Published online: 3 September, TAPS 2019, 4(3), 79-90
DOI: https://doi.org/10.29060/TAPS.2019-4-3/OA2088

Ardi Findyartini1, Justin Bilszta2, Jayne Lysk2& Diantha Soemantri1

1Faculty of Medicine, Universitas Indonesia, Indonesia; 2Melbourne Medical School, University of Melbourne, Australia

Abstract

Introduction: Transnational faculty development initiatives (FDIs) constitute a strategy to improve the quality of the teaching staff in medical schools. This study evaluates feedback from participants of an FDI designed as part of a collaborative transnational partnership between researchers of an Australian and an Indonesian medical school.

Methods: The FDI was a three-day program that explored four major topics: effective clinical teaching, methods of teaching and supervising in clinical settings, assessment of clinical learners and clinical education in practice. These topics were identified through comprehensive needs analysis and curriculum blueprinting exercises. Each participant (n= 27) submitted one piece of reflective writing and one critical appraisal or teaching/assessment assignment on each topic. Using a thematic analysis approach, two researchers independently reviewed each participant’s written assignments to identify emerging themes.

Results: Five core themes were identified. Most revolved around the benefits of the training, especially the learning issues that the participants identified during the FDI and how they could be applied to their local contexts. Additional themes covered participants’ views on the delivery of the FDI and cross-cultural implications. Peer observation of teaching, qualitative assessment and feedback provision were also significant issues raised by the participants.

Conclusions: This study presents important lessons for cross-cultural adaptation of best practices in the development and delivery of transnational FDIs.

Keywords:         Faculty Development, Transnational, Collaboration, Cross-cultural, Clinical Teacher

Practice Highlights

  • Cross-cultural factors need to be considered when developing transnational collaborative FDIs.
  • Methods of delivery in transnational FDIs should be interactive, collaborative and allow participants’ active engagement and participation.
  • Transnational collaborative FDIs enrich participants’ contextual understanding of best teaching practices.

I. INTRODUCTION

Faculty development initiatives (FDIs) refer to any systematic process(es) launched by an educational institution to develop the capabilities and capacities of their staff in all areas of their role: teaching, education, research and scholarship, and leadership (Steinert, 2014). FDIs can be informal or formal learning opportunities and can involve individuals and/or groups of academic staff. All forms of FDI are deemed vital, and the approach can be tailored according to institutional and/or individual needs (Steinert, 2010, 2011, 2014).

Clinical teachers are expected to possess adequate and up-to-date medical knowledge and clinical skills, develop positive relationships with students, foster supportive learning environments, practice good communication skills and show enthusiasm (Sutkin, Wagner, Harris, & Schiffer, 2008). Good clinical teachers should provide sufficient support, allow students to think for themselves, provide feedback that stimulates reflection and identify areas of improvement or development (Kikukawa et al., 2013). A systematic review by Steinert et al. (2016) on FDIs highlighted the importance of training clinical teachers in many settings. Although most institutions agree on the attributes of good clinical teachers, different institutions have different priorities. For example, Kikukawa et al. (2013) explained that medical knowledge and clinical skills attributes are less emphasised for clinical teachers in Japan than those in a western setting.

Much research has been undertaken on the development and implementation of the education curricula for transnational medical and health professions (e.g. Castelo-Branco et al., 2016; Waterval, Frambach, Driessen, Muijtjens, & Scherpbier, 2018) and FDIs (Burdick, Amaral, Campos, & Norcini, 2011; Burdick et al., 2010; Yoon et al., 2016). These studies have identified interesting aspects such as the relevance of FDI content, the variation in teaching and learning expectations and methods and the appropriateness of the FDI design given participants’ needs, culture and context (Steinert et al., 2016). Scholars have confirmed that it is critical to consider cross-cultural and contextual issues when conducting FDIs and for translating the lessons learned into practice (Altbach, 2013, Chapter 24; Hodges, Maniate, Martimianakis, Alsuwaidan, & Segouin, 2009).

In 2015, a formal collaboration (Partnerships in Clinical Education) was established between the Faculty of Medicine, Universitas Indonesia (FMUI) and the University of Melbourne (UoM) Medical School’s Excellence in Clinical Teaching (EXCITE) programme; it is described elsewhere (see Bilszta, Lysk, Findyartini, & Soemantri, in press). One of the outcomes of this collaboration was the development of a high-quality FDI for clinical teachers from FMUI. Further, this new FDI was delivered to a group of invited clinical teachers so that experienced facilitators could observe the process and model the delivery of the new academic content along the same lines.

While FDIs in various and pertinent forms are necessary for clinical teachers, transnational collaboration in developing and conducting FDIs (as reported in the present study) is expected to strengthen the contextual best practices of such programmes. However, previous studies on transnational FDIs (e.g. Burdick et al., 2011; Burdick et al., 2010; Yoon et al., 2016) have not explored the cultural issues in clinical education or in FDI methods despite arguments that favour adapting globalised practices in medical education to the local culture and context (Gosselin, Norris, & Ho, 2015). The aim of this study, therefore, is to evaluate the experiences of the clinical education leaders who completed a transnational FDI and identify the relevant cross-cultural issues in the content of the FDI and its delivery method. Accordingly, in the current study, the participants were asked to reflect on their teaching skills during the training and explore whether certain teaching approaches in clinical education could be translated into their settings. In discussing best practices of clinical education, the participants were encouraged to consider potential cultural issues that might influence the implementation of the FDI. The results of this study are expected to add to the understanding of collaborative clinical teacher FDIs.

II. METHODS

A. Context

A long-standing relationship between UoM and FMUI and the need for FMUI to advance the skills and professionalism of its clinical teachers led to this partnership in clinical education. The collaborative FDI project began with a needs-analysis exercise and the development of a training curriculum blueprint, as described by Bilszta et al. (in press). The needs analysis and curriculum blueprinting resulted in the identification of four major topics: effective clinical teaching, methods of teaching and supervising in clinical settings, assessment of clinical learners and clinical education in practice.

