Assessing Relational Coordination in a Clinical Skills Program during the COVID-19 Pandemic

doi:10.21203/rs.3.rs-1589461/v1

Background.

The global spread of the COVID-19 virus caused unprecedented interruptions in medical education. This paper evaluates Relational Coordination: communicating and relating for task integration; between the distinct roles responsible for delivering clinical teaching during the peak of the pandemic.

Methodology.

Using a cross-sectional design, this study assesses Relational Coordination between twelve groups within a Clinical Skills Program at a Medical School in the United Arab Emirates. It also measures three relevant well-being dimensions: namely, Job satisfaction, Work Engagement, and Burnout.

Results.

Overall, RC scores were moderate (3.65 out of 5.00) and were found to positively and significantly increase both job satisfaction (β = 1.1, p < 0.001) and work engagement (β = 0.8, p < 0.01). While being marginally associated with lower burnout (β=-0.5, p = 0.08). Fifty percent of participants experienced high job satisfaction, with a mean score of 5.0 out of 7.0, while 73% reported being enthusiastic about their job, with a mean score of 6.0 out of 7.0. About a third of participants (27%) reported feeling burnout.

Conclusions.

During times of disruption and crisis, medical education can benefit from higher levels of relational coordination. Our study shows the significant impact of relational coordination on well-being measures like job satisfaction and work engagement. To achieve favorable outcomes, and maintain academic excellence, we recommend six interventions to improve relational coordination in Clinical Skills Programs, focusing on improving communication, work processes, regular meetings, education innovations, capacity building, and the establishment of coaching and counseling programs for students and faculty.

Clinical Skills

Medical Education

Relational Coordination

COVID-19

Wellbeing

Work Engagement

Job Satisfaction

The fundamental mission of medical schools is to prepare students to address the health needs of society. Clinical skills teaching is an integral part of any undergraduate medical curriculum because students must attain physical diagnostic skills before starting clinical clerkships at teaching hospitals. The major challenges in teaching core clinical skills are related to departmental boundaries, culture, and the variations in educational and assessment strategies (19). Clinical skills training programs have also struggled with the supervision of learners, staff development, alignment of stakeholders, operational flexibility, and educational evaluation (6).

The COVID-19 pandemic has markedly influenced medical education across the globe. Teaching clinical skills during the pandemic was a global challenge (26). Traditional medical schools started relying heavily on new methods of curriculum delivery tools such as distance learning and simulation technologies with mixed perception from students and faculty alike. In a recent survey, 62.2% of medical students in South Korea were happy with online teaching, and 84.3% preferred to continue online education after the COVID-19 pandemic (20). On the other hand, 43.3% of preclinical students in the US felt unprepared for clinical clerkships due to lack of clinical skills teaching, laboratory, and hands-on training (27).

Relational coordination theory proposes that relationships of shared goals, shared knowledge, and mutual respect help to support frequent, timely, accurate, problem-solving communication and vice versa (5). High-quality relational coordination is associated with resilience and problem-solving skills, leading to better project outcomes (7). Moreover, relational coordination has increased satisfaction with university e-learning programs amongst students and instructors (21). In fact, high-level relational coordination, satisfaction with communication and work environment were inversely associated with turnover and intention to stay (9; 4). In addition to job satisfaction, relational coordination was associated with additional staff outcomes, namely less burnout and greater work engagement (12).

In higher education organizations, better educational outcomes are achieved through high-quality interprofessional communication and sharing knowledge and goals in an environment of mutual respect (21). A recent survey of relational coordination in higher education institutions in Pakistan showed weak relational coordination between program coordinators and administrative staff, departments heads and administrative staff, and faculty members and administrative staff (2).

People with greater work-life balance performed better when their psychological well-being was reinforced by their satisfaction with their co-workers (17). Furthermore, perceptions of peer justice increase staff's job satisfaction by strengthening the effect of high-performance work systems on relational coordination among workers (18). In addition to job satisfaction, relational coordination was associated with additional staff outcomes, namely less burnout and greater work engagement (12).

In this paper, we assess relational coordination and its impact on participants well-being in a Clinical Skills Program in the United Arab Emirates during the peak of the COVID-19 pandemic in 2020. We hypothesized that the relational coordination experienced by participants in the Clinical Skills Program can predict their well-being.

