1

Chapter 1
THE PROBLEM AND ITS BACKGROUND
Introducton
Commonly in undergraduate and postgraduate medical education programmes,
students get hold of a large part of their training in the workplace. Workplace learning
provides an authentic learning environment, because learning takes place in the same
environment where the learners will practice their future profession. Workplace learning
in undergraduate medical education mainly occurs in clinical clerkship rotations. Two
related developments in undergraduate medical education have drawn special attention
to clerkship learning. Firstly, the goals of undergraduate (and postgraduate) medical
education are increasingly being defined in terms of competences rather than discrete
learning obectives (!enekens, et. "l, #$$$).
Competences entail integration of relevant knowledge, skills and behaviour in
dealing with comple% situations and problems in a suitable manner. &ecause of their
integrated nature, competences are best learned in an authentic learning environment
('leuten, ())*). +econdly, as the nature and sites of clinical care have changed, many
medical schools have started to use community and ambulatory care settings for their
clinical training programmes (+wanson, (),*). Thus the focus of training in
undergraduate clinical clerkships today has shifted towards workplace learning as a way
to facilitate competence learning and to offer students specific e%periences in clinical
care. "s clerkship learning is becoming increasingly important in the undergraduate
medical curriculum, it is also becoming increasingly important to have knowledge of how
students learn in this conte%t and of the re-uirements to be met by clerkships as a
learning environment.
2
Bac!"round o# the Stud$
Clerkships are traditionally an important educational activity in the undergraduate
medical curriculum. .n clerkship students have to learn and practice on real patients on
ward rounds, in independent patient contacts, small/group tutorials, during attendance
at operations and besides teaching (0c 1eod 2 3arden, (),4).
The clerkship training program of the 5+T Faculty of 0edicine and +urgery is
designed to e%pose the medical clerk to patient service, teaching6learning activities and
research in compliance with the mission statements of the medical school and hospital.
!uring their final year of undergraduate medical education, they are e%pected to apply
previously learned skills in history taking and physical e%amination in order to diagnose,
work/up and manage patients entrusted to their care. .n the same manner, they are
e%pected to established their role in the medical community and develop the appropriate
interpersonal skills re-uired in dealing with superiors, subordinates, patients and their
relatives. "s the most unior members of the medical staff they are e%pected to develop
their sense of responsibility for the comprehensive care of their patients. .t is during this
year that the medical clerk is e%pected to graduate from being a medical student to a
physician (http766med.ust.edu.ph6showmyfile8htmlpages6clerkshipmanual.htm).
Furthermore, brief information on Clinical Rotation was discussed in the following
manner (http766www.ust.edu.ph6inde%.php9option8com:content2task8view2id8;*)7
Medicine
Clinical Clerkship is the final stage in the study of 0edicine in the undergraduate
curriculum. The activities include lectures, grand rounds, seminars and ward
work through which the medical clerk is given ma%imal learning opportunities in
the work/up management of patients. They are re-uired to be part of a medical
team serving patients form admission to discharge. They take histories, plan out
a diagnostic and therapeutic regimen under the guidance of the medical intern,
resident and consultant. "s often as possible, they are given opportunity to
3
diagnostic and therapeutic procedures under proper guidance. They are given
training opportunities in decision/making. "s part of their training in the
ambulatory medicine, they are given assignments in the emergency room and
out/patient division.
Obstetrics
Clinical Clerkship in <bstetrics affords the students to actual e%periences and the
practical application of the principles in <bstetrics. Consultants and the resident
staff teach and guide them in assisting all procedures performed within the limit
of the specialty. =rocedures such as normal spontaneous delivery, episiotomy
and repair, forceps, e%traction, curetage, caesarean section including total patient
care and instructed and properly supervised "ctivities in the service such as
teaching rounds with the consultants and resident staff, admitting and pre6post
operative conferences with the Chairman and the Chief of section, manne-uin
demonstrations, seminars and ournal reports, audio/visuals and pathology slide
conference, out/patient follow ups are also taken care of.
This is a ;4 days rotation in the !epartment of <bstetrics both at the pay and
clinical divisions of the hospital.
Gynecology
Clinical Clerkship in gynecology provides the students e%periences in practical
application of principles learned in >ynecology didactic. Training and guidance
are provided to the students by the consultant and resident staff in these areas7
!iagnostic, 0anagement =lanning? >ynecology pathology @eview? =roblem/
oriented @ecording? =atient Follow/up Care? Community .nvolvement and
.nterpersonal +kills are emphasiAed.

4
Surgery
Clerkship in +urgery is patient/oriented. .t aims to train apprentices in surgery,
learning how to solve surgical problems as they add on to their basic knowledge,
develop clinical udgment and perform motor skills through guided and
supervised patient care.