The resultant FDI was delivered via a workshop, titled the 1st Advanced Clinical Teacher Training and Training on Trainers Workshop, to a group of invited clinical education leaders. Short interactive lectures, small group discussions based on a collaborative learning approach, role-plays (for peer observation of teaching [PoT]) and individual and group reflections were conducted during the 3-day workshop in Jakarta in November 2016. The workshop was facilitated by the EXCITE teaching staff in collaboration with local medical education experts. The workshop schedule is described in Table 1. Twenty-seven FMUI clinical teachers (9 male, 18 female; 8 from surgery and 19 from medicine) participated in the workshop. These participants were invited because they had already completed a basic clinical teacher course (CTC) delivered by the FMUI and had served as instructors/tutors or resource persons in the CTC. Despite the small sample of clinical teachers involved, the distribution of the sample was representative in terms of gender and department of origin (medicine and surgery). These participants were selectively invited because they had been identified as possible education leaders.

B. Data Collection

On completion of the workshop, each participant was required to submit eight written assignments through an e-learning platform. Participants were asked to submit two assignments on each of the four major topics: one in-class assignment and one out-of-class assignment (Instructions for each assignment are given in Figures 1 and 2). For the in-class assignment, participants were asked to reflect on the topics being discussed (i.e. what new insights and awareness did they gain from the session; what questions triggered these learnings; how can they use the information to improve their own lesson plans and quality of teaching). For the out-of-class assignment, participants were required to either develop a critical appraisal of a journal article relevant to the topic or develop a learning or assessment activity.

C. Data Analysis

In line with the objectives of the study, participants’ assignments were reviewed not only to detect the cross-cultural issues identified by the participants but also to examine the lessons they learned about teaching, assessment practices and their contextual application. A thematic analysis approach was used to synthesise the qualitative data (Patton, 2002). Each assignment was anonymised so that the reviewers could not identify to whom the assignment belonged. Two of the authors (DS and AF) reviewed the assignments to identify specific patterns and generate a coding system. The codes were translated into appropriate subthemes and grouped into relevant themes. To capture the significance of each theme, the number of mentions of each theme was counted.

DS and AF are medical education experts from Indonesia and have been involved in the FMUI CTC for the past 10 years. Indonesia, in general, is considered to have a hierarchical culture in which the opinions or thoughts of seniors or experts are highly valued. Further, it has been a collectivist culture in which relationships with others and maintaining harmony within the group is considered critical (Hofstede, 2001). In FMUI and its teaching hospitals, where the clinical teachers and the authors work, this culture is, to some extent, still reflected in daily practice. The authors were aware of this ‘lens’ as they reviewed the participants’ assignments in this study.

Day 1
Session 1 – Effective clinical teaching
15 minutes Ice breaker Organiser
30 minutes Interactive lecture 1: Various principles of teaching and learning in a clinical setting Resource person 1 (UoM)
60 minutes Group discussion 1: Reflection on various principles of teaching and learning in a clinical setting Tutors (UoM and FMUI)
60 minutes Plenary: Various principles of teaching and learning in a clinical setting Resource person (UoM)
Session 2 – Methods of teaching and supervising in clinical settings (the clinical supervisor)
30 minutes Interactive lecture 2: Supervising students in clinical practice Resource person 2 (UoM)
60 minutes Group discussion 2: Students’ supervision and mentoring Tutors (UoM and FMUI)
30 minutes Closing of day 1
Day 2
Session 3 – Clinical education in practice (peer observation & peer assessment)
30 minutes Interactive lecture 3: Principles of peer observation and the use of peer feedback Resource person 1 (UoM)
60 minutes Group discussion 3: Role-play (peer observation and peer feedback) Tutors (UoM and FMUI)
60 minutes Group discussion 4: Peer assessment plan, training module development Tutors (UoM and FMUI)
Session 4 – Methods of teaching and supervising in clinical settings (assessing clinical learners)
60 minutes Interactive lecture 4: Principles of competency-based assessment Resource person 3 (UoM)
60 minutes Group discussion 5: Appraisal of various assessment instruments Tutors (UoM and FMUI)
60 minutes Plenary: Competency-based assessments and various assessment instruments Resource person 3 (UoM)
Day 3
Session 5 – Clinical education in practice (peer observation & peer assessment)
60 minutes Group discussion 6: Item development and review (MCQ and OSCE) Tutors (UoM and FMUI)
60 minutes Group discussion 7: Assessors’ standard setting (using video) Tutors (UoM and FMUI)
60 minutes Plenary: Workplace-based assessment Resource person 3 (UoM)
Session 6 – Reflection and action plan
60 minutes Group discussion 8: Reflection and action plan on the topics being discussed Tutors (UoM and FMUI)
60 minutes Plenary: Reflection and action plan on the topics being discussed Tutors (UoM and FMUI)
60 minutes Closing and explanation of assignment Organiser

Table 1. The 3-day workshop programme

In-class assessment:

For each topic area, participants are required to generate ‘artefacts’ that have been developed during the interactive lecture or group discussions, and this can include social media posts (e.g. Facebook, Snapchat or Twitter). Using these artefacts, participants must reflect on the key learnings from each topic area and how they will use these to modify/develop their clinical teaching practice.

EXAMPLE: As a group, participants might develop agreed criteria to define effective clinical supervision. Using the agreed criteria to define effective clinical supervision, a participant may comment/reflect on how they might apply these criteria to their own supervisory practice.

EXAMPLE: Each participant generates an MCQ and gets feedback from a colleague about the question and response options. Using this MCQ, a participant may comment/reflect on the development of their question and justify any changes made.

