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Although universities are higher education providers, incentive structures often favour research over teaching, a situation that is compounded in health care education by the additional demand of clinical care, the frequent wide geographical dispersal of clinical teachers and the high turnover of junior clinical teaching staff.1 Recently there has been a global drive to correct this imbalance and incentivise teaching excellence,2 for example through the introduction of the UK government mandated Teaching Excellence and Student Outcomes Framework, a controversial policy proposal linking higher education funding to performance on selected teaching quality metrics.1 Reprioritising teaching quality requires a shift in institutional culture that recognises, facilitates and rewards education, ensuring that teachers have the tools, training, and financial and physical resources to deliver excellence. In this article we provide practical steps for all stakeholders, from individual clinical teachers to institutional leaders, to recognise, support and reward teaching excellence systematically. These steps, based on global literature, fall into four categories applicable at different organisational levels, from the individual to the institution, as summarised in Figure 1 and illustrated by our institutional experience in Figure 2. Although universities are higher education providers, incentive structures often favour research over teaching, a situation that is compounded in health care education … Reprioritising teaching quality requires a shift in institutional culture that recognises, facilitates and rewards education … Given the high turnover of junior clinical teaching staff, peer observation of teaching (POT) provides opportunities for detailed feedback in reflective practice and skill development in situations where continuity and supervision may be low.3 We recommend that POT schemes focus on providing confidential, supportive feedback for professional development, not performance management. Anxiety regarding the objectivity of observer assessments and fear of criticism can be attenuated if POT is implemented and managed as a collaborative activity: for example, by ensuring the subject has input into deciding the evaluation criteria and emphasising the formative nature of POT.3 POT is a two-way learning process developing the observer as well as the teacher who is observed.4 We recommend that institutions provide training in both observer objectivity and subject self-reflective practice for POT to be reliable and useful.5 Recording teaching activities for POT training can assist in this regard.5 Structured matching processes may help teachers seeking improvement in a specific area (e.g. technology), and thus establish a method of sharing good practice. Cross-departmental observations or exchange programmes between institutions may increase learning opportunities and alleviate concerns about being observed by a colleague. Promotion decisions could consider regular participation in, and reflection on, POT (both as subject and observer), rather than the results of the observation itself. … peer observation of teaching … provides opportunities for detailed feedback in reflective practice and skill development in situations where continuity and supervision may be low Teaching portfolios are an effective way of capturing teaching activities, supporting evidence and reflections, in order to encourage teacher development.6 Evidence of both reflection and resulting action plans are essential if portfolios are to be meaningful for self-development. Systemically incorporating reflective practice on teaching into institutions can modify the culture and may provide a fairer tool for promotion decisions, rather than single quality metrics, such as student evaluations.7 Teachers can be supported in developing their portfolios through educational workshops. At Imperial College, workshops were delivered to novice educators locally and at a national conference. Participants used self-reflection and group discussion to identify achievements and development needs based on a published educational framework. At the 6-months follow-up, 92% of respondents reported that the workshop had led to sustained motivation for portfolio development.8 Effective mentorship facilitates honest reflection and feedback, and improves teaching effectiveness, providing the mentee with longitudinal development opportunities, which are particularly important for clinicians who may move frequently between hospitals.9 Mentors can demonstrate educational leadership, a requirement for senior-level accreditation from professional frameworks such as the UK Professional Standards Framework, championed by AdvanceHE (https://www.advance-he.ac.uk), a UK non-profit organisation that promotes excellence in higher education. Early-career clinical educators benefit from one-to-one support in a variety of areas beyond teaching, including practical advice on managing multiple commitments and job planning, as well as careers guidance and goal planning. Support can be provided in a variety of formats, including coaching, mentoring and supervision.10 At Imperial, a regional network of clinical teaching fellows (CTFs) was established with continuing support from senior educational faculty members, providing a community of practice for novice teachers to develop in a supportive environment.11 Starting as an electronic mailing list aiding communication, this has expanded to offer structured educational activities, including tailored induction, educational meetings with guest speakers, a newsletter and a handover booklet. Initial evaluation showed key benefits include peer-assisted learning, access to experienced clinical educators and careers guidance. The network has developed iteratively and now includes workshops on teaching and educational research skills, and educational research opportunities (Figure 2). Effective mentorship facilitates honest reflection and feedback, and improves teaching effectiveness, providing the mentee with longitudinal development opportunities … Standardised student course evaluations are useful as part of a constellation of tools to recognise teacher effectiveness.12 Students need briefing on the provision of constructive feedback, as they often comment on personal traits rather than teaching skills.12, 13 This is crucial in clinical settings, where teaching takes a variety of formats, often ad hoc. All qualified health care professionals will play an informal or formal role in the development of their juniors, so teaching clinical students feedback skills prepares them for this future responsibility. At Imperial, delivering effective feedback in clinical teaching scenarios is embedded in the core curriculum. Avoiding ‘evaluation fatigue’ by alternating responsibility for feedback provision between subgroups of students may increase the quality of the feedback.14 Interested students could also undertake training in evaluating teaching to become ‘expert students’, providing detailed anonymised feedback to teachers in ‘mystery shopper’ style. Such systems can be administered collaboratively between student unions (university-based student-led organisations that represent students’ interests) and educational development units, and these have shown success in providing useful qualitative feedback.13 Students need briefing on the provision of constructive feedback, as