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CAPLE: Creating A Positive Learning Environment

Overall goal of the CAPLE project

The CAPLE project aims to work with clinical staff to improve teaching and learning, and the overall clinical workplace atmosphere to make a positive environment for learning for all.

Welcome to the CAPLE project website, and thank you for your interest. If you would like to know more, please contact the researchers

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Staff researchers

Lynley Anderson

PhD MHealSci DipPhysio

Lynley Anderson (profile photo)Lynley Anderson is an Associate Professor in the Bioethics Centre, University of Otago. She convenes the Professional Development curriculum for second- and third-year MB ChB students. She is the incoming chair of the Health Research Council Ethics Committee.

She has experience in code writing for the Australasian College of Sports Physicians, the NZ Physiotherapy Board, and the NZ medical student code of conduct.

Her research areas include consent in surgery, sports medicine ethics, professionalism, and research ethics.

Althea Blakey

PhD MHealSci (Dist) BHealSci Cert.Couns

Althea Blakey (profile photo)Althea (Alfie) Blakey came to work in NZ in the mid-1990s. Since this time she has worked at Southern District Health Board for 10 years in Radiation Oncology and has taught on the MB ChB program since 2010.

She is currently also working as a Postdoctoral Fellow at the Bioethics Centre.

Her research interests include clinical teaching, developing student thinking, developing teacher and student values, small group teaching and professional development of medical and clinical teachers.

Kelby Smith-Han

PhD MHealSci BA

Kelby Smith-Han (profile photo)Kelby is a Postdoctoral Fellow for The Department of Anatomy and Otago Medical School, and a Teaching Fellow for Otago Medical School. Kelby has been teaching on the MB ChB programme since 2007.

Kelby’s research focuses on the process of how medical students become doctors through interacting with the formal, informal and hidden curriculum.

Specifically, this includes the socialisation of medical students, medical student identity, the clinical experience of medical students, student support, health workforce shortage and the hidden curriculum. Further interests include facilitating small group learning, using discussion as an approach to teaching, and reflective practice.

Emma Collins

RN MN BEd DipTchng PGCert Higher Ed

Emma Collins (profile photo)Emma is an experienced Paediatric nurse in an inpatient as well as community setting at various locations throughout New Zealand and abroad.  She has been working in the undergraduate nursing programme since 2011 and is now a senior lecturer specialising in paediatric nursing, research, professional practice and sociopolitical practice.

Her areas of interest include paediatric nursing, health informatics, ePortfolios and Postgraduate Nursing Education.

She actively supervises a number of students on clinical placement and is passionate about students reaching their potential in their clinical experiences.

Liz Berryman

BHSc (Nursing) PgDipHSc MHSc

Liz Berryman (profile photo)Liz Berryman is a fifth-year medical student at the Dunedin School of Medicine, University of Otago. She has been the past president of Otago Medical Students' Association and the New Zealand Medical Students' Association, and is a current New Zealand Medical Association board member.

She has a background in Emergency and Family Medicine, completing a Master of Health Science in Nursing before starting her medical programme. She is passionate about student wellbeing and family medicine. 

Tim Wilkinson

MB ChB MClinEd PhD MD FRACP FRCP

Tim Wilkinson (profile photo)Tim Wilkinson is director of the MB ChB programme, Professor in Medicine and Associate Dean (Medical Education) at the University of Otago. He also works as a consultant physician in geriatric medicine.

His research interests are assessment of clinical competence and performance, workplace learning, selection into medical school, and professionalism.

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Summary

Learners (students, trainees, any staff member undergoing on-going learning) in the clinical workplace commonly describe mixed experiences in their interactions. Experiences that are more negative are described in detail in the international and national literature.

Locally, recent media reports from the New Zealand Medical Students Association (NZMSA), and the Royal Australasian College of Surgeons (RACS) support what is found in the wider literature; that the impact of negative experiences on any learner can be significant; from doubts about career choice, failure to learn, stress and longer term mental health issues such as depression. Such experiences can affect any person in the work place and can come from a variety of people in the workplace.