EXAMPLE: On completion of the microteaching session, a participant could take a photo which represents what they learnt from completing this activity, post this to Facebook or Snapchat and comment on how they might use this activity in their work place.

EXAMPLE: A participant might develop an action plan outlining how they intend to collect peer feedback on a teaching and learning activity they deliver regularly and reflect on the areas within their teaching they want feedback on and why they want feedback in these areas.

EXAMPLE: A participant might comment/reflect on Facebook or Snapchat post made by a colleague about an activity completed during one of the teaching sessions.

Time will be provided at the end of each interactive lecture and group discussion for the development of these reflections. Reflection prompts will include the following questions:

· What new insights or awareness arose for me in this session

· What questions or puzzlements did this session trigger for me?

· How can we use this information to improve/critique own practice?

· How can we use this information to scale up the quality of teaching?

· How can we use this information to understand or to direct our own lesson planning and design?

Figure 1. Instruction for in-class assignment

Out-of-class assessment:

Each participant is expected to:

· Effective clinical teaching

o Appraise and develop at least 500 – 1000 words summary based on at least 1 article discussing about effective teaching methods in clinical setting (the article is published in the past 5 years). The appraisal should be concluded by why and how the participant would implement the method in his/her setting.

(The topic can be on undergraduate and postgraduate clinical education and according to clinical setting in which the participant has been involved).

· Effective clinical supervision

o Develop a summary of participant’s experience in dealing with struggling students and how the participant will supervise and mentor the student(s). The participant should reflect on how he/she would supervise and mentor the student: the strengths, the weaknesses and actions for improvement. The participant should add at least 1 reference (published within 5 years) to support the reflection.

· Principles of clinical assessment

Participant may choose one of the following assignment for this topic:

o Appraise and develop at least 500 – 1000 words summary based on at least 1 article discussing assessment in a clinical setting (the article is published in the past 5 years). The appraisal should be concluded by why and how the participant would implement the method in his/her setting.

o Develop 1 rubric of assessment explaining aspects/criteria to be assessed, the description of each aspect/criterion, and the scoring and its description. Please elaborate the justification (around 500 words) that the instrument developed by the participant has fulfilled principles and relevant criteria for each assessment method. Relevant reference(s) can be used to support the justification.

o Develop 3 MCQs fulfilling criteria of good MCQs or 1 station OSCE and its scoring sheet. Please elaborate the justification (around 500 words) that the instrument developed by the participant has fulfilled principles and relevant criteria for each assessment method. Relevant reference(s) can be used to support the justification.

· Clinical education in practice: peer observation and peer assessment

o Record his/her teaching session at the clinical setting. The participant will need to reflect on his/her teaching and seek feedback from the paired participant where possible.

Figure 2. Instruction for out-of-class assignment

III. RESULTS

The following five core themes, each with its own subthemes, were identified from the thematic analysis: lessons learned and teaching beliefs in relation to clinical teaching; cross-cultural issues in collaborative FDI; contextual education practice; methods of delivery used in the FDI; and cultural issues in supervision of clinical practice (see Table 2). Both reviewers reached consensus on the themes in one iteration of analysis. Minor disagreements in coding were resolved through discussion.

Theme Subtheme Number of comments for each theme
Lessons learned and teaching beliefs in relation to clinical teaching 82
Assessment for learning and of learning
Feedback in clinical supervision
Effective clinical teaching
Successful PoT
Importance of valid and reliable assessment
Cross-cultural issues in collaborative FDI 15
Cross-cultural application of teaching and assessment approaches
  Hierarchical barriers in cross-cultural application of PoT
Language limitations in cross-cultural FDI
Contextual education practice 15
Lack of feedback culture
Limited ability to provide specific qualitative data in assessment
Contextual application of teaching and assessment methods
Cultural issues in supervision of clinical practice 5
Influences of cultural issues in clinical practice on teaching
Teaching cultural issues in the clinical setting
Methods of delivery used in the FDI 8
Peer discussion within collaborative learning
Role-playing through micro-teaching activity

Table 2. List of themes and subthemes identified

A. Lessons Learned and Teaching Beliefs in Relation to Clinical Teaching

Participants indicated that they benefited from the training in many ways, and they mentioned the lessons learned in their assignments. More than half of the subthemes fell under this category. The subthemes ranged from effective clinical teaching to the importance of valid and reliable assessment.

This core theme had four main subthemes, and participants identified the important lessons learned under each subtheme. For example, under the subtheme of successful PoT, participants reflected on the importance of self-reflection, a partnership between the observer and the observe, and a supportive, respectful environment.

“From peer observation, the clinical teacher can reflect their teaching, set a clearer learning goals for the student, could improve   their own teaching skills after peer feedback and repeated observation.”

(IC-PO-06)

“I learned that peer observation is quite a complex process, involving partnership and trust among the observer and observee; the judgement was based on a set of agreed criteria.”

(IC-PO-09)

On the subtheme of assessment, participants reported a growth in their understanding of assessment purposes, especially the difference between assessment for learning and assessment of learning. The FDI also increased their awareness of the importance of valid and reliable assessment.

“We also learnt that assessment consisted of assessment for learning (formative) where there is rich of feedback and assessment of learning (summative) that is characterised of limited feedback.”

(IC-Ass-08)

“From my experience with the OSCE in psychiatric clinical skills, we have developed the checklist but in my opinion it still difficult to make it objective… I learn from the session, that we could improve the objectivity by listing the behaviour that we want to observe.”

(IC-Ass-15)

The importance of student-centred feedback was a frequently cited subtheme in the lessons learned in relation to clinical supervision. On the subtheme of effective clinical teaching, participants discussed some influencing factors such as understanding the learning process, understanding medical teachers’ competencies as well as students’ background, and the importance of preparation before teaching.

