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 Table of Contents  
ORIGINAL RESEARCH ARTICLE
Year : 2021  |  Volume : 34  |  Issue : 2  |  Page : 64-72

A pilot study of the implementation and evaluation of a leadership program for medical undergraduate students: Lessons learned


1 Medical Education Unit, BPS Government Medical College for Women, Sonepat, Haryana; GSMC-FAIMER Regional Institute, Seth GS Medical College, Mumbai, Maharashtra, India
2 GSMC.FAIMER Regional Institute, Seth GS Medical College, Mumbai; Office of Research and Medical Education Technology, N. K. P. Salve Institute of Medical Sciences and Research Centre, Nagpur, Maharashtra, India
3 GSMC-FAIMER Regional Institute, Seth GS Medical College, Mumbai; Department of Psychiatry, Topiwala National Medical College and B.Y.L. Nair Charitable Hospital, Mumbai, Maharashtra, India
4 Medical Education Unit, BPS Government Medical College for Women, Sonepat, Haryana, India

Date of Submission01-Oct-2020
Date of Decision07-Oct-2021
Date of Acceptance05-Nov-2021
Date of Web Publication21-Dec-2021

Correspondence Address:
Sumita Sethi
Medical Education Unit, BPS GMC for Women, Khanpur, Sonepat, Haryana
India
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/1357-6283.332959

  Abstract 


Background: Most Indian medical schools lack formal leadership training though students are expected to evolve into leaders. The Student Leadership Program (SLP) was designed and evaluated with an objective to incorporate and strengthen leadership skills in undergraduates and to initiate change in organizational practice through the development of a Student Leadership Society. Methods: The SLP was designed using best evidence guidelines in medical education. Competencies and learning outcomes were identified in four domains: reflective writing, self-management, team management, and experiential learning. A stepwise program was implemented over 6 months in which participants wrote reflections at the end of each program session. So as to gain objective evidence of behavioral change in participants in relation to the leadership training, their reflections were qualitatively analyzed and corresponding codes and themes were derived. Results: We describe the content and stepwise process of implementation of our pilot leadership program, which included 24 final-year students. Results of qualitative analysis are presented in relation to the domains of self-management, team management, and evaluation of experimental learning. Among the findings were: students viewed assertive skills training as the most powerful learning experience within self-management, and in team management, the session on “Myers–Briggs Type Indicator for understanding one's own leadership style” was seen as the most powerful learning tool, while the session on conflict management was the most difficult in this domain. A Student Leadership Society was instituted. Discussion: In this study, students' reflections helped us better understand factors (the “how” and “why”) that make leadership training more effective. The SLP, with a strong evidence base, achieved the intended learning outcomes. A Student Leadership Society was constituted as a networking platform to explore the long-term effects of leadership training on organizational practice. The content and process of our pilot leadership program and lessons learned through understanding of students' perspectives should be applicable to subsequent iterations of student leadership development programs here and in other settings.

Keywords: Leadership development program, leadership, medical students, program evaluation, qualitative evaluation


How to cite this article:
Sethi S, Chari S, Shah H, Agarwal R, Dabas R, Garg R. A pilot study of the implementation and evaluation of a leadership program for medical undergraduate students: Lessons learned. Educ Health 2021;34:64-72

How to cite this URL:
Sethi S, Chari S, Shah H, Agarwal R, Dabas R, Garg R. A pilot study of the implementation and evaluation of a leadership program for medical undergraduate students: Lessons learned. Educ Health [serial online] 2021 [cited 2022 Jan 23];34:64-72. Available from: https://www.educationforhealth.net/text.asp?2021/34/2/64/332959




  Background Top


At the undergraduate level, medical education has traditionally focused on the diagnosis and management of various diseases. As part of the curriculum, medical undergraduates do participate in various activities with multi-professional teams, fellow students, and patients. However, their roles are merely observational, and no demands are made in terms of taking responsibilities for their actions or to interact formally with other team members and stakeholders.[1],[2] A few schools, through clinical activities or other curricular exercises, do intend to address leadership, yet leadership is rarely the primary focus of these exercises.[3] It is ironic that though students are expected to take the role of physician leader from the very beginning of their health-care career, most medical schools lack formal leadership programs. This may reflect the hierarchical nature of the medical profession,[4] traditional physician's training as “heroic lone healers,”[5] lack of consensus on leadership content and methodology, and limited resources and time constraints owing to an already packed undergraduate curriculum.[6],[7]