they often comment on personal traits rather than teaching skills Institutions should provide the practical and financial resources for delivering evidence-based, interactive teaching formats. The conversion of didactic lecture-based courses to active learning formats is resource intensive, requiring additional teaching time and physical space that supports small group interactions. We recommend that institutions adopt a robust digital learning strategy that emphasises the evidence-based and constructive use of technology in enhancing education and provides practical support for technology-enhanced learning and innovation, such as the Digital Learning Hub at Imperial (Figure 2). Investment in software, equipment and additional technical expertise may be needed. It should be clear how faculty members can access funds. At Imperial, we hold competitive funding rounds regularly to support educationalists in accessing the resources required for using new teaching formats. Engaging students as curriculum co-creators benefits student engagement by improving teaching delivery, keeping curricula relevant and improving student–faculty member relationships.15-17 At Imperial, students are equal members of curriculum committees, are involved in testing new teaching methods in sample teaching sessions and, through a ‘StudentShapers’ initiative (Figure 2), have held paid roles in course design with significant benefit. We recommend that teachers demonstrate how they have incorporated student input into the design of their teaching activities by keeping a log of student engagement in the design of a learning activity, and its impact, in their teaching portfolios. High-profile teaching awards, nominated by students or colleagues, reward able teachers and can be a source of motivation. In addition, institutions can send a clear message to faculty members that they value teaching through a transparent promotion framework that rates education on an equal footing with research activity. Fung and Gordon state that for teachers ‘promotion and opportunities for career development are the most highly valued reward’.2 To enable educators to reach the most senior positions within their faculty, it is recommended that promotion panels include a mix of clinicians, researchers and teachers, and make decisions based on the total impact of the candidates’ clinical, educational and scientific achievements, as occurs at our institution (Figure 2).2 Professional accreditation and postgraduate qualifications enable faculty members to demonstrate commitment and educational expertise. We recommend that institutions support this career development by providing opportunities for study through national organisations, such as the Academy of Medical Educators (AoME) in the UK (Figure 2) and the Academy of Health Professions Educators in India, which provide professional standards frameworks and/or recognition programmes. Teachers who have received structured longitudinal training are rated more highly by their students for teaching quality and have a more student-centred focus than non-trained colleagues.18 Education development units (EDUs) are training units staffed by expert educators, providing continuing training opportunities to support self-development. Clinical teachers and researchers may have little formal teacher training,12 and faculty development initiatives can increase teacher confidence, encourage educational innovation and improve teaching delivery.9 Longitudinal programmes, rather than one-off workshops, are most effective at enhancing teacher development and educational research.9, 19 EDUs also play a significant role in providing institutional support for POT and mentoring programmes. At Imperial College, the EDU has been instrumental in providing a structured programme of workshops to assist teachers gain accreditation from AdvanceHE and complete postgraduate degrees in higher education (Figure 2). The EDU has also provided significant support to teachers as the college goes through the process of curriculum review via a programme of seminars and the sharing of good practice. Institutional health professions education scholarship units (HPESUs) are academic centres of education research and innovation, promoting evidence-based practice specific to the challenges of health care education. There are numerous HPESUs throughout the UK, North America and Australia. They can be funded by universities and external grant funding. They are distinct entities from EDUs, which primarily provide teacher training. Alongside their own research activities, HPESUs support clinicians (who are usually unfamiliar with social science research methods) with advice on education research and sometimes with research and conference grants. HPESUs also create professional learning communities, whereby educators may ‘critically interrogate their practice as a collective enterprise’, facilitating discussion and sustainable change in teaching practice.20 At Imperial, the Medical Education Research Unit (MERU), established 5 years ago, is a multidisciplinary community of academics, students and clinical teachers who conduct and support innovative medical education research to expand understanding in medical education and directly enhance the medical student experience. MERU is led by a professor in medical education and has dedicated education research fellows (both qualified clinicians and pure educationalists, with a focus on medical education research). Anybody within the faculty or a partner clinical teaching site may join the MERU community, which meets virtually for regular seminars or discussion sessions on educational topics and face-to-face for an annual conference to share research and innovation from across the membership. Competitive grants support education research and conference attendance. It is vital that senior leaders demonstrate the same commitment to programme excellence as individual teachers.2 At Imperial, senior management shows visible support for the institution's strategic commitment to teaching: for example, by attending grassroots activities such as open-forum student meetings and student–faculty member education review meetings, and most importantly through the provision of funding to support educational initiatives (Figure 2). Newsletters featuring educational achievements alongside research demonstrate the equal emphasis on both activities. Fung and Gordon define educational leaders as ‘individuals who make impact for the good of others’, including those not in formal leadership roles.2 To initiate cultural change, institutions need role models at every level. Education champion schemes reward and nurture staff with a proven dedication to teaching. Prizes and small grants can motivate staff towards evidence-based practice and provide role models for staff at all levels. There is now a global drive towards teaching attaining equal priority with research on strategic agendas. As clinical educators, we have a duty to our trainees and future patients to provide excellent teaching. Although no single intervention guarantees teaching excellence, we have presented globally applicable tools that form a multi-faceted approach for recognising, encouraging and rewarding teaching excellence in clinical education. Many of these steps rely on cultural change from the top down, fostering an open and honest dialogue at all levels and adopting fair incentive schemes.
Vassie et al. (Thu,) studied this question.