Ethical Approval

This study was approved by the United Arab Emirates University Social Sciences Research Ethics Committee: Reference No. ERS_2021_7313. All participants provided informed consent for the study.

Setting

The study was conducted at the College of Medicine and Health Sciences, United Arab Emirates University (UAEU). The Clinical Skills Program is a 12-credit hour mandatory 2-year program. Third- and fourth-year medical students complete the program before joining clinical clerkships at affiliated clinical teaching sites (8). The course comprises ten modules of 6-8 weeks duration and conducted at the Medical Simulation Center. In each module, students learn a specific set of clinical skills ranging from medical interviewing and communication skills to physical diagnostics and bedside clinical procedures. Two course directors oversee the entire course assisted by two coordinators for each module. The directors, coordinators and clinical tutors come from diverse clinical departments within the college and affiliated hospitals and clinics. Multiple interdependent teams and departments within the college and off-campus worked together to deliver the course.

To assess coordination levels in the Clinical Skills Program, the relevant roles and workgroups engaged in administering the program were mapped. Figure 1 shows the complex, interdependent and cross-cutting coordination needed to run the program in 2020.

Participants and survey

All eligible participants from the twelve selected roles, including students, staff, course managers, and faculty, were invited to participate in a 7-item validated Relational Coordination Survey (RCS). The Relational Coordination Survey (RCS) is a short 7-item instrument that asks participants to rate each dimension of the relational coordination between them and other roles in the workplace on a 5-point Likert-type scale. The RCS is a fully validated instrument whose unbounded property makes it applicable across multiple levels- cross-professional, cross-unit, cross-organization, and between providers and clients (14,30). The analytics generated from the RCS reveal the strength of relational coordination networks among all the interdependent interprofessional teams, as experienced by participants.

In addition to assessing relational coordination, participants were also asked to assess their job satisfaction, work engagement, and burnout levels. These three aspects of participant well-being were assessed using a 7-point Likert-type scale, ranging from 1 (never experienced) to 7 (experienced every day). Job satisfaction and work engagement are positive scales, where higher scores indicate greater well-being. In contrast, burnout is a negative scale, where higher scores indicate poor well-being.

Analytic methods. Survey data were analyzed using STATA17. Proportional weights were created to adjust the regression models for lower response rates for specific roles, ensuring that the results reflect the sampled population.

Eighty-two participants responded out of 264 invited. Sixty-five participants completed the survey. The overall response rate was 25%. Response rates varied across the different roles; adjunct faculty (7%), academic secretaries (14%), course students (17%), IT & audiovisual support (25%), medical curriculum committee (33%), module coordinators (36%), course administrators (50%), clinical faculty (67%), simulated patients (67%). The lowest participation rate was from the COVID committee, with none of the invited members filled the survey. On the other hand, all invited participants from the simulation center and course directors' workgroups have filled the survey with a response rate of 100%.

Relational coordination. Across all roles involved in the clinical skills course, relational coordination (RC) was moderate, with a total RC index of 3.65 out of 5.00. Mutual respect was the strongest dimension reported by participants with a total score of 4.01, followed by problem-solving communication and frequent communication (total scores of 3.95 and 3.92, respectively). The strongest RC between roles was reported with the simulation center, which received a score of 4.13, where the strongest dimensions were frequent, timely, accurate, and problem-solving communication (4.37, 4.06, 4.15, 4.22, respectively). The weakest RC between roles was reported with the undergraduate medical curriculum committee (3.27 out of 5.0) and medical students (3.35 out of 5.0). Academic secretaries reported the strongest RC ties with other roles, with a total RC of 4.61 out of 5.00, followed by simulated patients with a total RC of 4.54 out of 5.00. The undergraduate medical curriculum committee, course directors, and the simulation center experienced weaker RC ties with other roles (overall reported RC indices were3.07, 3.13, 3.31, respectively).