The course trains the students on how to gather information using a systematic
methodology towards intelligent diagnosis. .t introduces the students to current
ancillary diagnostic studies utiliAed in the practice of surgery as well as instructs
them on logical, scientific and moral approaches to problem/solving in the
specialty as unior members of the surgical team.
Conferences, bedside rounds and grand rounds form an integral part of the
course making available to the student the e%pertise and e%perience of
consultants in the surgical staff. Clerkship is +urgery is a two month rotation.
Pediatrics
Clerkship in the fourth year includes an eight/week rotation in the !epartment of
=ediatrics which affords the student more ward e%periences and provides clinical
training in newborn care, ambulatory pediatrics and emergency room
management. Clerks are assigned patients in the .n/and/<ut patient services
(Well/Child and +ick/Child Clinics). They participate in the diagnostic work/up
management of the cases. &edside training is provided for by assigned faculty
members and house staff. "ttending staffs teaching rounds are conducted
several times weekly. <utpatient rotation includes a visit to the local 3ealth
Center where they are e%posed to government health services. .n "mbulatory
=ediatrics, emphasis is on =reventive =ediatric health care to include7
developmental6behavioral assessment, sensory screening and screening for T&,
anticipatory guidance and dental referral. Clerks attend and participate in all
regularly schedule departmental teaching6training activities. Teaching sessions
5
are conducted in pediatric radiology, pediatric emergencies and some
microbiology6parasitology techni-ues. The undergraduate pediatric curriculum is
competency/based.
To date, the entire medical curriculum at 5niversity of +to. Tomas lasts B years.
.n a three/year preclinical period students are mainly taught basic sciences. .n the
clinical period (; years) students start with a *$/hour course of skills training. Cunior
clerkships thereafter consists of (( periods of D weeks in years ;, 4, and *. +tudents
attend rounds and work in the hospital but follow lectures in the afternoon. The above/
mentioned clerkships are obligatory7 internal medicine, surgery, paediatrics, and
gynaecology and obstetrics. +even periods are elective.
Training in basic and clinical procedural skills is nowadays considered an
important part of the core undergraduate medical curriculum ("ssociation of =hilippine
0edical Colleges .nc., #$$).) 3owever, there is a reason to assume that unior doctors
are not ade-uately trained in these skills (!erese 2 1eroy, ());).
.t is thus in this light that the present study establishes the need for medical
studentsE to evaluate the medicine clerkship rotation specifically the above/mentioned
courses. The study features necessary information on the importance of medical
education particularly the clerkship program and how does it can be utiliAed by the
medical students in achieving its learning competencies.
State%ent o# the Pro&'e%
This study entitled (Medca' C'er!)* E+a'uaton o# the Ma,or Rotatona' at UST
- .MS Medca' C'er!*hp Pro"ra% #or the A/0 1212 - 1211F, is an attempt to
determine whether an undergraduate clerkship program has a positive effect on the
learning environment of the student.
6
0ore specifically, this study sought the following -uestions7
(. 3ow may clinical teaching effectiveness contribute to learning competencies9
#. 3ow the students are evaluating the maor rotational of medical clerkship
program9
D. What are the best features of the clerkship rotation9
;. !o you feel there should be an improvement or changes in the current
clerkship program9
4. .s there any significant assessment of the medical students on the maor
rotational of clerkship program9
Nu'' H$pothe**
The hypothesis to be tested at .$4 level of significance is7
There is no significant difference on the assessments of the medical students on
the maor rotational of clerkship program.
S"n#cance o# the Stud$
The findings of this research provide insights on the evaluation of clerkship
program and related learning e%perience of the batch #$(( medical students of 5+T. .t
is envisioned to serve as tool and reference. The result of this study will be of
importance to the following7
The .acu't$ o# Medcne may find the result of the study as a basis for the
formulation of plans, programs and strategies geared towards the enhancement of the
present curriculum. The outcome of the study will also arm instructors with creative,
innovative and proactive ways of empowering its students in their chosen career as
future doctors.
The .acu't$ Re*earch Pro"ra% will recogniAe knowledge of the underlying
problems and acknowledge the necessity to create feasible measures in response to
the result of the study.
7
Medca' Student* / >etting a glimpse of where they are now will inspire them
to enhance their productive endeavors for their learning achievement as well as for the
development of their career.
Other Re*earcher* G This study will serve as an invitational research agenda for
further research and development in response to the continuous search for
contemporary approaches to further understand of concerns parallel to this work.
Scope and L%taton* o# the Stud$
The study simply determines whether an undergraduate clerkship program has a
positive effect on the learning environment of the student. The validation of the data
that point to the evaluation of the respondents will be limited to data and information
gathered from the survey -uestionnaires given to one hundred (($$) medical students
of 5+T.
