially when they are your good friends and when you do not want to hurt or embarrass them. However, the practice of peer feedback improved when students realized its importance for the growth of their friends. The students were explained the importance of being honest in relationships and not just say nice things about each other

 Discussion



Developing emotional competence is the key for fostering professionally competent physicians.[16],[17] Available evidence suggests that techniques of reflection and 360-degree feedback have been used among doctors and other health professions to increase EI around the globe.[23],[24],[25],[26],[27] In this study, personal introspection in the form of reflection and peer feedback was used as tools for improving EI scores. One of the initial challenges for using reflection was that most of the students had never practiced self-introspection of their own behaviors or emotions and it was a new thing for them. The students who were habituated to daily diary writing were the ones that more readily wrote in-depth reflections. Reflective writing has been used for goal setting and personal development wherein reflective writing was performed in different stages starting from self-awareness to putting growth goals into practice.[28] This is very similar to findings in which the ability of students to reflect back on their own behavior deepened with practice from “ I did this right/wrong” to drawing lessons for future behavior. The constraints for practicing reflective writing (time constraint and distrust) are similar to those identified in the present research.[29]

The Enabling forces for practising Reflection and Peer-feedback were stronger as compared to the hindering forces. More enabling forces indicate that students could be motivated for cultivating softer skills like EI provided a conducive environment is made available to them. The students were positive because this aspect of personal development was new to them and its importance for self-development as a professional appealed to them. Their own openness to accept their limitations and support from the friends and family to help them improve were the enabling factors for improving their EI. The hindering factors identified by the students should be considered while planning training on emotional competence. Emphasizing the importance of being emotionally competent, providing dedicated time-slots in the curriculum for developing emotional competence, and establishing an open and conducive environment with mutual trust and support could facilitate the process of self-development among students.

Comparing the result of this study with existing literature is beset with certain difficulties. Despite our best efforts, we could not find studies that used self-reflection or peer feedback for augmenting EI scores in medical undergraduates. However, our findings are in concordance with findings of similar research from other fields wherein reflection and feedback have been used for improving EI of the participants.[23],[24],[25],[26],[27],[28],[29],[30],[31]

This study has certain limitations. It is possible that the prevailing mood and motivation to participate might have had considerable bearing on results. A self-administered questionnaire was used in the study. The questionnaire contained questions about life situations that they might have faced in the past. Some questions needed the individual to imagine a hypothetical situation and his/her reaction to that situation. But what a person would think of doing may not be the same as what he/she actually does. Thus, the possibility of reporting bias cannot be entirely ruled out. This study has limited external generalizability as the sample consisted of only final-year (Part I) medical students from a single medical college with comparatively limited clinical exposure, and the findings of the present study should be interpreted in this context. It will be interesting to evaluate if the same results could be obtained with the students as their clinical exposure increases. There was no comparison group and hence it is difficult to attribute all the change that is seen in EI scores to this intervention alone. Future studies could address these issues.

Based on the study findings, we can conclude that if teachers take efforts to emphasize the importance of soft skills and are able to train their undergraduate students in personal-introspection methods such as reflection or peer feedback, this can help students to improve their emotional competence. In this way, future Indian doctors will be better equipped as professionally competent physicians with good doctor–patient relationships and better job satisfaction. In India, there still is little formal training provided to medical students to improve their emotional competence, and as it cannot be left for self-learning through mere observation of what their teachers do or do not do, we urge EI to be integrated into medical curricula in India and to create more evidence on effective training strategies for developing EI.

Acknowledgments

We thank Professor and Head, Department of Community Medicine, MGIMS, Sevagram, for allowing me to conduct the research in the department. My heartfelt thanks to all faculty and postgraduate students of the Department of Community Medicine, MGIMS, Sevagram, without support and encouragement of whom it would not have been possible for me to complete this research project.We thank Dr. Sunita Vagha, Professor, Department of Pathology and Director, School for Health Professions Education and Research (SHPER), JNMC, Sawangi (Meghe), and all other faculty of MCI Nodal Centre, JNMC, Sawangi, for their timely guidance and support.We acknowledge the active participation of the participating students without which this research work could not have been completed.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.

 Annexures



Annexure I: Reflection

Please think of all the professional, personal encounters in the last week and then reflect on your own behavior. This will include thinking about the teaching-learning encounters in the college and hospital, encounters with your friends or family members in hostel or home.

Are you happy with the week that has gone by? Yes/NoAre you happy with your own behavior over the last week? Yes/No

'Aha' moment

Is there a moment from the last week that you will like to cherish? Yes/NoIf Yes, think of the reasons regarding why you will like to cherish it?Think of how you managed your behavior/emotions in that momentCould you have managed your behavior/emotions in a better way? Yes/NoIf yes, how?

'Oh no' momentIs there a moment from the last week that you regret? Yes/NoIf Yes, think of the reasons regarding why you regret it?Think of how you managed your behavior/emotions in that momentCould you have managed your behavior/emotions in a better way? Yes/NoIf yes, how?

Learning

What lessons you draw from this for improving your behavior in future or for managing your emotions in a better way?

Annexure II: Peer feedback

Instructions

Kindly feel this feedback form for your chosen “buddy” at the end of each month to give him/her feedback regarding his/her behavior.

Please answer each statement below by putting a circle around the number that best reflects your degree of agreement or disagreement with that statement. There are no right or wrong answers.

Try to answer as accurately as possible.

You have five possible responses, ranging from 1=Completely Disagree to 5=Completely Agree

Items Score

1.He/she was relaxed when under pressure in situations. 1 2 3 4 5

2.He/she could gear up at will for a task. 1 2 3 4 5

3.He/she could initiate successful resolution of conflict with others. 1 2 3 4 5

4.He/she could calm self quickly when angry. 1 2 3 4 5

5.He/she could know when he/she was becoming angry. 1 2 3 4 5

6.He/she could regroup quickly after a setback and stay motivated. 1 2 3 4 5

7.He/she could recognize when others are distressed. 1 2 3 4 5

8.He/she could build consensus with others. 1 2 3 4 5

9.He/she could stay motivated when doing uninteresting work. 1 2 3 4 5

10.He/she did help others manage their emotions. 1 2 3 4 5

11.He/she did make others feel good. 1 2 3 4 5

12.He/she was able to identify mood shifts. 1 2 3 4 5

13.He/she could stay calm when was the target of anger from others. 1 2 3 4 5

14.He/she could stop or change an ineffective habit. 1 2 3 4 5

15.He/she could show empathy toward others. 1 2 3 4 5

16.He/she could provide advice and emotional support to others as needed. 1 2 3 4 5

17.He/she could know when he/she was thinking negatively and head it off. 1 2 3 4 5

18.He/she could follow his/her words and actions. 1 2 3 4 5

19.He/she could engage in intimate conversations with others. 1 2 3 4 5

20.He/she could accurately reflect peoples' feelings back to them. 1 2 3 4 5

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