Participant well-being. Fifty percent of participants reported experiencing high job satisfaction every day or a few times a week, with a mean score of 5.0 out of 7.0, while 73% of participants reported being enthusiastic about their job every day or a few times a week, with a mean score of 6.0 out of 7.0. About a third of participants (27%) reported feeling burnout "almost every day" or “a few times a week," with a total mean of 3.8 out of 7.0. Comparing across roles, academic secretaries reported the highest job satisfaction and work engagement and the lowest burnout level, while course directors and module coordinators reported the highest level of burnout. Also, medical students reported high levels of burnout despite reporting high work engagement and job satisfaction. Figure 2 shows the well-being scores reported by each participating role.

Impact of relational coordination on participant well-being. Multivariate regression models were conducted to predict the impact of relational coordination on participant well-being. Relational coordination total index was found to positively and significantly increase job satisfaction (β=1.1, p <0.001). Problem-solving communication had the highest impact (β=1.6, p <0.001). Table 1 summarizes the regression models for relational Coordination Total Index and its seven dimensions on participants' job satisfaction.

Aside from frequency of communication, all RC dimensions were also positively and statistically associated with higher work engagement. Work engagement was also positively and significantly associated with relational coordination total index (β=0.8, p <0.01). Table 2 summarizes the regression models for Relational Coordination Total Index and its seven dimensions on participants' work engagement.

The regression model showed that relational coordination was also associated with lower burnout (β=-0.5, p=0.08). Moreover, there was a statistically significant association between shared goals and shared knowledge and lower burnout levels (β=-0.67, β=-0.75, respectively). Table 3 summarizes the regression models assessing the impact of total relational coordination and its seven dimensions on participants' burnout levels.

Overall, participants in this Clinical Skills Program experienced moderate relational coordination with “mutual respect” dimension being the strongest. Well-defined roles and responsibilities within the course and the college may help to explain the elevated levels of mutual respect. On the other hand, relationships dimensions of “shared goals” and “shared knowledge” were weak. In comparison, three dimensions of communication (frequent, accurate, and problem-solving) were moderately strong, except “timely communication” which was the weakest dimension across all participants. Simulation center staff reported moderate relational coordination amongst themselves, scoring the weakest on shared goals. They all have distinct but complementary tasks that range from classroom setup to training and supervising simulated patients. Working from home for some staff may have contributed to weaker relational coordination ties with their team members.

Though moderate relational coordination is preferable to weak relational coordination, it is not sufficient for achieving the desired outcomes needed to maintain academic excellence and build the reputations of leading medical schools. In addition, there was a wide variation in the relational coordination experienced by participants. Our analyses showed how these variations impacted participants' well-being in significant ways. In particular, the Course Directors and Module Coordinators reported the highest burnout levels due to the constant stress related to the demanding work of managing a 2-year program during a global pandemic. The coordinators were faculty members of clinical departments with other tasks and duties. In addition to their responsibilities within the clinical skills program, the course directors and module coordinators were asked to assist with additional administrative, teaching, and clinical duties.

Evidence from prior studies suggests that improving relational coordination across the board can lead to favorable employee outcomes such as reduced burnout and emotional exhaustion (16,12). In our study, relational coordination was found to positively and significantly increased job satisfaction and work engagement and was marginally associated with lower burnout. These results are in keeping with prior well-established research in which high-quality relationships and communications promote emotional and physical well-being (10). Though learning outcomes were not measured in this study, variations in relational coordination significantly impact learning outcomes, based on what we know from relational coordination theory (5) and from previous research (8,3, 32, 23).

Medical students reported the highest levels of burnout as there were unpredictable class cancelations, rescheduling, and an overall dislike of the online teaching model in medical education. These findings mirror similar recent studies that reported high-stress levels by medical students in Saudi Arabia, with 22.3% of students stating severe stress after introduction of online learning (1).

Practice Implications

Relational coordination theory has been tested in 74 industry contexts such as airlines, banking, pharmaceuticals, software, financial services, the criminal justice system, multiple levels of education including higher education, and many areas of healthcare, and in 37 countries (5). The results of this study clearly show a moderate level of relational coordination between all groups. Although many participants reported positive well-being, 27% of participants still reported high levels of burnout. According to the Relational Model of Organizational Change (11), relational coordination can be strengthened by adopting organizational structures such as shared accountability for outcomes, shared reward systems, shared meetings, shared work protocols, and shared information systems, as well as hiring and training staff to engage in interdependent teamwork. Figure 3: shows structure-process-outcomes model of relational coordination.