The time frame for this study is from "pril to +eptember #$($ covering the data
gathering period and <ctober G Canuary #$(( for processes and analysis, writing up for
the report and final dissertation. Thus, any or all developments that occurred thereafter
are deemed e%cluded.
De#nton o# Ter%*
The following terms have been operationally defined according to the overall
orientations of this study7
C'er!*hp - a course of clinical medical training in a specialty (as pediatrics,
internal medicine, or psychiatry) that usually lasts a minimum of several weeks and
takes place during the third or fourth year of medical (0erriam/Webster.com).
Currcu'u% - is the set of courses, and their content, offered at
a school or university. " curriculum is prescriptive, and is based on a more
8
general syllabus which merely specifies what topics must be understood and to what
level to achieve a particular grade or standard (wikipedia.com).
Learnn" Co%petenc$ - is a characteristic that distinguishes a superior from a
fully/successful performer (http766www.ilpi.wayne.edu6files6roth:present.pdf).
Medca' Student - .t refers to a learner who is enrolled in a medical school
(thefreedictionary.com).
Strate"e* - These are ways and means of implementing6managing a program
which are practical, effective and efficient. +trategies referred to in this study are those
that facilitate empowerment of students through the clerkship program.
9
Chapter 1
RE3IE4 O. RELATED LITERATURE AND STUDIES
This chapter presents concepts, theories, opinions, viewpoints, and insights of
related literature and studies. .t is organiAed in the following manner. First, it will give a
summary of frameworks of reference where a discussion on the learning process in
medical setting, understanding student/teacher relationship in a medical setting, and the
evaluation of learning outcomes are presented. +econdly, it will give a summary on
evaluation of skills training by students during their clerkship and its importance. Finally,
it will give a synthesis e%plaining the salient differences of the present study from the
others.
Su%%ar$ o# .ra%e5or!*
Learning Process in Medical Setting
.n most undergraduate and postgraduate medical education curriculum, students
receive a large part of their training in the workplace. Workplace learning offers a
genuine learning environment, because learning takes place in the same setting where
the learners will practice their future profession. Workplace learning in undergraduate
medical education primarily occurs in clinical clerkship rotations. Two related
developments in undergraduate medical education have drawn special attention to
clerkship learning. Firstly, the goals of undergraduate (and postgraduate) medical
education are increasingly being defined in terms of competences rather than discrete
learning obectives (C"H0I!+,#$$$ 2 Jarle, #$$#). Competences re-uire integration
of relevant knowledge, skills and behaviour in dealing with comple% situations and
problems in an appropriate manner. &ecause of their integrated nature, competences
are best learned in an authentic learning environment.(@agehr 2 Horman, ())*).
+econdly, as the nature and sites of clinical care have changed, many medical schools
have started to use community and ambulatory care settings for their clinical training
programmes (Woolliscroft, #$$#). Thus the focus of training in undergraduate clinical
10
clerkships today has shifted towards workplace learning as a way to facilitate
competence learning and to offer students specific e%periences in clinical care. "s
clerkship learning is becoming increasingly important in the undergraduate medical
curriculum, it is also becoming increasingly important to have knowledge of how
students learn in this conte%t and of the re-uirements to be met by clerkships as a
learning environment.
1ikewise, the principal aim of medical education is to begin to provide medical
students with necessary competencies in both basic medical sciences and clinical skills.
Traditionally the first two to three years in medical education are devoted to basic
medical sciences teaching, whereas clinical skills teaching takes place at the ne%t
stage. Clinical skills are typically taught by e%posing students to patients through clinical
clerkships. !uring these clerkships, students ac-uire diagnostic treatment and patient/
physician communication skills. Clinical clerkships are commonly organiAed by rotating
students through different disciplines. The e%periences of students in these rotations are
variable, largely due to the unpredictable availability of patients with specific clinical
findings and the occurrence of clinical situations. This makes teaching in clinical
rotations much less structured than teaching in basic medical sciences. Hevertheless,
clinical rotations are crucial to the training of medical students, as they provide an
opportunity for students to first apply their knowledge and be introduced to the
environment of their future work. Clinical skills teaching is provided both in ambulatory
and inpatient settings. This combination of teaching settings is likely to provide the most
effective approach to medical students (0urray, et al., #$$$).
Understanding Student-Teacher
.n medical education these days a lot has improved in the formal curriculum.
The Can0eds and intensive evaluations were put into formal education programs.
0oreover, courses on communication skills, ethics, professionalism etc. were
introduced (http766rcpsc.medical.org6canmeds6inde%.php).
