6
External Factors
Session objective: To discuss external factors decision makers need to be aware of when selecting paths for the role of learners in the health system during a crisis.
As with the other sessions, Erin Patel, acting chief of health professions education for the Office of Academic Affiliations at the Veterans Health Administration, opened with a reflection on the previous sessions, adding the most recent workshop on cultural safety to the list. The preceding session, she reminded the audience, looked at cultural safety considerations for learners across professions. These earlier sessions laid the foundation for a discussion on external factors that decision makers need to be aware of when selecting paths for the role of learners in health systems during crises. Robert Cain, president and chief executive officer of the American Association of Colleges of Osteopathic Medicine, then framed the discussion using the decision tree as a tool (Appendix B), before introducing the moderator of the session on external factors, Mark Merrick.
EXTERNAL FACTOR CONSIDERATIONS
Mark Merrick, College of Health and Human Services, University of Toledo, moderated and provided opening remarks for the session on external factors. In previous workshop sessions, he said, participants explored the question of whether learners should be considered part of the health workforce, when and whether they should be removed from clinical or community experiences during a crisis, and who makes this decision and how. What particularly struck him during these sessions was how these decisions were largely made at the institutional level, without input from learners themselves, and usually without a plan in place. “We had to wing it,” he reflected, and the goal of these workshop sessions and the decision tree that is evolving, is to ensure decision makers do not have to wing it in the future.
In this session of the workshop, speakers explored external factors during a crisis. Instead of focusing on learners’ individual needs or the institutions’ responsibilities, this session looked through the lens of stakeholders concerned with public safety, a prepared health care workforce, and quality of care. For example, the decision to keep learners in or remove them from clinical care environments could have implications for patient care: trainees may improve access to care during times of staff shortages, but they also may not be fully trained or prepared for the tasks they are asked to do. Furthermore, learners’ experiences (or lack thereof) in a clinical setting during a crisis may affect their development of competencies and their credentialing as a health professional. These decisions may have downstream effects on workforce capacity and workforce readiness in the future. Merrick then introduced the roundtable discussants representing accreditation, licensure, and regulation.
Initial Response to COVID-19
Merrick began the discussion by asking each of the discussants to describe how COVID-19 affected or informed the work of their organizations. Barbara Barzansky, cosecretary of the American Medical Association’s Liaison Committee on Medical Education (LCME), starting things off saying accreditors have a responsibility to be prospective. They require institutions to define their outcomes and monitor those outcomes. When the pandemic hit, institutions had to consider new ways to meet their defined outcomes. Without such predefined standards, she said, institutions would have had a more difficult time tracking learning within the educational program.
Veronica Catanese, LCME cosecretary for the Association of American Medical Colleges, built on those remarks saying the LCME secretariat posted guidance documents during the pandemic that emphasized the importance of institutions taking a deliberate look at their competencies and objectives and then finding ways to meet those objectives despite the limitations and challenges. Having clearly defined programmatic objectives and expected experiences for students proved to be a “very valuable tool” for institutions in responding to the pandemic, she noted. Using these objectives, and being able to shape students’ experiences around them, is useful both in crisis and noncrisis times.
Eric L. Sauers, president of the Commission on Accreditation of Athletic Training Education (CAATE), then said, in CAATE’s initial guidance about COVID-19, it chose not to take a position about whether learners should stay in the clinical environment. However, the guidance did emphasize the importance of being respectful of students and their choices, and of early communication with students about what decisions were being made. In addition, the guidance covered standards for distance learning and simulation, new opportunities for telehealth, and the use of binary grading that was deemed unnecessary. Sauers remembered offering “a lot of flexibility” but also making clear that if learners could not access the right types of learning environments, the completion of their program may have to be delayed. The guidance also addressed the immediate concerns around pass rate standards for national boards, said Sauers, and reiterated how CAATE would be monitoring the situation and communicating any changes.
Nancy R. Kirsch, president of the board of directors of the Federation of State Boards of Physical Therapy (FSBPT) New Jersey, then spoke saying one of the main challenges for FSBPT was providing the licensing exam in a way that was accessible but still protected the integrity of the exam. The exam is a critical piece of ensuring learners are competent to practice, she said, and determining who was ready to take the exam and how it would be administered was “one of the main things we were grappling with.”