In order to confront the challenges being faced by modern health care, experts and organizations are acknowledging the need for an increase in leadership capabilities of future physicians.[6],[8],[9],[10],[11] The Accreditation Council for Graduate Medical Education requires students to demonstrate the ability to “work effectively as a member or leader of a health-care team or another professional group.”[12] The recently introduced competency-based curriculum of the Medical Council of India recognizes “leader and member of the health-care team and system” as one of the five roles identified for an “Indian Medical Graduate.”[13]

Leadership is made up of a series of definable skills that can be well taught and learned, and undergraduate medical education can provide an ideal setting to lay the foundation for leadership competencies. The Student Leadership Program (SLP) was undertaken as a curricular innovation project for a fellowship of the Foundation for Advancement of International Medical Education and Research (FAIMER) Regional Institute (GSMC-FAIMER Regional Institute, Mumbai, India). The pilot program was introduced with the objectives of incorporating and strengthening leadership skills in medical undergraduate students and providing an opportunity to practice these leadership skills through experiential learning and a long-term vision of setting up an institutional Student Leadership Society to provide networking opportunities at different stages of professional development. In this study and analysis, we describe the various modules used in our program for formal leadership training along with their stepwise implementation as well as highlight the lessons learned in this process from qualitative analysis of students' reflections.


  Methods Top


The SLP was introduced as a pilot project at BPS Government Medical College for Women, Haryana, India, in May 2019 in three stages: designing and validation, implementation, and finally, evaluation.

Stage I: Module designing and validation

Competencies, specific learning objectives, and teaching–learning methods

After an extensive literature review, leadership competencies integral to the development of leadership were identified in different domains. Specific learning objectives were defined and dedicated teaching–learning (TL) methods were selected ensuring higher-order thinking skills and addressing leadership using a variety of techniques such as cooperative learning activities, small-group discussions, think-pair-share, role-plays, and simulations.

Experiential learning

An experiential learning project with focus on real-life conditions and local problems was planned to be included for each student at the end of the program.

Reflection diary

It was decided that all the sessions would be followed by reflective writing for that particular learning activity by each participant.

Validation

The whole module was discussed and internally validated by the supervisor and co-supervisors of SLP (authors 1 and 5), Institutional Medical Education Unit (MEU) members (authors 4 and 6), and FAIMER faculty guides (authors 2 and 3).

Stage II: Program implementation

After approval from the Institutional Ethical Committee, a call for participation was given to final-year MBBS students, with the number of participants for the pilot program not to exceed 25. The program was implemented through four modules:

Module I: Reflections

Reflective practice (RP) self-assessment was undertaken by participants individually at the beginning of the session through the RP self-assessment instrument.[14] Thereafter, reflective writing sessions were conducted over 3 weeks (one 2-h session/week) to familiarize participants with: concepts of reflective thinking and writing, Gibbs' reflective cycle,[15] Rolfe et al.'s framework for reflective learning,[16] stages of reflective writing, etc., Each participant undertook at least three reflective writing sessions, which were scored individually as per the REFLECT rubric.[17]

Module II: Self-management

With four sessions of 2 h each, 1/week, participants were involved in dedicated activities such as self-image, self-confidence, and looking and setting targets – all aimed at improving their managerial capabilities with themselves.

Module III: Team management

With four sessions of 2 h each, 1/week, participants focused on how to get along with team members through dedicated activities such as group dynamics, Myers–Briggs Type Indicator®[18] to understand one's own leadership style, difficult conversations, and conflict management.

Module IV: Experiential learning project

After completion of sessions, participants were asked to identify a problem within a real-life scenario (clinical or educational) and work out its solution through an experiential learning project. After completion of all projects, a report was prepared and presented in the form of a poster to a panel of members of the Institutional MEU. A scoring system was designed and finalized for a student leadership award for the year.