11
.n the ne%t section, the Hidden Curriculum in Medical Education
(http766www.shockmd.com6#$($6($6#,6the/hidden/curriculum/in/medical/education6),) in
#$($ were discussed7
5nfortunately some research show an erosion of communication skills and
attitudes during clinical internship. This has been attributed to the Khidden
curriculumF to which these young medical students are e%posed during clinical
rounds. The hidden curriculum sometimes also called the culture in medical
schools or medical departments is all about individuals sharing the same set of
premises that are taken for granted. I%amples of these premises can be7
!octors do not make mistakes
Lou can know everything if you ust try hard enough
.t is <J to be rude when you are doing something really important
Communication skills are nice to have but not essential
1eaving the hospital is a sign of weakness
Lou must not -uestion doctors more senior than you
"ccording to a recent essay some principles should be important to the
student/teacher relationship. These principles are from work on adult education.
0edical students especially those in clinical rounds should be viewed as adults
needing to be educated in a difficult environment.
=rinciples of adult education and of importance for changing the hidden
curriculum to a more healthy culture are7
The teacher student relationship should take into account the personhood
of each other. 1earning especially during medical training should not be a
simple delivery or KdownloadingF a lot of information into the student.
.nstead of content delivery, teaching is the creating an interpersonal
conte%t that fosters learning. .dentity forming of the student teacher
interaction has powerful effects on studentsM professionalism.
12
Imotions are important for learning. Hegative emotions such as fear and
anger interfere with learning. =ositive emotions improve the efficacy of
learning and promote positive learning behaviors such as asking
-uestions, testing hypotheses.
The learning interaction can lead to growth for both learner and teacher,
reciprocal influence is important.
Conse-uently, a commonly held assumption is that a fundamental task of
teaching is to convey (or, as in a computer, to download) subect matter to students,
who then gather that knowledge in their minds for future retrieval and use (Tiberius et
al., #$$#). The personhood of the teacher and student in such a paradigm is lost,
because the maor focus of the educational activity becomes content delivery rather
than creating an interpersonal conte%t that fosters learning. " number of theorists have
challenged the NNdownloadingMM assumption, arguing that learning is constructed, rather
than merely delivered (&ransford, et al., #$$$). .n this different paradigm, students who
are e%posed to content and ideas delivered by the teacher will construct meaning from
those ideas, connecting them to previous e%perience and knowledge, evaluating them,
and making udgments about them (Tiberius 2 &illson, ())()..n such a paradigm,
relationships become important, because they provide the conte%t that shapes the
construction of meaning, and thus, the construction of learning.
@ichard Tiberius describes the importance of relationship in this process7
KThe relationship between teachers and learners can be viewed as a
set of filters, interpretive screens, or e%pectations that determine
the effectiveness of interaction between teacher and student . . .
within OeffectiveP relationships, learners are willing to disclose
their lack of understanding rather than hide it from their teachers?
learners are more attentive, ask more -uestions, are more actively
engaged . . . learning is conte%tual, and one of the most important
conte%ts for human beings is other people who said it and what is
13
the relationship of the learner to the teacher (Tiberius, ());)F.
This statement gives a hint in our study about the significant relationship between
student and teacher relationship towards better competency of every student.
" number of theorists and researchers in the education literature have observed
that high/-uality student/teacher relationships are associated with studentsM intrinsic
motivation to learn (!avis, #$$D). +uch relationships have important effects both on
learning and on studentsM sense of social identification. This NNidentity formingMM aspect of
the student/teacher relationship can have powerful effects on studentsM professional
choices and behaviors, and can be harnessed by the teacher who attends to the
personhood of themselves and the student (Jern, et al., #$$;).
Ealuation o! the Learning Outcome
!r. "ndrAe WotcAak (#$$() found the following7
The evaluation that attempts to determine different aspects of educational
structure, process and outcomes may have several forms. The formative
individual evaluation provides feedback to an individual learner identifying areas
and provides suggestions for improvement, whereas the formative program
evaluation provides information and suggestions for improving a curriculum and
programEs performance. <n the other hand, summative individual
evaluation measures whether specific performance obectives were
accomplished, certifying competency or its lack in performance in a particular
area, and summative program evaluation measures the success of a curriculum
in achieving learner and process obectives.
When a high degree of methodological rigor is re-uired, the measurement
instrument must be appropriate in terms of validity and reliability.
Istablishing +a'dt$ is the first priority in developing any form of assessment. .n
14
simple terms, this means ensuring that it measures what it is supposed to
measure. The test must contain a representative sample of what the student is
e%pected to have achieved. This aspect of validity, known as content validity, is
the one of most concern to the medical teacher. <n the other
hand, re'a&'t$ e%presses the consistency and precision of the test
measurements. There are a variety of factors, which contribute to reliability. .n a
clinical e%amination, there are three variables / the students, the e%aminers and
the patients. .n a reliable assessment procedure, variability due to the patient and
the e%aminer should be removed. .n the clinical e%amination, wherever possible,
a subective approach to marking should be replaced by a more obective one.