“Teaching is facilitating students’ construction of knowledge… The teacher is responsible for recalling prior information as the foundation of learning and give feedback to refine the knowledge that has been constructed.”

(CT-I-03)

“The ideal educators should have competent medical/clinical knowledge, capable of clinical and technical skills competence, conducting clinical reasoning, having positive relationships with students and supportive learning environment, communication skills and enthusiasm.”

(CT-I-15)

“In every teaching process in the clinical setting, the target of teaching and competencies to be achieved need to be determined first, also the teaching methods should be adjusted according to the limited time available…”

(CT-I-10)

B. Cross-cultural Issues in Collaborative FDI

Interestingly, though the assignment instructions did not ask participants to comment specifically on cross-cultural issues, these issues were still raised. An example of a cross-cultural issue that was identified pertained to language. It is summarised in the following comment.

“[When we have to mark a Melbourne medical student in a video conducting history taking], for us as the Indonesian teachers, [we] thought that the clinical reasoning and the communication of the Melbourne student is already good or excellent. Maybe this is because we, Indonesian, are not English native speaker…”

(IC-Ass-16)

The other cross-cultural issue was related to the application of certain concepts or practices of teacher development. Questions were raised about transposing activities from an Australian context directly into an Indonesian context. Most comments under this theme discussed whether PoT, which is regularly exercised in Australia, was suitable for Indonesia. PoT has been defined as a means to assure the quality of teaching and learning process in higher education which involves teachers as observers who provide feedback to their peer teachers on teaching and learning practice (Hammersley-Fletcher & Orsmond, 2004; Shortland, 2004). Some of the identified barriers were hierarchical; that is, the participants noted that because of the cultural boundaries between the senior and junior staff, providing feedback to someone older may be seen as impolite or unusual.

“At the beginning, I thought this practice would be very difficult in the implementation, since it is not so commonly used in our institution and even we are quite afraid to comment on our colleague’s style of teaching. I was thinking it may lead to a feeling of being evaluated or judged and it may not so comfortable for certain people, in particular for colleagues who are more superior (senior).”

(IC-PO-14)

“The Indonesian culture does not seem to allow teaching staff to critique each other… Critique, or more precisely, feedback is commonly misinterpreted as an ‘insult’ and can result in lack of harmony between each member of staff.”

(IC-PO-23)

Cross-cultural issues seemed to influence not only PoT but also the models of teaching and assessing students’ performance. One participant highlighted the differences in scoring between the FMUI clinical teacher and one from UoM’s in the following words.

“Our group during the session discussed the difference of the scores given for the student. I was more stringent in giving the score, although at the end I knew that my scoring was more in line with the standards of Melbourne Medical School for students at that particular level…”

(IC-Ass-04)

C. Contextual Education Practice

While the participants learned many lessons, they had questions about how the theory and concepts learned could be applied in real educational settings, specifically in Indonesia. Contextual issues were identified in the application of teaching and assessment methods appropriate to an Indonesian setting.

“I think those theories need to be understood contextually. I also think that the most important thing is to be able to implement them adaptively according to teaching learning situations.”

(CT-I-01)

“This is a significant challenge for Faculty of Medicine Universitas Indonesia in implementing programmatic assessment, since the school has limited number of available faculty members.”

(OC-Ass-04)

Applying theory, concepts or best practices from Australia called for careful consideration of the local context and cultural issues in an Indonesian clinical setting. Participants also acknowledged the lack of feedback culture in their institution and their inability to provide qualitative data during assessment.

“Most assessments rely on numbers… The greater challenge, I think, would [be]… in encouraging the clinical teachers to write down their comments or feedback on the evaluation sheet. Our experience with the use of Mini-CEX (Mini Clinical Evaluation Exercise) shows that most assessors would only provide general feedback such as ‘excellent’, ‘good’ or ‘needs further improvement’ without further written deliberation on the Mini-CEX form due to time constraints.”

(OC-Ass-01)

D. Cultural Issues in Supervision of Clinical Practice

Certain culture issues in the clinical practice environment influence how teaching and supervision are delivered. Clinical teachers should be aware of such matters in order to provide targeted teaching and feedback. Further, clinical teachers should teach or stimulate discussions on the sociocultural aspects of patient problems.

“In sexual transmitted infection clinic… students are often uncomfortable examining patients… During clinical supervision, this condition can be ‘read’ by the clinical supervisor. This situation becomes material for feedback from teachers to students. Some students do not like these patients because they consider high-risk sexual behaviour as intolerable sin.”

(CS-I-25)

“For example, in the discussion, the patient and partner sexual behaviours will be discussed. How can the student maintain confidentiality of the patient’s disease, when [at the same time] the student has to treat patient’s sexual partner too?”

(OC-Ass-08)

E. Methods of Delivery Used in the FDI

A major focus for the FDI participants was observing the delivery of FDI content by experienced facilitators in order to model their delivery process. The methods used in delivering the materials included approaches such as collaborative learning, role-playing and micro-teaching. The participants found those approaches to enhance their learning; moreover, the approaches also encouraged the participants to engage in peer discussion and visualise the application of training materials in real situations of teaching. Participants felt that they may apply the delivery methods used in the FDI when teaching medical students.

“This micro-teaching activity gave the real situation on how we should prepare in a short time for teaching effectively: plan-teach (in short time)-feedback-debrief and reflect.”

(CT-I-07)

“We were given a group work in the form of jigsaw activity. The materials delivered through collaborative methods encouraged us to learn together and share with each other. A very useful method to train ourselves in giving opinions, although they may differ, they can be collated or formulated to reach a consensus.”