Based on our findings, we propose the following interventions to improve the work at the clinical skills program. First, create a bidirectional closed-communication platform for the clinical skills course, accessible by all participating teams, including students to foster shared information systems. Effective communication at times of crisis is crucial for institutions to mitigate risks associated with unpredictability and extraordinary situations and develop resilience (24). Second, hold regular student-faculty meetings with teams across multiple units within the college, including senior college leadership. These meetings should focus on streamlining work processes, addressing issues with clear role definitions, tracking outcomes, and ensuring accountability amongst all workgroups. Third, provide targeted training focused on interprofessional teamwork to improve relational coordination, as seen in previous studies (12). Given the necessity for interprofessional teamwork in clinical practice, these training opportunities should be available to all team members and medical students.

Fourth, adopt creative and innovative solutions such as the use of modern learning management systems as well as increasing the utilization of new teaching methods such as medical simulation programs (15) and introduction of early clinical exposure of medical students to the clinical setting (25).

Fifth, incorporate medical residents and students' peer teaching in the course. One of the major issues encountered during the pandemic was the shortage of available clinical tutors. Clinical clerks appreciate teaching by residents, which brings about greater satisfaction in clinical rotations (28). Moreover, utilizing a pool of dedicated medical residents to teach basic clinical skills to preclinical medical students will be an excellent option to improve the supply of future clinical tutors for the course. The college could also use a select group of senior medical students to teach and supervise preclinical students learning clinical skills. These practices have been used in many medical schools as students tend to learn better from their seniors, especially in small group structured sessions in clinical skills (22).

Finally, create a college-wide coaching and counseling program for education managers, directors, coordinators, and faculty and staff is essential to focus on resilience and crisis management skills and provide enough support for faculty members. Ongoing coaching and counseling programs will support the course directors, coordinators, and faculty members by polishing their managing skills at times of crisis (29).

Limitations:

There are few limitations worth mentioning in our study. First, the study is cross-sectional, which limits evidence of causality. Secondly, the study was conducted in May 2020, which coincided with the holy month of Ramadan in the United Arab Emirates. This might explain low response rates, especially for specific roles as the COVID- 19 committee members and Undergraduate Medical Curriculum Committee. Finally, demographic data were not available alongside the relational coordination and well-being metrics. It would be on interest to explain some variability in participants’ experiences with the hybrid teaching model for different age and gender groups.

This study assessed RC amongst 12 roles integral to the Clinical Skills Program in a Medical School in the United Arab Emirates, along with three well-being measures: Job satisfaction, Work Engagement, and Burnout using a cross-sectional design. Our medical college has managed to continue curriculum delivery of the Clinical Skills Program despite challenges imposed by the COVID-19 pandemic. The participants in this Clinical Skills Program experienced moderate relational coordination with many participants reported positive well-being. Yet, 27% of participants still reported high levels of burnout. Relational coordination was found to positively and significantly increase job satisfaction, work engagement, and marginally lower burnout. Practice-based interventions are proposed to foster higher relational coordination with the aim of improving learning outcomes and staff wellbeing within the Clinical Skills Program.

Ethics approval and consent to participate

This study was approved by the United Arab Emirates University Social Sciences Research Ethics Committee: Reference No. ERS_2021_7313. All participants provided informed consent for the study.

Consent for publication

Not applicable.

Availability of data and materials

The datasets generated during and/or analyzed during the current study are available from the corresponding author on reasonable request.

Competing interests

The authors declare that they have no competing interest.

Funding

No funding was used for this study.

Authors

*First and Corresponding Author name: Ali S. Alfazari

Author email address: [email protected]

Author affiliation: Director, Medical Simulation Center, College of Medicine & Health Sciences, United Arab Emirates University

Second Author name: Hebatallah A. Naim Ali

Author email address: [email protected]

Author affiliation: Ph.D. Candidate, The Heller School for Social Policy and Management, Brandeis University

Third Author name: Awad Alessa

Author email address: [email protected]

Author affiliation: Instructor in Medical Education, College of Medicine & Health Sciences, United Arab Emirates University

Fourth Author name: Mohi Eldin Magzoub

Author email address: [email protected]

Author affiliation: Chair, Department of Medical Education, College of Medicine & Health Sciences, United Arab Emirates University

Authors' contributions

ASA devised the design of this study. HNA analyzed the data. ASA wrote the manuscript. AE, AA, MM edited the manuscript. ASA and AA supervised the study progress. All authors contributed to critical revision of the manuscript. All authors read and approved the manuscript prior to submission.