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Costs to the workplace from mistreatment

There are a number of tangible costs associated with mistreatment in health care. These include the significant toll on those directly mistreated, but also other staff, the patient and the wider clinical workplace and institution. Costs include (and are not limited to):

  • Student costs: career and speciality doubts, failure to learn, potentially poor skill base, stress, acute and chronic mental health issues, fostering negative intergenerational behaviours, failure to learn good teaching methods to teach, and pass on to the next generation.
  • Staffing costs: staff attrition, costs of recruitment and orientation of new staff, absenteeism, poor or non-productive relationships, demotivation and dissatisfaction.
  • Patient costs: actual patient harm and overall heightened risk of harm and error, poor satisfaction with clinical service, potential bad press/media attention from patient complaints, lack of continuity of care and ongoing increase in costs associated with fixing this.6
  • Institutional costs: potential adverse patient outcomes, increased readmission rates,7 poor staff retention, challenges to staff recruitment, poor workforce development, negative media attention related to budget or complaints.
  • Culture costs: contribution to a ‘cycle of mistreatment’ in which those who are treated poorly may go on to treat others similarly and perpetuation of an overall negative behavioural culture.

Each of these costs represents a significant financial and human loss to the institution and the national health budget.

Mistreatment is can be costly to prevent or manage and is notoriously difficult to change long term. An additional complexity in this, is that mistreated learners are more likely to go on to mistreat others, and the next generation of staff.1 Thus, mistreatment can escalate and contribute to an overall workplace culture in which mistreatment is rife but accepted as 'normal'2. This persistent, significant problem in our healthcare systems can affect the quality and efficiency of the health service as a whole: for example, mistreatment is a significant causative factor in some adverse patient outcomes, staffing, retention and training issues and overall increasing costs (e.g. readmission, iatrogenic disease)3.

In response to this phenomena, we offer a specialised workplace intervention based on participatory action research into teaching and learning. Known as the CAPLE project, this intervention is currently being implemented in clinical workplaces.

The CAPLE project is designed to help all staff develop and evaluate ways to improve teaching and learning within their specific clinical environments. The project uses a focussed positive approach to values and behaviour change by getting alongside staff, understanding their working environments and supporting them to try new ways to work with learners and others within busy clinical environments. We aim to avoid marginalising staff, making them feel targeted or the often fruitless administration of generic professional development opportunities (which have been shown to be ineffective in many cases and so to perpetuate and exacerbate some behaviours). As issues of mistreatment have been shown to straddle professional divides the CAPLE project staff take an inter-professional approach to include all staff (nurses, doctors, allied health and administrative staff).

The CAPLE project is informed by a significant and up-to-date body of evidence and is fully researched across a range of metrics (student, staff, patient and institution). Our programme utilises a multi-pronged approach of survey and participatory action research (PAR)5 methodologies to develop and implement the programme, and monitor and measure its success.

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What will staff be asked to do in the CAPLE project?

In each CAPLE intervention cycle (3 months) we will:

  • Identify and work closely alongside 12 (approx.) identified clinical staff members from a targeted clinical area.
  • Ask all staff to fill in an atmosphere survey to assess what people think of working in their clinical area.
  • Offer a range of evidence-based interventions initially in the form of workshops from which the 12 key participants will select 4-5 according to the needs of that particular work environment (e.g. ‘offering students effective feedback under time pressure’).
  • All clinical staff within the clinical area can come to these workshops, and they will be repeated so that we can get maximum attendance.
  • Evaluate the effectiveness of each intervention
  • Provide professional development support (in person and by email) for each of the 12 participants, so that these people can evaluate the effectiveness of their own interactions with learners. These people will be fully supported by CAPLE staff through any learning or values change. This long-term and in-depth contact and support is one of the most significant points of difference of this approach to staff development and we believe will be a positively influential factor in the effectiveness of this research.
  • Ask staff to complete an atmosphere survey again to assess whether there is any change.

In summary, the CAPLE programme aims to:

  • Work with personal values issues as they arise, between researcher and staff member
  • Incorporates a needs assessment, evidence-based, and bottom-up approach for engaging with staff participants and their requirements.
  • Deliver interventions in a manner that participants want (engagement)
  • Focus on creating a positive teaching and learning environment to effectively engage with all staff members to enhance their practice and avoid marginalisation.
  • Measure outcomes to determine the effectiveness of the programme.

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Specific example of workplace costs – negative learning environment

Senior Nurse

Habitual mistreatment of a student or staff member in the workplace can significantly impair productivity and performance on a local level and for the institution itself7. The exact effect of one act of mistreatment is context-dependant and therefore difficult to quantify. However, research done in this area allows us to report a conservative estimate of the loss of efficiency and productivity on a workplace following the chronic mistreatment, and subsequent resignation of one senior nurse staff member. This financial estimate does not take into account any potential costs of medical error (etc.) that can also occur as a result of mistreatment.