(IC-PO-05)

IV. DISCUSSION

This present study aims to evaluate the experiences of the clinical education leaders who completed the transnational FDI between FMUI and UoM. A thematic analysis of the written reflections by the FDI participants highlighted five key themes: lessons learned and teaching beliefs in relation to clinical teaching, cross-cultural issues in collaborative FDI, contextual education practice, methods of delivery used in the FDI and cultural issues in supervision of clinical practice.

According to the faculty development model, the FMUI-UoM FDI training program can be categorised as a formal programme involving workshops and reflections on the participants’ experience (Steinert, 2010, 2011, 2014). The development and implementation of the FDI was based on comprehensive needs analysis and curriculum blueprinting activities, which ensured the appropriateness of the content and the teaching methods. Such needs analysis is deemed necessary to ensure congruence between the content and mode of delivery in the FDI programmes, on the one hand, and the needs of clinical teachers, on the other hand, who generally tend to be very busy and work in either community-based or hospital-based settings (Behar-Horenstein, Garvan, Catalanotto, & Hudson-Vassel, 2014; Damp et al., 2016; Houston et al., 2004).

The participants of this study identified many relevant lessons from each of the four FDI topics. While describing the lessons learned in their written assignments, they also explored their teaching beliefs, particularly in relation to the materials delivered in the FDI. Teaching beliefs are known to significantly influence teachers’ behaviour in the classroom (Samuelowicz & Bain, 2001; Taylor, 2003). Reflecting on their teaching beliefs is also known to help clinical teachers understand the information discussed in the training program and contextualise it according to the levels of experience and competence of the students and the clinical practice context (Taylor, Tisdell, & Gusic, 2007).

The participants of the FDI appreciated the variety of the delivery methods used. They also noted that delivery methods such as collaborative learning and micro-teaching were used appropriately, and they contributed to enhancing their learning and positive attitude towards peer discussion. It is likely that the participants could relate more with these methods because they have been already implemented in the clinical teacher training at FMUI. As programme developers, the present authors were aware of the importance of engaging participants in the training as much as possible. Since this was an advanced training programme in which participants were expected to share their deeper understanding of the given topics, collaborative learning and peer discussion were used. These methods are known to strengthen the experiential learning process and initiate the development of a community of practice among participants (Steinert, 2010). Peer discussion during the training also enabled group reflection, which is acknowledged as a critical process for clinical teachers seeking to actively improve their teaching (van Lierop, de Jonge, Metsemakers, & Dolmans, 2018).

While findings on teaching beliefs and methods of delivery in FDI have been reported extensively, the other three themes – cross-cultural issues in conducting FDI, contextual education practice and cultural issues pertinent to supervision in clinical education – represent the salient factors of this study, which highlight the importance of cultural awareness in collaborative FDI. When discussing cross-cultural issues in conducting FDI, participants pointed to the language issues in the training. Nonetheless, they still found the training to be engaging and relevant to their needs. Collaborative teacher training involving resource persons and participants from different countries should seriously consider and address the language problem (Yoon et al., 2016). Other related issues found in this study pertained to communication and the cultural competence of resource persons and participants in the FDI programme. Interaction between resource persons and participants and among participants from different cultural backgrounds calls for an understanding of how important messages in an FDI can be delivered, discussed and received. For example, Slootweg et al. (2016) found that some cultural factors may influence how clinical teachers speak up in team meetings in a postgraduate training setting. They noted that meetings can be more fruitful if they have clear aims, a flexible structure and a positive environment to express ideas and provide feedback (Slootweg et al., 2016). These suggestions are also relevant to the FDI environment in which participants may need to ask questions and express ideas openly, and resource persons may need to identify and discuss certain ideas further. Given the hierarchical and collectivist culture in Indonesia (Hofstede, 2001), promoting such interactions during FDIs is an important mechanism, whereby resource persons (considered the experts with ‘power’) can encourage open discussions, and participants can freely present their views, without being judged by other fellow participants. To facilitate the process, in this study, the FDI was deliberately designed to include local medical education experts. They were exposed to various methods of learning, which enabled them to revisit their understanding, ask questions and share arguments in a friendly and positive environment.

Peer-teaching observation was viewed as a new concept by most participants in the training. The FDI participants highlighted that implementing PoT in an Indonesian setting could be a challenge. PoT can be broadly categorised into three models: evaluation, developmental and peer-review (Gosling, 2002). When PoT is used as part of a teaching audit, a teacher as the observer and the observee may feel threatened. On the other hand, a more friendly and constructive process occurs when PoT focuses on teachers’ development. The development model of PoT (i.e. teaching-observation-reflection-feedback), involving peer teachers and education experts, is reported to increase critical reflection and applied feedback among the teachers involved, which are highly relevant to improving the quality of teaching practice (Yiend, Weller, & Kinchin, 2014). Sullivan, Buckle, Nicky and Atkinson (2012) noted that positive feedback from clinical teachers involved in PoT in an undergraduate paediatric teaching was viewed as non-threatening and valuable for promoting insights and reflection.

In the present study, PoT was considered an evaluative process by the participants. They noted that providing feedback especially to senior colleagues could be very challenging given the hierarchical culture in Indonesia. The authors of this study suggest that the implementation of PoT in an Indonesian clinical education setting should aim to support the development of fellow clinical teachers’ teaching quality instead of evaluating their performance. This is in line with the best practices of PoT, which aim at supporting the effective development of teachers by encouraging reflection on teaching and a conceptual understanding of teaching in various settings (Bell & Mladenovic, 2015). Both senior and junior colleagues engaged in an FDI can agree on the agenda of development and accordingly build an action plan after the observation. This will help strike a balance between collegiality and the autonomy of teachers (Bell & Thomson, 2018). In addition, senior colleagues can be involved as role models and champions in conducting the PoT focused on teaching development. This way, the best practices of PoT may be implemented while still respecting the local culture.