5nreliability in clinical e%aminations result from the fact that different students
usually e%amine different patients, where one may help some students while
obstructing others.
"lso important is the practca't$ of the assessment procedures. Factors such as
the number of staff available, their status and specialties, availability of patients
and space, and cost have to be taken into account. The ideal e%amination should
take into account the number of students to be assessed, as an assessment
procedure appropriate for twenty students may not be practical for hundreds.
5nfortunately, the resources available to conduct evaluations are always
restricted. 3owever, if medical schools want to achieve minimally acceptable
standards of validity and reliability, they have to be prepared to e%pend more time
and resources in this area. This applies particularly to the assessment of clinical
skills, where much longer or more fre-uent observations of student performance
than is usually undertaken are re-uired.
The first step in planning the evaluation is to identify the likely users of the
evaluation. !ifferent stakeholders who have responsibility for, or who may be
affected by the curriculum will also be interested in evaluation results. .n addition,
15
students are interested in the evaluation of their own performance. Ivaluation
results may also be of interest to educators from other institutions.
The ne%t step in designing an evaluation strategy for a curriculum is to identify
whether the evaluation is used to measure the performance of individuals, the
performance of the entire program, or both. The evaluation of an individual
usually involves determining whether the person has achieved the obectives of a
curriculum. <n the other hand, program evaluation usually assesses the
aggregate achievements of all individuals, clinical or other outcomes, actual
processes of a curriculum implementation and perceptions of learners and
faculty. "nother use of an evaluation might be for formative purposes (to improve
performance), summative purposes (to udge performance), or for both.
The long/term goal underlying revision of the curriculum is to produce better
physicians with -ualities such as e%tensive and appropriate knowledge,
humanism, compassion, career achievement, the ability and desire to learn
throughout life, and receptiveness to patientsE care and clinical research. .n that
situation, the proper time of evaluation is graduation or later.
Whatever the purpose and whenever performed, such assessments will have a
powerful effect on what students learn and how they go about their studies, and
the assessment of clinical competence is one of the most important tasks.
Therefore, the assessment should be regularly incorporated within the
coursework to provide ongoing feedback to students and teachers which usually
is undertaken at the end of a clinical course to certify a level of achievement.
"ssessment of 0edical Competence
"lthough the evaluation of professional competence is considered one of the
most important final goals of medical education and the most important tasks of
teachers, until very recently, we have used the term c'nca' co%petence rather
16
loosely without a general agreement. =resently, co%petence is defined in terms
of what the student or doctor should be able to do at an e%pected level of
achievement, such as at graduation or when commencing an internship. Thus,
competence is the synthesis of all attributes necessary to do the task for which
one is being trained, and clinical competence may be regarded as the mastery of
relevant knowledge and ac-uisition of a range of relevant skills, which would
include interpersonal, clinical and technical components. Competence itself, of
course, is only of value as a prere-uisite for performance in a real clinical setting.
There is a tendency to separate the term clinical competence from the
term c'nca' per#or%ance. =erformance is defined as what a student or doctor
actually does under specific conditions? for instance, during a test, or while being
watched, or in real clinical practice. What more, QperformingQ is ongoing and
continuous, and indicates activity rather than the finished product. To know that a
student is competent, we need to observe the student performing in io, not an
isolated performance under in itro test conditions. .n many ways, it is easier to
assess competence than performance. This matter is of less concern in the
undergraduate arena, where assessment of competence is particularly
appropriate, as students are not e%pected to practice in an unsupervised
situation.
Fig.( Components of clinical competence (Hewble, ())#)
17
5nfortunately, competence does not always correlate highly with performance in
practice. &oth competence and performance are influenced by professional
attitudes? however, assessing this component poses great difficulties.
The prevailing approach is analytic in nature, and is used by educators to break
up competence into separate parts called skills, knowledge and attitudes. The
components of clinical competence include abilities such as obtaining a detailed
and relevant patient history, carrying out a physical e%amination, identifying
patient problems, choosing appropriate diagnostic methods, performing
differential diagnosis, interpreting obtained results, and undertaking an
appropriate case management approach including patient education. .n this way,
the assessment of competence re-uires a whole series of performances
reflecting the interaction of patients and competent physicians, and what varies
from patient to patient. This helps avoid situations where more attention is paid to
the detection of abnormal physical findings during e%aminations rather than
student observations of history/taking from patients and their interactions.
What should be assessed is not simply whether the student is able to do a
specific task when observed by a teacher, but how he or she is assessed by a
patient. .t is why the clinical e%amination is broadly regarded as of key
18
importance in the assessment of a studentEs competence to practice medicine
and the cornerstone of -ualifying e%aminations. This re-uires observation of
student performances in real practice settings.