Should a staff member resign as a result of workplace mistreatment, there will then be extensive and additional consequences for the person and institution. For example, senior nursing staff are invaluable for the experience, efficiency and knowledge base that they bring to a department11. An incident of ongoing negative behaviours and following unexpected resignation can have the following additional costs to an institution, and a person, should this be the case:

Total costs of one senior nurse staff member being mistreatment and resigning as a result (conservative estimate) = NZ$289,263.00

Loss of staff efficiency Cost
Table 19. Institution: Financial cost to DHB of loss of efficiency per year resulting from the resignation of one senior nurse due to mistreatment (in NZ$).
Mistreated person (Senior Nurse, NZNO Grade 4)
50% of wage = 50% of NZ$83,292
NZ$41,646.00
Other employees in direct contact (e.g. 4 × Grade 3 Nurses)
33% of wage, each = 30% of NZ$78,749 × 4
NZ$104,997.00
Other employees in slight contact (e.g. 8 × Grade 3 Nurses)
20% of wage each = 20% of NZ$78,749 × 8
NZ$125,998.00
Perpetrator – Can vary greatly; 20% at least.
If more senior nurse at higher Grade 5 = 20% of $87,834
NZ$17,556.00
Total (conservative)
NZ$122,563.00

As a result of mistreatment of one senior nurse and his or her resignation, the following related costs have also been calculated:

Event Cost
Table 2. Other quantifiable costs of mistreatment in the clinical workplace10.
Absenteeism NZ$13,924
Replacement costs of staff member NZ$15,000
Investigator's time for grievance investigation NZ$4,220
Local and line management time NZ$3,694
Higher management time NZ$5,200
Disciplinary process (hearing, solicitor) NZ$7,560
Witness interview costs NZ$2,400
Total (conservative)
NZ$51,998
Event Cost
Table 3. Specific costs of recruitment.
Locum cover, 2 months (wages at 1.25 × NZNO10 rate) NZ$83,292 × 1.25 = 104,115 ÷ 12 × 2 NZ$17,352 (NZ$3,470 more than budgeted)
Recruitment / orientation and training new staff member (conservative) NZ$14,000
Total
NZ$31,352

Percentage figures taken from extensive research10 and given in New Zealand dollars.

Other costs of mistreatment are less quantifiable but nevertheless have a significant impact on the efficiency of the workplace.

Other less-quantifiable costs

Staff costs: Bullied staff member
  • Loss of livelihood
  • Mental health costs
  • Counselling costs
  • Family costs (mental health, etc)
  • Family costs—while seeking new employment
Staff costs: Other staff
  • HR input
  • Mediator input
  • Legal costs
  • Staff turnover costs more generally
Student / learners: Costs to service and learning institution
  • Lack of support and/or leadership from bullied person (is a senior staff member)
  • Loss of learning experiences from bullied staff, and others
  • Involvement of learning institution in disciplinary action if students involved
Patient
  • Lack of skill base of senior nurse
  • Staff who are unhappy are less likely to give less than 100% to a patient
  • Staff who are in a state of retraining
  • Error rate increases and associated readmissions / morbidity
Institution
  • Negative media attention
  • Public relations costs
  • Error rate increases and associated readmissions / morbidity

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Alternative approaches

There are a range of alternative options that an institution might choose as a way to approach mistreatment of learners or other staff.

Alternatives have associated problems and risks:

Approach Problem / risk
  • Deny there is a problem
  • Ignore the problem
  • Hope that it will go away on its own
  • Hope that a staff member will leave
  • Ongoing financial costs via inefficiency and loss of productivity
  • Opening institutions up to complaints
  • Negative media attention
  • Personal grievances (NZ Health and Safety at Work Act, 2015)
  • Ongoing intergenerational behaviours
  • Tell learners and staff that it is 'just the way so-and-so is' or that they need to 'toughen up'
  • Threatens the viability of the clinical workplace as a place for learning and sets learners up to fail
  • Do a survey or write policy to make people feel better but ignore the results
  • Risks alienation of staff in the long term
  • Negative attention for management
  • Refer the problem to human resource department
  • Human resources departments may lack staff with specific expertise that long-term positive values and behavioural change might require7
  • May exacerbate behaviours if wrong approach
  • Initiate a training programme that seems worthy, for all staff
  • Any professional development activity presented by an 'outsider' can easily risk staff disengagement / intolerance by implication of 'lack'12
  • Initiate programmes that target individuals
  • Risks marginalising that person, escalation of their behaviours and exacerbation of the problem and further intergenerational mistreatment behaviours
  • Initiate programmes that focus on one professional group only
  • Risks missing other professions that can contribute to the problem and the solution