Another important lesson learned by the participants was on the implementation of clinical assessment. Participants of the FDI understood the principles of assessment and the various methods of clinical assessment (Epstein & Hundert, 2002). They also learned that clinical assessment requires observation, and the purpose of assessment can be both formative and summative. They also realised, however, that the current clinical setting is often challenging, and clinical teachers do not always have the time to observe students and provide feedback. These are actually global challenges of clinical education (Ramani & Leinster, 2008). Most participants of the FDI felt that the feedback culture had not been effectively integrated into clinical training. A study by Suhoyo et al. (2017) underlined the hierarchical or power distance (Hofstede, 2001) issues in a clinical setting where students value feedback from the experts, but seeking feedback is not considered the common practice. In cultures marked by hierarchy, high uncertainty avoidance and collectivism, as in Indonesia (Hofstede, 2001), feedback is usually sought indirectly from peers or subordinates to avoid embarrassment (de Luque & Sommer, 2000). This FDI has addressed this issue and equipped the clinical teachers for providing constructive feedback to the students. Considering the cultural context in Indonesia and busy clinical settings, clinical teachers as experts in their area should be allowed by the system (i.e. healthcare and clinical education systems) to have formal multiple, short, valid observations of student performance at the workplace before providing constructive feedback to students. Similarly, students’ feedback-seeking behaviour can be encouraged by creating a safe environment that fosters a reciprocal relationship between the students and credible clinical teachers. In such an environment, both positive and negative feedback will be considered constructive to the students’ development (Oktaria & Soemantri, 2018).

The participants of the FDI also reported that providing qualitative data during an assessment posed a challenge. Since assessments can be formative in nature, detailed narratives on the student’s performance quality may actually help clinical teachers and students identify and document the gap in skill and the actions for future improvement (Hanson, Rosenberg, & Lane, 2013). Such qualitative assessment calls for the articulation of the performance of individual students and judgement expertise on the part of the assessor (van der Vleuten et al., 2012). In addition, to ensure rigour in judgement, the assessor should conduct valid observations of student performance over multiple occasions (Cook, Ayelet, Hatala, & Ghinsburg, 2016). This study revealed that most clinical assessments still relied on numbers and that the written feedback provided in workplace-based assessment forms (e.g. Mini-CEXs) was generic. Such feedback failed to indicate the aspects that are necessary for a student’s future improvement. The present authors argue that the lack of ability to provide qualitative assessment data, in addition to other factors such as poor feedback provision skills, a weak clinical education system and low quality of observation, may also be explained by one of the cultural dimensions: the tendency of uncertainty avoidance (Hofstede, 2001). Clinical educators may be wary of proving individualised feedback because narratives or qualitative comments cannot be standardised.

Finally, while exploring concepts in clinical teaching, clinical supervision, clinical assessment and PoT, the participants discussed how the translation of these aspects into teaching practice in an Indonesian setting should depend on the local context. Some participants noted how cultural issues in a clinical practice environment, such as interactions with patients about special conditions (e.g. sexually transmitted diseases), highlight the need for a contextualised approach. This presents an interesting point because clinical practice and the educational environment depend on the health and education systems, the cultural and social norms and the public needs in a certain country (Altbach, 2013, Chapter 24; Hodges et al., 2009). Cultural issues can be woven into the FDI content, and clinical educators can translate best practices into the local context in two ways: (1) by reflecting on the current clinical education environment, expected outcomes, and students’ characteristics and (2) by considering the healthcare system and the patients’ characteristics. Ideally, clinical educators should be aware of the cultural diversity influencing their relationships with the students, patients and healthcare environment and should be able to adjust their mentoring and supervision approaches accordingly (Wong, Wong, & Ishiyama, 2013).

Best practices in medical education should attempt to balance the influence of globalisation and local culture. As suggested by Gosselin et al. (2015), highlighting cultural distinctions, addressing local needs and contexts and presenting local case studies and innovations are needed to contextualise the best practices. This also applies in the current collaborative FDI where attempts to enhance the quality and meet global standards have been accompanied by the incorporation of local values and wisdom. These attempts were beneficial because the participants succeeded not only in grasping the main concepts and best practices of the clinical teaching shared by the Australian research team but also in considering the local cultural context while applying them. Learning can thus become more contextual and relevant, and this in turn can enhance the value of such training.

The limitations of the present study are as follows. First, the participants involved in the study were few and from the same institution. However, they belonged to different clinical departments and had experience in teaching and learning in clinical settings. This allowed for a better contextual understanding and richer perspectives on the FDI topics. Second, the participants were selected from those who had already completed basic clinical teacher training. Therefore, their active engagement in the various FDI activities reflected their desire to challenge their ideas about teaching and learning and explore new approaches to their teaching behaviour. Given the aim of the study, this active engagement was beneficial because they could explore the lessons learned while still considering the best practices and contextual implementation.

V. CONCLUSION

The findings of this study highlight the several important considerations for developing and delivering an FDI designed as part of a collaborative transnational partnership. These include the methods for delivering the teaching and learning activities, participants’ interaction with the ideas and concepts introduced and the application of new knowledge and teaching behaviours in the participants’ own clinical environment. FDI developers should be aware of the interaction of these elements to promote cross-cultural adaptation of best practices in faculty development in general and in clinical teacher training in particular.

Notes on Contributors

Dr Ardi Findyartini is a Senior Lecturer in Medical Education and currently the Head of Department of Medical Education and Head of Medical Education Unit, Faculty of Medicine, Universitas Indonesia.

Dr Justin Bilszta is a Senior Lecturer in Medical Education, Department of Medical Education, Melbourne Medical School University of Melbourne.

Dr Jayne Lysk is a Lecturer in Clinical Education, Department of Medical Education, Melbourne Medical School University of Melbourne.