.n the clinical e%amination, there are three variables7 the student, the e%aminer
and the patient. The aim should be to standardiAe the e%aminer and the patient
so that the studentEs performance can be seen as a measure of his or her clinical
competence. The assessment of clinical competence is usually undertaken in
one of two settings, such as a ward/ or practice setting, or an e%amination
setting. The ward/ or practice/based assessment is the most desirable
environment to assess a student. .t provides the opportunity to make multiple
observations in a variety of clinical situations, such as how students perform
patient histories and e%aminations. .t may also provide the opportunity for
students to get specific feedback (formative assessment) and appropriate
remedial teaching. .n some parts of the world, competencies are certified by
passing so/called e6a%naton* &a*ed a**e**%ent7 consisting largely of
multiple/choice written tests. .n other parts of the world, the tradtona' c'nca'
e6a%naton, consisting of long and short cases based on patients, is seen as a
critical component of final e%aminations. The former approach suffers from a low
level of validity, and the latter from a very low level of reliability
(http766www.iime.org6documents6elo.htm).
Theoretca' .ra%e5or!
The study employed a simplified model of clerkship learning shows medical
students interacting with patients under the supervision of e%perienced clinicians. .n
recent years, however, the number of hospitaliAed patients and the length of hospital
stay have decreased dramatically. .n addition, patients who are admitted to hospital are
19
often very seriously ill, which limits the possibilities for students to interact with these
patients. .n community care and in the out/patient clinic, there are more patients who
can contribute to student learning, albeit that organiAational constraint in ambulatory
care may interfere with learning opportunities (.rby, ())4). .n the last few decades, an
array of health care workers, such as members of staff, nurses, residents and other
students have acted as studentsM supervisors. .n short, the clinical setting is a highly
comple% learning environment that is not easy to study. .t is therefore not surprising that
research into clerkship learning is difficult and sparse (Woolliscroft, #$$#). <n clerkship
rotations, the ac-uisition of competences generally starts with students observing others
performing these competences. >radually, students progress to Nlearning by doingM and
thus to performing competences themselves. Jey factors in the effective ac-uisition of
competences in clerkships are ade-uate supervision and feedback (@olfe, #$$#). The
effectiveness of clerkships as a learning environment is thus highly dependent on
variables like supervision and feedback. 0oreover, supervision and feedback are often
provided by professionals who are not fully -ualified (residents). "lthough little research
has been done into the -uality of feedback and its content, many authors are in
agreement as to the importance of certain factors for the -uality of supervision and
feedback (Jilminster, #$$#). These factors are7 clear agreement about obectives, good
structure, and continuity. <ther important factors are7 reflection on performance and, for
beginners, direction of performance.
Iffects of "ssessment on the 1earning Invironment
"ssessment has been described as the most powerful influence on student
learning behaviours (0essick, ());). 0oreover, the knowledge that a particular
competence is likely to be assessed can lead to an increase in supervision and
feedback in relation to that competence ('an der 'leuten, ())*). "ssessment can drive
learning through different mechanisms, such as content and format, the information
given during an assessment and the programming of assessment in the curriculum. Van
('an 1uik +C 2 van der 'leuten, ())$). This means that assessment is a powerful tool
for manipulating the learning environment and that it can be used strategically to create
20
the desired effects. &ecause assessment can affect learning through many
mechanisms, the impact of assessment on the learning environment must be monitored
very closely. This means that it is of vital importance to research the effects of
assessment so as to establish whether it is actually steering student learning into
desirable directions.
=erformance &ased "ssessment in Clerkships
"ccording to Wass et al. (#$$$), the main goal of assessment in undergraduate
clinical training is to determine whether students are able to perform competences they
have ac-uired during clerkships to a standard that ustifies admittance to postgraduate
training programmes. 0iller described a competence pyramid conceptualiAing four
levels of clinical competence and proposed appropriate assessment formats for each
level (Figure #).