Stage III: Program evaluation

All experiential learning projects were multisource evaluated by a team consisting of two supervisors of SLP, two peers of the SLP, one faculty member of the department under which the project was done, and one miscellaneous member. Participants were told to maintain a reflection diary and, at the end of each session, were asked to write their reflections about how the session helped them in achieving the particular leadership skill (outcome) and how they were going to further utilize the skill in the future.

Analysis

All results were de-identified before any analysis was undertaken. Reflections were analyzed qualitatively using thematic analysis.[19] Coded data were scrutinized and themes were identified from the transcribed and coded data by authors 1, 5, and 6. Inter-observer comparisons were made and, after resolving discrepancies through detailed discussion amongst authors, the final analytical structure was agreed upon.

Those participants who could not attend a particular session were briefed about the session individually so that they could smoothly move on to the next session but were not allowed to complete the feedback form and write reflections for that particular session.


  Results Top


A total of 24 student volunteers in the MBBS final year were included in the pilot 2019 SLP; since the institute where the study was carried out is an all-women's school, all participants were females. The program was delivered longitudinally over 6 plus months. One 2-h session was conducted per week over 3 months for phases I, II, and III. Phase IV consisting of individual experiential learning projects was completed over another 3 months (but length could vary depending on student planning for the session as well as availability of departmental faculty and multisource evaluators). RP self-assessment was undertaken by participants at the beginning of each session, and at least three individual reflective writing assignments were to be completed. By the end of the session, all students had reached the stage of reflection as described in the REFLECT rubric (i.e., had moved beyond descriptive writing to the stage where they could make an effort to understand and analyze the event).

Analysis

Results of the qualitative analysis are summarized in [Table 1]a, [Table 1]b, [Table 1]c. Extracts of students' reflections which were used for deriving the codes and the corresponding themes form an exhaustive list. Selected extracts are presented in the table in italics; the number in brackets indicates the code and the corresponding quote. As an example, quote 1.2.2 represents code 1.2 and quote 2 used to derive the particular code.


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After successful completion and evaluation of the pilot program, required changes were undertaken in the program protocol as per participants' observations and responses and a call for participation in SLP 2020 was put out to the next class. With the consent of stakeholders (director and dean of the institute), a “Student Leadership Society” has been created by voluntary participation of students from both the pilot program and next classes.


  Discussion Top


With an understanding that there is clear need for leadership development from the early stages of professional careers in the context of training, we planned this exclusive and dedicated leadership development program for undergraduate medical students at our institute as a pilot program. To the best of our knowledge, this is the first detailed report from the Indian subcontinent for implementation of this type of program, and the first report in the literature taking a qualitative approach to program evaluation. The focus of this work has been on both the implementation process and program evaluation methods.

The SLP was designed according to best evidence guidelines in medical education, and the content validity was ensured in line with a comprehensive literature review under guidance of a FAIMER faculty expert in leadership training (authors 2 and 3).[20],[21] The domains, competency, and outcomes required for leadership development included in SLP were drawn from components of established and standardized frameworks such as Medical Leadership Competency Framework,[22] the Duke Healthcare Leadership Model,[23] and FMLN leadership and management standards for medical professionals.[24] The first of the 12 tips for integrating leadership development into undergraduate medical education highlights the importance of understanding the evidence, rationale, and outcomes required for leadership development.[25] Aiming toward understanding of best practices in leadership education, a systematic review of the literature concluded that the aligning of leadership curricula with standard frameworks would create opportunity to standardize the evaluation of outcomes and better understanding of best practices.[26]

Another important concern in leadership training is the use of appropriate TL methodology. Many experts in this field argue that leadership training transcends the disciplines and prepares students for all professions.[27],[28] Identifying signature pedagogies in leadership training has been pointed out to be a challenging task. In this, we referred to studies[29],[30],[31] which suggested interactive lecture and discussion as the signature pedagogy in leadership training for undergraduate education. Another study identified analytically the TL methods used in leadership education that teachers most often used and learners viewed as most impactful.[21] Based on these studies and a few others,[32],[33] we included dedicated higher-order TL methods in the program.

Another prerequisite in leadership training is that of trainers. While some argue that it should be done by trained managers, others insist that medical faculty should themselves be trained as trainers for such programs. We emphasize that if such programs are to run as institutional programs, it is important that the medical faculty is sufficiently trained to teach leadership skills through dedicated techniques. In our program, it was ensured that all sessions were taken by trained faculty backed by experts in matters of leadership.