Dr Diantha Soemantri is a Senior Lecturer in the Department of Medical Education, currently the Vice Director, Medical Education of the Indonesian Medical Education and Research Institute (IMERI), Faculty of Medicine, Universitas Indonesia.

Ethical Approval

This research was approved by the FMUI Research Ethics Committee (Number 0720/UN2.F1/ETIK/2018).

Acknowledgements

The authors would like to thank all Advanced Clinical Teacher Training participants at the Faculty of Medicine, Universitas Indonesia. The authors would like to also thank the Faculty of Medicine, Universitas Indonesia and the Department of Medical Education, Melbourne Medical School, University of Melbourne for supporting this collaboration.

We would like to thank Editage (www.editage.jp) for English language editing.

Funding

This project was supported by the Commonwealth of Australia through the Australia-Indonesia Institute of the Department of Foreign Affairs and Trade (Application No: AII00004 of AII Grant Round 1 2014). Generous in-kind support was provided by Faculty of Medicine, Universitas Indonesia and the Department of Medical Education, Melbourne Medical School, University of Melbourne.

Declaration of Interest

The authors declare that they have no conflict of interest.

References

Altbach, P. (2013). The international imperative in higher education. Rotterdam, The Netherlands: Sense Publishers.

Behar-Horenstein, L. S., Garvan, C. W., Catalanotto, F. A., & Hudson-Vassel, C. N. (2014). The role of needs assessment for faculty development initiatives. The Journal of Faculty Development, 28(2), 75-86.

Bell, A., & Mladenovic, R. (2015). Situated learning, reflective practice and conceptual expansion: Effective peer observation for tutor development. Teaching in Higher Education, 20(1), 24-36. https://doi.org/10.1080/13562517.2014.945163

Bell, A., & Thomson, K. (2018). Supporting peer observation of teaching: Collegiality, conversations, and autonomy. Innovations in Education and Teaching International, 55(3), 276-284. https://doi.org/10.1080/14703297.2016.1212725

Bilszta, J., Lysk, J., Findyartini, A., & Soemantri, D. (in press). Establishing and sustaining transnational clinical teacher faculty development initiative. The Asia Pacific Scholar.

Burdick, W. P., Amaral, E., Campos, H., & Norcini, J. J. (2011). A model for linkage between health professions education and health: FAIMER international faculty development initiatives. Medical Teacher, 33(8), 632-637. https://doi.org/10.3109/0142159X.2011.
590250

Burdick, W. P., Diserens, D., Friedman, S. R., Morahan, P. S., Kalishman, S., Eklund, M. A., … Norcini, J. J. (2010). Measuring the effects of an international health profession’s faculty development fellowship: The FAIMER Institute. Medical Teacher, 32(5), 414-421. https://doi.org/10.3109/01421590903394587

Castelo-Branco, L., Finucane, P., Marvão, P., McCrorie, P., Ponte, J., & Worley, P. (2016). Global sharing, local innovation: Four schools, four countries, one curriculum. Medical Teacher, 38(12), 1204-1208. https://doi.org/10.1080/0142159X.2016.1181731

Cook, D. A., Ayelet, K., Hatala, R., & Ghinsburg, S. (2016). When assessment data are words: Validity evidence for qualitative educational assessment. Academic Medicine, 91(10), 1359-1369. https://doi.org/10.1097/ACM.0000000000001175

Damp, J. B., Dewey, C. M., Wells, Q., Horn, I., Kroop, S. F., & Mendes, L. (2016). Faculty development on clinical teaching skills: An effective model for the busy clinician. Journal of Medical Education and Curricular Development, 3, 187-191.https://doi.org/10.4137/JMECD.S40798

de Luque, M. F. S., & Sommer, S. M. (2000). The impact of culture on feedback-seeking behavior: An integrated model and propositions. Academy of Management Review, 25(4), 829-849. https://doi.org/10.2307/259209

Epstein, R. M., & Hundert, E. M. (2002). Defining and assessing professional competence. JAMA, 287(2), 226-235.

Gosling, D. (2002). Models of peer observation of teaching. Retrieved from
https://www.researchgate.net/profile/David_Gosling/publication/267687499_Models_of_Peer_Observation_of_Teach
ing/links/545b64810cf249070a7955d3.pdf

Gosselin, K., Norris, J. L., & Ho, M. J. (2015). Beyond homogenization discourse: Reconsidering the cultural consequences of globalized medical education. Medical Teacher, 38(7), 691-699. https://doi.org/10.3109/0142159X.2015.1105941

Hammersley-Fletcher, L., & Orsmond, P. (2004). Evaluating our peers: Is peer observation a meaningful process? Studies in Higher Education, 29(4), 489-503.https://doi.org/10.1080/030750704200
0236380

Hanson, J. L., Rosenberg, A. A., & Lane, J. L. (2013). Narrative descriptions should replace grades and numerical ratings for clinical performance in medical education in the United States. Frontiers in Psychology, 4, 668. https://doi.org/10.3389/fpsyg.
2013.00668

Hodges, B. D., Maniate, J. M., Martimianakis, M. A., Alsuwaidan, M., & Segouin, C. (2009). Cracks and crevices: Globalization discourse and medical education. Medical Teacher, 31(10), 910-917. https://doi.org/10.3109/01421590802534932

Hofstede, G. (2001). Culture’s consequences: Comparing values, behaviors, institutions and organisations across nations(2nd ed.). Thousand Oaks, CA: Sage Publications.