."ure 1 Theoretca' Parad"%
The level of (isolated) theoretical knowledge (NknowsM), which forms the base of
the pyramid, and the ne%t level, that of the application of knowledge (Nknows howM), can
be assessed by written test formats. 3owever, these formats are not suitable for
DOES
("ction)
SHO4S HO4
(=erformance)
KNO4S HO4
(Competence)
KNO4S
(Jnowledge)
21
assessing actual skills performance and behaviour re-uired for ade-uate performance
of integrated competences. The two upper levels of 0illersM pyramid are characterised
as Nshows howM and NdoesM. N+hows howM refers to students demonstrating their ability to
perform a competence. This level is generally assessed in simulated carefully controlled
e%amination settings. The NdoesM level of competence or the NperformanceM level consists
of what students or professionals actually do in authentic workplace settings. .n
practice, performance/based assessment at the NdoesM level is difficult to implement,
because it re-uires a careful balance between issues of reliability, validity and feasibility
in real life workplace. The level of (isolated) theoretical knowledge (NknowsM), which
forms the base of the pyramid, and the ne%t level, that of the application of knowledge
(Nknows howM), can be assessed by written test formats. 3owever, these formats are not
suitable for assessing actual skills performance and behaviour re-uired for ade-uate
performance of integrated competences. The two upper levels of 0illersM pyramid are
characteriAed as Nshows howM and NdoesM. N+hows howM refers to students demonstrating
their ability to perform a competence. This level is generally assessed in simulated
carefully controlled e%amination settings. The NdoesM level of competence or the
NperformanceM level consists of what students or professionals actually do in authentic
workplace settings. .n practice, performance/based assessment at the NdoesM level is
difficult to implement, because it re-uires a careful balance between issues of reliability,
validity and feasibility in real life workplace conditions (+chuwirth 2 'an der 'leuten,
#$$;).
Conceptua' .ra%e5or!
Formulation of the problem
And the research uestions
!ethodolo"#
$ata %atherin"
Frame&or's of
(eference
)*iterature+
22
."ure 8 Conceptua' .ra%e5or! o# the Stud$
The first step in doing this research was the formulation of the problem and the
creation of the research -uestions. Thereafter, the researchers thought about the
methodology which would best fit the problem under research. "fter that, we gathered
secondary data in the form of books and articles in order to improve our understanding
of the research problem. "t this time, we also started to write the research outline. The
-uestionnaire about motivation and self/esteem was created, based on the knowledge
of the theoretical research.
Thereby, several decisions in data gathering such as the form of the -uestions,
the language used in the -uestionnaire, as well as the procedure in performing the
survey instrument had to be made. The -uestionnaire was tested and several days later
delivered to each employee of the two hospitals. <ne week later the -uestionnaires
were collected and a period of editing and analysing the data started. These results
were used to get a deeper understanding of the study. !uring the entire time between
determining the methodology and the end of writing down the analysis the frameworks
of reference was created. Finally, the research report was completed by adding the
conclusion and the closing comments.
Anal#sis
,onclusions
23
Chapter 8
RESEARCH METHODLOG0
This research was conducted in order to determine whether an
undergraduate clerkship program has a positive effect on the learning environment of
the student. .n order to answer these research goals, the researcher chose the view of
medical students in line with this topic. This chapter presents the methodology of the
study. +pecifically, it discusses the research design, research setting, respondents of
the study, research instruments, data/gathering procedure, and the statistical tools used
in data analysis.
Re*earch De*"n
The descriptive method of research was used for this study. To define the
descriptive type of research, Creswell (());) stated that the descriptive method of
research is to gather information about the present e%isting condition. The importance is
on describing rather than on udging or interpreting.
.n this study, the descriptive research method was employed so as to identify the
role and significance of using -uestionnaire in evaluating faculty teaching, clinical
effectiveness, and clerkship program from the time of research. The researchers chose
to use this research method considering the obective to obtain first hand data from the
24
respondents. The descriptive method is advantageous for the researchers due to its
fle%ibility? this method can use either -ualitative or -uantitative data or both, giving the
researchers greater options in selecting the instrument for data/gathering. The aim of
the research is to determine the effectiveness of clerkship rotation in the learning
environment of the students? the descriptive method is then appropriate for this research
since this method is used for gathering prevailing conditions.
For this research, two types of data were ontained. These included the primary
and secondary data types. The primary data were derived form the answers the
participants gave during the survey process. The secondary data on the other hand,
were obtained from published documents and literatures that were relevant to
evaluation -uestionnaire. With the use of the survey -uestionnaire and published
literatures, this study took on the combined -uantitative and -ualitative approach of
research. &y means of employing this combined approach, the researchers were able to
obtain the advantages of both -uantitative and -ualitative approaches and overcome
their limitations.
<n the other hand, -ualitative approach generates verbal information rather than
numerical values (=olgar 2 Thomas, ())4). .nstead of using statistical analysis, the
-ualitative approach utiliAes content or holistic analysis? to e%plain and comprehend the
research findings, inductive and not deductive reasoning is used. The main point of the
-uantitative research method is that measurement is valid, reliable and can be
generaliAed with its clear anticipation of cause and effect (Cassell 2 +ymon, ());).
The researcher used to integrate the -ualitative approach in this study due to its
significant advantages. The use of -ualitative data gathering method is advantageous
as they are more open to changes and refinement of research ideas as the study
progresses? this implies that -ualitative data gathering tools are highly fle%ible.