Alex M. Siegel, director of professional affairs for the Association of State and Provincial Psychology Boards (ASPPB), added to the discussion stating that some jurisdictions require prelicensure psychologists to see a certain number of patients in person and telehealth hours do not count toward the required supervised experience. ASPPB is currently working with these jurisdictions to look at the unintended consequences, he said, noting the effect will not be felt for several years from now when these learners begin to apply for licensure.
Learners as Part of the Workforce
Some nursing schools, said Nancy Spector of the National Council of State Boards of Nursing (NCSBN), asked governors to declare nursing students “essential” so they could be in the clinical environment. This was for two reasons: first, because nursing students needed the in-person experience, and second, because there were staff shortages in the hospitals. NCSBN encouraged schools to participate in academic–practice partnerships and developed a policy brief to make the case for nursing students as essential workers. Another change during the pandemic, said Spector, was the rapid adoption of virtual simulation. Although some programs needed assistance to start using simulation, it is now a tool that could be used again quickly when needed.
Following up on Spector’s comments, Merrick asked other panelists to share their perspectives on learners as part of the essential workforce and how these perspectives shaped the decisions made during the pandemic. Barzansky believed it is critical to consider the level of the learners and to ensure that students “don’t do anything beyond what they’ve been trained to do.” Supervision is necessary to make sure students are given appropriate tasks and to assess and monitor where students are in their competencies so appropriate tasks can be assigned.
Catanese followed saying during the early days of the pandemic, health care workers were inundated with COVID-19 patients, had to deal with insufficient personal protective equipment (PPE), and were being pulled in multiple directions. From both a safety and educational perspective, it was essential to ensure students were only in the clinical environment if there was an adequate level of supervision. Spector concurred, adding that the supervision is also essential for nursing learners, and that in some areas of the country, it was not possible to have learners in the clinical environment because would-be supervisors were overwhelmed. Where it did work, she said, was in places where nursing learners could obtain clinical experience by taking care of non-COVID-19 patients. While there were some delayed graduations, “we are working really hard” to get back on track.
Stakeholders in the Decision-Making Process
Merrick shared his observation that during the early days, some students were eager to “roll up their sleeves” and contribute to addressing the crisis but were not allowed to do so in some cases. He asked the discussants what perspectives they sought when making decisions about learners during the pandemic—whether it was an entirely in-house decision-making process or whether they reached out to other stakeholders for input. Barzansky replied saying LCME reached out to medical schools to see how they were thinking about educational formats, clinical experiences, and assessment methods. After reviewing the schools’ input, LCME considered how these new approaches fit with the accreditation standards and how flexibility could be possible to allow students to meet the curriculum expectations and to graduate on time.
Catanese added that she and Barzansky spoke to about one-third of medical schools’ leadership and had conversations with stakeholders including deans and student affairs groups; these discussions were aimed at looking for common pressure points or places where guiding principles could be helpful.
Early in the pandemic, the worst thing was the “not knowing and the confusion and different kinds of recommendations,” said Kirsch. FSBPT reached out to stakeholders, including state licensing boards, educators, accreditors, students, and employers, to find out what was happening on the state level, who was being allowed in the clinical environment, and what was needed. The organization also held regular webinars to communicate with stakeholders. These meetings allowed FSBPT to reach a much broader group than before, which was a “real positive.” Spector agreed, saying the value of regular phone calls with stakeholders was very helpful in identifying issues and developing approaches for moving forward.
Sauers commented that in addition to its own stakeholders, CAATE looked to peer organizations and governmental bodies to get a sense of who was doing what in terms of clinical placements. The goal, said Sauers, was to be consistent with its own standards while remaining flexible enough for the circumstances. Looking at others’ best practices and rationales was helpful and made it feel “less like we were making decisions in a vacuum.”
Siegel reported that ASPPB pulled together a number of stakeholders in different jurisdictions to determine how to cope with the complicated consequences of the pandemic. For example, he said, a learner may have done their supervised work in Ohio, then moved home to Pennsylvania during the pandemic, and wants to work but is not able to take the exam because the licensing board is not meeting. Siegel added that he is not overly concerned about preparing for the next pandemic, but instead is focused on preparing for “the next hurricane, the next Florida freeze, and wildfires
in California.” These crises can result in shutdowns similar to COVID-19, which can cause “havoc in the supply chain of people finishing their degrees and getting licensed.”