Houston, T. K., Ferenchick, G. S., Clark, J. M., Bowen, J. L., Branch, W. T., Alguire, P., … Kern, D. E. (2004). Faculty development needs: Comparing community-based and hospital-based internal medicine teachers. Journal of General Internal Medicine, 19(4), 375-379. https://doi.org/10.1111/j.1525-1497.
2004.30619.x

Kikukawa, M., Nabeta, H., Ono, M., Emura, S., Oda, Y., Koizumi, S., & Sakemi, T. (2013). The characteristics of a good clinical teacher as perceived by resident physicians in Japan: A qualitative study. BMC Medical Education, 13, 100. https://doi.org/10.1186/
1472-6920-13-100
https://doi.org/10.1186/1472-6920-13-100

Oktaria, D., & Soemantri, D. (2018). Undergraduate medical students’ perceptions on feedback-seeking behaviour. Malaysian Journal of Medical Sciences, 25(1), 75-83.

Patton, M. Q. (2002). Qualitative research & evaluation methods(3rd Ed.). Thousand Oaks, CA: Sage Publications.

Ramani, S., & Leinster, S. (2008). AMEE Guide no. 34: Teaching in the clinical environment. Medical Teacher, 30(4), 347-364. https://doi.org/10.1080/01421590802061613

Samuelowicz, K., & Bain, J. D. (2001). Revisiting academic beliefs about teaching and learning. Higher Education, 41(3), 299-325.

Shortland, S. (2004). Observing teaching in HE: A case study of classroom observation within peer observation. International Journal of Management Education, 4(2), 3-15.

Slootweg, I. A., Scherpbier, A., van der Leeuw, R., Heineman, M. J., van der Vleuten, C., & Lombarts, K. M. J. H. (2016). Team communication amongst clinical teachers in a formal meeting of post graduate medical training. Advances in Health Sciences Education, 21(1), 207-219. https://doi.org/10.1007/s10459-015-9627-8

Steinert, Y. (2010). Faculty development: From workshops to communities of practice. Medical Teacher, 32(5), 425-428. https://doi.org/10.3109/01421591003677897

Steinert, Y. (2011). Commentary: Faculty development: The road less traveled. Academic Medicine, 86(4), 409-411. https://doi.org/
10.1097/ACM.0b013e31820c6fd3

Steinert, Y. (2014). Faculty development: Core concepts and principles. In Y. Steinert (Ed.), Faculty development in the health professions: A focus on research and practice(pp. 3-25). Dordrecht, The Netherlands: Springer Netherlands.

Steinert, Y., Mann, K., Anderson, B., Barnett, B. M., Centeno, A., Naismith, L., … Dolmans, D. (2016). A systematic review of faculty development initiatives designed to enhance teaching effectiveness: A 10-year update: BEME Guide No. 40. Medical Teacher, 38(8), 769-786. https://doi.org/10.1080/0142159X.
2016.1181851

Suhoyo, Y., Van Hell, E. A., Kerdijk, W., Emilia, O., Schönrock-Adema, J., Kuks, J. B. M., & Cohen-Schotanus, J. (2017). Influence of feedback characteristics on perceived learning value of feedback in clerkships: Does culture matter? BMC Medical Education, 17, 69. https://doi.org/10.1186/s12909-017-0904-5

Sullivan, P. B., Buckle, A., Nicky, G., & Atkinson, S. H. (2012). Peer observation of teaching as a faculty development tool. BMC Medical Education, 12, 26. https://doi.org/0.1186/1472-6920-12-26

Sutkin, G., Wagner, E., Harris, I., & Schiffer, R. (2008). What makes a good clinical teacher in medicine? A review of the literature. Academic Medicine, 83(5), 452-466. https://doi.org/
10.1097/ACM.0b013e31816bee61

Taylor, E. W. (2003). The relationship between the prior school lives of adult educators’ and their beliefs about teaching adults. International Journal of Lifelong Learning, 22(1), 59-77.

Taylor, E. W., Tisdell, E. J., & Gusic, M. E. (2007). Teaching beliefs of medical educators: Perspectives on clinical teaching in paediatrics. Medical Teacher, 29(4), 371-376.

van der Vleuten, C. P. M., Schuwirth, L. W. T., Driessen, E. W., Dijkstra, J., Tigelaar, D., Baartman, L. K. J., & van Tartwijk, J. (2012). A model for programmatic assessment fit for purpose. Medical Teacher, 34(3), 205-214. https://doi.org/10.3109/0142159
X.2012.652239

van Lierop, M., de Jonge, L., Metsemakers, J., & Dolmans, D. (2018). Peer group reflection on student ratings stimulates clinical teachers to generate plans to improve their teaching. Medical Teacher, 40(3), 302-309. https://doi.org/10.1080/0142159X.2017.
1406903

Waterval, D. G. J., Frambach, J. M., Driessen, E. W., Muijtjens, A., & Scherpbier, A. J. J. A. (2018). Connected, attracted, and concerned: A Q study on medical crossborder curriculum partnerships. Medical Teacher, 40(12), 1293-1299. https://doi.org/
10.1080/0142159X.2018.1431618

Wong, L. C. J., Wong, P. T. P., & Ishiyama, F. I. (2013). What helps and what hinders in cross-cultural clinical supervision: A critical incident study. The Counseling Psychologist, 41(1), 66-85. https://doi.org/10.1177/0011000012442652

Yiend, J., Weller, S. I., & Kinchin, I. (2014). Peer observation of teaching: The interaction between peer review and developmental models of practice. Journal of Further and Higher Education, 38(4), 465-484. https://doi.org/10.1080/0309877X.2012.726967

Yoon, H. B., Shin, J. S., Lee, S. H., Kim, D. H., Sung, M., Amgalan, N., & Chinzorig, T. (2016). Transnational collaboration for faculty development in health professions education in Mongolia. Korean Journal of Medical Education, 28(4), 381-390. https://doi.org/10.3946/kjme.2016.43

*Diantha Soemantri
Department of Medical Education
Faculty of Medicine, Universitas Indonesia,
Jalan Salemba Raya No. 6, Jakarta 10430, Indonesia
Email: diantha.soemantri@ui.ac.id, dianthasoemantri@yahoo.com