Corresponding author

*Correspondence to Ali S. Alfazari ([email protected])

Acknowledgements

We thank the Relational Coordination Analytics, Inc. for the data collection support.

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Table 1. Regression models for predicting employee job satisfaction.

Variables	Job Satisfaction
	Model1	Model2	Model3	Model4	Model5	Model6	Model7	Model8
TotalRC	1.1***	-	-	-	-	-	-	-
Frequent Comm	-	0.68**	-	-	-	-	-	-
Timely Comm	-	-	0.78***	-	-	-	-	-
Accurate Comm	-	-	-	0.69***	-	-	-	-
Problem-Solving Comm	-	-	-	-	1.16***	-	-	-
Shared Goals	-	-	-	-	-	0.70***	-	-
Shared Knowledge	-	-	-	-	-	-	0.85***	-
Mutual Respect	-	-	-	-	-	-	-	0.88***
Constant	1.0^NS	2.48*	2.47**	2.65***	0. 52^NS	2.71***	2.13**	1.75^NS
Adjusted R2	0.32	0.15	0.25	0.22	0.31	0.21	0.29	0.28
F-TEST(P-VALUE)	29.91***	8.34**	14.37***	11.90***	23.13***	12.43***	19.11***	11.70***

(*) p <0.05, (**) p <0.01, (***) p <0.001, (NS)no statistical significance.

Table 2. Regression models for predicting employee work engagement.

Variables	Work Engagement
	Model1	Model2	Model3	Model4	Model5	Model6	Model7	Model8
Total RC	0.78**	-	-	-	-	-	-	-
Frequent Comm	-	0.42^NS	-	-	-	-	-	-
Timely Comm	-	-	0.61**	-	-	-	-	-
Accurate Comm	-	-	-	0.43*	-	-	-	-
Problem-Solving Comm	-	-	-	-	0.73*	-	-	-
Shared Goals	-	-	-	-	-	0.48*	-	-
Shared Knowledge	-	-	-	-	-	-	0.77**	-
Mutual Respect	-	-	-	-	-	-	-	0.71***
Constant	2.81**	4.12***	3.64***	4.20***	2.89^NS	4.06***	2.98**	2.97**
Adjusted R2	0.17	0.06	0.16	0.09	0.13	0.10	0.26	0.20
F-TEST(P-VALUE)	8.89**	0.09^NS	7.46**	3.98*	4.12*	4.32*	10.57**	12.06***

(*)p <0.05, (**)p <0.01, (***)p <0.001, (NS) no statistical significance.

Table 3. Regression models for predicting employee burnout.

Variables	Burnout
	Model1	Model2	Model3	Model4	Model5	Model6	Model7	Model8
Total RC	-0.52^NS	-	-	-	-	-	-	-
Frequent Comm	-	-0.45^NS	-	-	-	-	-	-
Timely Comm	-	-	-0.41^NS	-	-	-	-	-
Accurate Comm	-	-	-	-0.19^NS	-	-	-	-
Problem-Solving Comm	-	-	-	-	-0.44^NS	-	-	-
Shared Goals	-	-	-	-	-	-0.67**	-	-
Shared Knowledge	-	-	-	-	-	-	-0.75^**	-
Mutual Respect	-	-	-	-	-	-	-	-0.08^NS
Constant	5.77^***	5.59^***	5.24^***	4.50^***	5.44^**	6.07^***	6.55^***	4.02^***
Adjusted R2	0.05	0.04	0.04	0.01	0.03	0.14	0.15	0.00
F-TEST(P-VALUE)	3.19^NS	2.31^NS	2.27^NS	0.67^NS	0.96^NS	11.12^**	10.92^**	0.08^NS

(*)p <0.05, (**)p <0.01, (***)p <0.001, (NS)no statistical significance.

No competing interests reported.

Assessing Relational Coordination in a Clinical Skills Program during the COVID-19 Pandemic

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Abstract

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Discussion

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