There is evidence in the literature that near-peer learning can provide a supplementary teaching mechanism in leadership development.[25],[34] In the near future, through the Student Leadership Society, we plan to include near-peer-assisted learning wherein the trained students will help in conducting sessions and guiding new participants.

Developing as a leader requires learning new behaviors and skills through experience. To be effective, programs need to provide an opportunity for application, experimentation, and deliberate practice of the learned leadership skills.[6],[9] Through an analysis of student and faculty perspectives of the leadership curriculum in undergraduate medical students, we have concluded that experiential learning is the most effective for the teaching of leadership skills.[35] In our program, the experiential learning projects, involving multidisciplinary teams, helped students reinforce essential skills for practice in real-life situations and also helped in improving students' attitudes toward their ability to work effectively within a team-based system. This was clearly evident from the student reflections.

A strength of our study is the qualitative evaluation process exploring objective evidence of effects of training on development of leadership skills. There are studies that report learner satisfaction and increase in knowledge but lack objective evidence of learner's behavioral change.[26] An extensive review of the literature regarding training in leadership skills suggested that there is need for intervention studies on the effects of training on leadership skills. Past research has suggested qualitative methods such as participants' diaries between individual sessions,[10] and there is additional evidence for the use of reflections in medical education[36] and in leadership education.[21] The method has also been accepted to lead critical thinking and self-development.

We emphasize that it is important to understand the underlying factors which make the learning of a particular leadership skill effective by finding answers to “why” and “how” a particular session helped in achieving a specific leadership trait. Thus, the lessons learned through analysis of participants' reflections form a substantial part of our evaluation process. Certain very interesting themes emerged which helped us to understand students' perspectives; for example, participants appreciated the concept of “changing self-talk” as very effective in improving self-image and confidence, but they found it difficult to put this concept into practice in daily life, reinforcing the fact that there should be opportunities in such programs for transfer of learned skills to practical situations. Another interesting observation was that the participants realized the importance of assertiveness not only in their professional life as leaders but also personal life. They, however, reflected that the reason for their passiveness is grounded in the way they (especially women) have been brought up in their Indian families.

In our program, the experiential learning projects along with multisource evaluation helped us in reinforcing Kirkpatrick level 3 of behavioral change. At this point, we argue that project-based learning should not be claimed to have reached level 4 and, if done, is likely to overestimate program effectiveness. To reach the highest level of learning, long-term follow-up is needed which will provide tangible results in the form of change in organizational practice. We suggest an institutional Student Leadership Society with the opportunity for networking and keeping engaged in leadership activities in different stages of one's professional development as a step forward. Students with specific interests can attend activities held by the leadership society outside curricular hours and make an effort to make identified changes in organizational practices.

Limitations

A single program in a single institute should not lead to the generalization of conclusions to other settings. However, lessons we have learned in the course of conducting the pilot program have helped us in developing an understanding of the factors which make leadership training effective. We are now better equipped to propose a formal, longitudinally integrated leadership program with many advantages. Skills such as communication and teamwork which were earlier taught in an informal manner will now be branded as leadership competencies, thus making them a part of a competency-based curriculum and being reinforced longitudinally. There will also be more opportunities for experiential learning at different stages of professional development. Within this context, in the future, we plan to provide a generalizable model for leadership training of undergraduate medical students in Indian schools under the new competency-based curriculum.


  Conclusion Top


The pilot SLP with a strong evidence base and dedicated methodology to explicitly address leadership and opportunity for experiential learning helped in incorporating and strengthening the leadership skills of program participants. Through analysis of participants' reflections, we gained objective evidence of behavioral change and tried to understand the underlying factors which make the learning of a particular leadership skill effective. Through the formation of a Student Leadership Society, we look to provide the opportunity to keep students engaged in leadership activities in different stages of their professional career and explore the long-term effects of leadership training on organizational practice. Further, description of the various evidence-based modules used in our pilot program and lessons learned through qualitative analysis of participants' reflections may contribute to the development of customized formal leadership programs at other institutions.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.



 
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