Balance Between Flexibility and Accountability
Lastly, Merrick asked the panelists how they balanced the need to ensure competency of learners with the need to graduate learners and allow them to move into the workforce. “It was pretty easy in the regulatory world,” said Kirsch, “because you have public protection as the guiding mission.” FSBPT sought to “not be a roadblock,” but to facilitate the learning and graduation of physical therapists as efficiently as possible. Siegel echoed this perspective, saying that ASPPB strove to “bend but not break the requirements,” but there are certain criteria that cannot be ignored. Sauers agreed the circumstances required flexibility, and “grinding everything to a halt” would have had many negative downstream consequences for both the learner and the workforce.
As an accreditor, CAATE tried to articulate the accountability it was still expecting for programs, within parameters of flexibility. “We had to be flexible and just put a lot of faith in our peers, as the educators, and assume they were going to … do the right thing,” he said. Barzansky said the LCME standards allow a certain amount of flexibility in the processes schools use to meet the accreditation requirements “even in the best of times,” but it was “a little bit more dramatic during COVID-19.”
Catanese added that LCME did not alter its expectations, but instead it opened the door to collaborate with schools on ways of meeting those expectations through new approaches. In some instances, the changes were things that the schools had been planning to make before the pandemic, and there were adaptations in LCME processes that were pushed forward by COVID-19. Clearly, Catanese concluded, “we would rather not” have had the pandemic, but “some very positive things” came from it.
BREAKOUT GROUPS
Following the panel discussion, workshop participants divided into interprofessional groups to explore one of three questions on various aspects of the decision-making process related to learners in the clinical environment. The leader of each group shared major ideas discussed by the participants of their group.
Group 1: How Do We Protect the Learner’s Educational Experience to Ensure Learner Readiness for Practice After Graduation?
Three themes came up during the discussion, said the group leader, Jonathan Amiel, Columbia University Vagelos College of Physicians and Surgeons. First, having a solid educational infrastructure—meaning, a clear understanding of core required competencies or expectations—made it easier for programs and accrediting bodies to make decisions about how to vary learners’ experiences while still meeting overall educational outcomes. Second, flexibility was critical in the clinical learning environment. Greater challenges were experienced by programs considered “more locked into certain models,” such as time-based blocks or longitudinal integrated clerkships, to ensure learners attained what they needed. Third, frequent multimodal communication with stakeholders was important, and engaging with learners was also high ranking although “not done as fully as it might have been.”
Group 2: How Do We Protect the Public and Patients by Ensuring Competency Is Attained by the Learner?
When thinking about protection of patients and the public, said Reena Karani, Icahn School of Medicine at Mount Sinai, the role of regulators and accreditors is “very clear.” This structure helps learners think through what they need to learn and helps programs know the required expectations. It is the responsibility of the program, continued Karani, to demonstrate that learners attained those competencies and outcomes. While the pandemic provided a “tremendous opportunity to spark innovation,” regulators and programs have continued to put forward clear descriptions of expected learner competencies to protect the health of the public.
Group 3: How Do We Balance the Needs of Institutions with the Needs of Learners, Educators, and the Public and Patients?
Participants in the third group spoke about many of the same issues as the first and second, said VanHoose, but added the concept of justice—justice for the institution and justice by the institution. More specifically, there was a need during the pandemic for flexibility to align activities with the institutional mission, as well as flexibility to adjust the products and services that are provided. Furthermore, institutions have a responsibility to provide justice to the learner and other stakeholders by adapting to their needs. A member of her group suggested supportive competency-based education might be a means for accomplishing these outlined aims.
In closing, Merrick remarked about the degree of consistency there was in the session conversations despite all the inconsistencies experienced during the pandemic. The level of agreement may have been because, regardless of the profession or role, many were thinking about the same things. These included learner competence, learner confidence, learner safety, and protecting the needs of the public. While all had these foci, said Merrick, each group presenting today found its own way to address these challenges. To him, the theme of the session can be summed by “consistency of intent but different approaches to getting there.”