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Unique value proposition

The CAPLE project differs from other interventions because it:

  • Is a research-informed model for culture change within large DHB organisations faced with ongoing non-productive interpersonal behaviour between staff and towards students
  • Is fully researched across student, staff, patient and institutional metrics, yet also aims to be flexible to respond to staff needs
  • Offers a multi-disciplinary approach that recognises the importance of all health care disciplines and their contribution to the culture of an institution
  • Will improve the research capacity of staff in the target clinical area through their involvement in this multi-pronged approach of survey and participatory action research
  • Will improve the skill base of clinical staff in their teaching role and improve the research capacity of participants
  • Utilises a research team that brings a mix of experience in medical and nursing education research, health professional teaching, clinical experience and specific skills of staff development (e.g. values and behaviour change).
  • Is a joint project between a medical and nursing school, with researchers from a number of health professions.  The CAPLE team utilises an approach that takes into account all contributors to the culture of a targeted area.
  • Has a student member on the CAPLE team to ensure our interventions remain relevant and student focused.

Potential stakeholders

  • District Health Board leadership
  • Ministry of Health
  • Health Workforce New Zealand
  • Health Quality and Safety Commission
  • Health and Disability Commissioner
  • Otago Medical School
  • Auckland Medical School
  • Otago Polytechnic and nurse education programs nationwide
  • Associations and unions
  • Allied health professional education programs nationwide


Pilot intervention adopters

One clinical ward within the Southern DHB, September 2016, selected solely due to the proximity to the researchers.

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References

  1. Kapur, N. Mid-Staffordshire hospital and the Francis report: What does psychology have to offer? Psychologist. 2014; 27: 16-20.
  2. Wilkinson T., Gill D.,Fitzjohn J., Palmer C., Mulder R. The impact on students of adverse experiences during medical school. Medical Teacher, 2006; 28(2).
  3. http://www.uptodate.com/contents/hospital-discharge-and-readmission [downloaded 26 Aug 2016]
  4. Herr K and Anderson G. The Action Research Dissertation: A guide for students and Faculty. 2014; London: Sage.
  5. McGregor F. Bullying - The Perspective of the Accused. In: The Handbook of Dealing with Workplace Bullying. 2015, Surrey: Gower Publishing Ltd.
  6. Bell, S.K., Delbanco, T., Anderson-Shaw, L., McDonald, T.B. and Gallagher, T.H., 2011. Accountability for medical error: moving beyond blame to advocacy. Chest Journal, 2011; 140(2), 519-526.
  7. Blakey, A. Cultivating student thinking and values in medical education: What teachers do, how they do it and who they are.  Unpublished Doctoral Thesis, 2015; University of Otago, Dunedin, NZ.
  8. Vincent CA, Coulter A. Patient safety: What about the patient? Quality and Safety in Health Care. 2002; 11(1): 76-80.
  9. Tee S, Özçetin Y, Russell-Westhead M. Workplace violence experienced by nursing students: A UK survey. Nurse Education Today, 2016; 41:30-5.
  10. Einarson S, Hoel, H., Zapf D. and Cooper C. [Eds.] Bullying and Harassment in the workplace [2nd Ed.]. 2011; Florida: CRC Press.
  11. http://bullyonline.org/old/workbully/typical.htm [Retrieved Sep 9 2016]
  12. Longo J. Bullying and the older nurse. Journal of Nursing Management. 2013; 21(7):950-5.
  13. Webb G. Understanding Staff Development. Oxon: Routledge; 2012.
  14. Roff S. McAleer S., Harden, R, Al-Qahtani, M., Ahmed, A., Deza, H., Groenen, G. and Primparyon, P. Medical Teacher, 1997; 9(4), 295-299.
  15. Einarsen S., Hoel H. and Notelaers G. Measuring exposure to bullying and harassment at work: Validity, factor structure and psychometric properties of the Negative Acts Questionnaire-Revised. Work & Stress 2009; 23(1), 24-44.

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