0oreover, no manipulation of the research setting is necessary with this method? rather
than employ various research controls such as in e%perimental approaches, the
25
-ualitative data gathering methods are only focused on understanding the occurring
phenomena in their naturally occurring states. "side from these advantages,
researchers use -ualitative data/gathering tools as some previous researchers believe
that -ualitative data are particularly attractive as they provide rich and well/grounded
descriptions and e%planations as well as unforeseen findings for new theory
construction. <ne of the notable strengths of the -ualitative instruments is that they
evoke a more realistic feeling of the research setting which cannot be obtained from
statistical analysis and numerical data utiliAed through -uantitative means. These data
collection methods allow fle%ibility in conducting data gathering, research analysis and
interpretation of gathered information. .n addition, -ualitative method allows the
presentation of the phenomenon being investigated in a more holistic view.
Re*earch En+ron%ent
To test the application acceptability, the convenience sampling method was
applied. The convenience sampling (Calderon 2 >onAales, ())D), a general type of
non/probability sampling techni-ue which involved the process of selecting out people
in the most convenient and fastest way to immediately get their reactions to a certain
hot and controversial issue. The setting was conducted in the 5niversity of +to. Tomas.
0easures to preserve confidentiality will be properly observed and practiced.
Re*earch In*tru%ent
" survey instrument was administered containing -uestions covering variables to
determine the whether a clerkship program has a positive effect on the learning
environment of the student. "s shown in "ppendi% ", the survey -uestionnaires have
four parts.
=art . contains / Faculty Teaching >lobal @ating +cale
=art .. contains / Clinical Teaching Iffectiveness Ivaluation
=art ... contains / 5ndergraduate 0edical Iducation +tandard Clerkship
Ivaluation
26
=art .' contains G >eneral Ruestions
The -uestions were structure using the 1ickert format. .n this survey type, five
choices are provided for every -uestion or statement. The choices represent the degree
of agreement each respondent has on the given -uestion. The scale below was used to
interpret the total responses of all the respondents for every survey -uestion by
computing the weighted mean7
The following point/scale values with their e-uivalent interpretation are used.
Ran"e* Interpretaton
;.4( G 4.$$ +trongly "gree
D.4( G ;.4$ "gree
#.4( G D.4$ Heither "gree or !isagree
(.4( G #.4$ !isagree
(.$$ G (.4$ +trongly !isagree
Re*pondent* o# the Stud$
The researcher distributed -uestionnaires to a total of ($$ medical students from
5+T were asked to participate in the study.
Data Gathern" Procedure*
Pre"aration o! Materials
27
There were ($$ copies of the -uestionnaire which contains the four parts of
survey -uestionnaire. "ppro%imately, twenty bo%es of 0onggol pencils will be prepared
for the utiliAation of the participants during the testing procedure.
E#"eriment Pro"er
Preparaton o# the Partcpant*. The researchers asked their batch mates for
their permission to participate in this study. The subects were given consent
forms, which included various information and data regarding the study. <nly
those who agreed to sign the consent forms were included in the study.
Ad%n*traton o# the Sur+e$ 9ue*tonnare
The -uestionnaire, which contained the combined four parts, were given to the
participants. " ma%imum of D$ minutes were allotted for the participants to
complete their answers. "fter gathering all the completed -uestionnaires from
the respondents, total responses for each item were obtained and tabulated. .n
order to use the 1ikert/scale for interpretation, weighted mean to represent each
-uestion was computed.
!ata gathered were edited, tabulated6encoded, processed and
interpreted6analyAed.
Stat*tca' Treat%ent
The data that were obtained from the instrument used in the survey were treated
independently. The following statistical tools were used in the interpreting the data.
The Lic$ert Scale
.t was used to describe the relevance of the respondentsM answer. The weighted
mean (%) is the sum of the weighted mean (Sfw) (W0) divided by the number of items
(H). This is measured of central tendency or the point where most of the scores cluster.
28
T 8 SW0
H
%eighted Mean
.n order to give -uantities being averaged in their proper degree of importance, it
is necessary to assign them weight and then calculate the weighted mean. .t was used
to determine the ade-uacy of the -uestionnaires.
Weighted mean is the average wherein every -uantity to be averages has a
corresponding weight. These weights represent the significance of each -uantity to the
average. To compute for the weighted mean, each value must be multiplied by its
weight. =roducts should then be added to obtain the total value. The total weight should
also be computed by adding all the weights. The total value is then divided by the total
weight.
Standard &eiation
The method was used to gain an indication of the spread of observation about
the mean. The researchers measured the scatter observation. +tandard deviation is
defined as the s-uare root of the arithmetic mean of the s-uared deviations
(www.animatedsoftware.com6statgios).