Hidden benefits of a peer-mentored ‘Hospital Orientation Day’: First-year medical students’ perspectives

Abstract

Background: Entering the clinical environment is potentially stressful for junior medical students.

Aims: We evaluated first-year medical student feedback on a peer-mentored ‘Hospital Orientation Day’ designed to provide insight into future clinical training.

Method: Using a mixed methodology approach data were collected from first-year medical students. Responses to a questionnaire were used to develop a topic guide for focus groups held the next academic year. The questionnaire was completed by 230 first-year students and 32 second years participated in the interviews. Thematic analysis was used to draw conclusions.

Results: Analysis of questionnaire responses indicated that students gained insight into future learning. Focus groups then generated five themes: (1) entering the hospital without fear, (2) linking the present with the future, (3) understanding the culture of learning in the clinical years, (4) a ‘Backstage Pass’ to the clinical world and (5) peer mentors make or break the day.

Conclusions: Using peer mentors during the Hospital Orientation Day allowed insight into future learning. We highlight the importance of student Mentors in the success of hospital orientation. To maximise the benefits for first years, we recommend a mentor selection procedure, mentor training opportunities and incentives to optimise mentor performance.

Introduction

Developing a school leaver into a doctor is a complex educational challenge. It can be a daunting experience for students stepping into the hospital environment for the first time due to their fear of not living up to patient expectations (Russell 2002). Although mature students cope better (Shacklady et al. 2009), the emotionally intense situations that students experience, including dealing with severely ill or dying patients, make the transition potentially traumatic (Pitkala & Mantyranta 2003). Medical students can have difficulty in applying pre-clinical knowledge and also problems relating to professional socialisation with students finding difficulties coming to terms with the working hours and adapting to their new environment (Prince et al. 2000).

Early clinical exposure (ECE) can help students develop a professional identity, improve interpersonal skills and boost confidence (Littlewood et al. 2005). International recommendations suggest that medical schools timetable ECE opportunities for students (General Medical Council 1993; WFME 1998; Wartman et al. 2001). Over half of the European countries have now developed curricula that involve ECE (Başak et al. 2009). In the UK, all medical schools now use ECE, with most introducing it within the first semester. There is, however, a wide variation in the amount of clinical exposure between institutions (Hopayian et al. 2007).

Mentoring in medical school is a well-recognised process which is valued by students (Coates et al. 2008) and has been shown to enhance professional and personal development (Kalen et al. 2010). In addition, such schemes have shown that mentors benefit from the experience by improving their communication skills and developing an increased interest in teaching (Stenfors-Hayes et al. 2010).

At the University of Birmingham, despite 16 years experience of students attending community-based medicine (CBM) attachments in general practice from the start of the course, the transition to hospital placements in year 3 is difficult for many students (Jones & Helbren 2007). It was felt that an early introduction to the hospital environment, in contrast to the smaller more personal CBM placements, would prepare students better if they saw the way in which older students were expected to direct their own learning. A ‘Hospital Orientation Day’ (HOD) for first-year students was introduced in the second semester of 2009–2010 academic year designed by several faculty members within the medical school at Birmingham. The first-year students, individually or in pairs, were randomly matched with one fifth-year student mentor to provide them with support and also enable senior students to gain experience of mentorship. The course also aimed to help first-year medical students understand their direction of travel within the course and contextualise the learning that takes place in the university setting. Students and mentors received a handbook outlining course requirements and first years also attended a lecture to explain the learning outcomes.

With the working hypothesis that the HOD would be a valuable educational experience, we evaluated first-year medical students’ feedback immediately after, and 1 year on, for the first HOD at the University of Birmingham. The results from this study will be used to guide development of the HOD in future years.

Table

Practice points

Students were made aware of their ‘learning trajectory’. Improved awareness of the relevance of pre-clinical learning. First years appreciated the culture of hospital learning. Student mentors were ideal for first years to gain the most from this day. Possible improvements include developing processes for mentor incentives, selection and training.

Methods

Participants

A total of 230 first-year medical students voluntarily completed the online questionnaire (61% response). One year after the HOD, group interviews were conducted with an opportunistic sample of 32 second-year students, details of which are included in Table 1. Only students who had successfully completed the first year and were not repeating the second year were included. The students were approached to participate in the study via email after it had been identified that they were not timetabled for other educational activities at the time of the interviews. All ethnic groups were included. Information about the study was given verbally to participants, and they were not required to sign a consent form.

Table 1.  Demographics of students that participated in group interviews

	Male	Female
Number of students	15	17
Age (years)
Mean	19.9	19.9
Range	19–25	19–21
Gap year	3	4
Medical work experience (weeks)
Mean	4.4	5.3
Range	1–12	1–14

Course expectations

First years were expected to contact their assigned fifth-year mentor prior to the HOD to organise travel and meeting arrangements. They were asked to complete a pre-visit planning sheet to identify their learning objectives and expectations for the day. During the HOD mentors were expected to orientate the first-year student to the hospital and also get them to attend a fifth-year teaching session. In addition, first years were expected to observe a fifth year undertaking some self-directed learning. At the end of the day, mentors were asked to debrief mentees who were then expected to complete a post-visit reflection sheet.

Questionnaire survey

The HOD was evaluated using an online questionnaire on the Medical School intranet designed by the course leaders. No pilot questionnaire was performed. Closed questions (yes/no) were included to assess the organisational aspects of the HOD. A deeper understanding of the educational benefits was achieved using open-ended questions allowing free text responses which were grouped into common answers. These responses were used to develop a topic guide for group interviews the following academic year. The questions included are shown in Table 2.

Table 2.  The questionnaire

Question	Response options
Did you complete the pre-visit planning sheet?	Yes/No
Did you make initial contact with the 5th year?	Yes/No
Did you attend a planned 5th year teaching session?	Yes/No
Did you observe the 5th year engage in some self-directed learning?	Yes/No
Did you discuss the visit with your 5th year at the end of the day?	Yes/No
Did you complete the post-visit reflection sheet?	Yes/No
Should the HOD be included in the curriculum at Birmingham in future years?	Yes/No
What is the most important thing you have learnt from the day?	Free text
What were the best things about the day?	Free text
What were the main problems with the day?	Free text
What improvements could be made to the day?	Free text

Group interviews

Initially, the intention was to hold mini-focus groups consisting of four to five students and facilitate group discussion about aspects of the HOD. However, mixed methodology was used as it soon became clear that the views of individuals were not congruent, as experiences within the groups were heterogeneous. It was necessary to modify the approach to involve elements of semi-structured group interview methodology (Morgan 1997). Group interviews facilitated by one researcher were digitally recorded, then transcribed verbatim. Realist semantic thematic analysis was manually performed on the data obtained from the groups, using the six phase approach: (1) familiarisation with the data, (2) generating initial codes, (3) searching for themes, (4) reviewing the themes, (5) defining and naming themes and (6) producing a report (Braun & Clarke 2006).

Ethical considerations

Following consideration by the Department of Academic Practice and Organisational Development Project Approval committee, this study did not require ethical approval as no student identifiable material was available to the authors. A single researcher performed the thematic analysis and reflexivity was undertaken throughout by discussions with an independent advisor in order to minimise researcher bias.

Results

Questionnaire responses

A total of 64% of first years completed the pre-visit planning sheet and 56% contacted their mentor in advance with the others being contacted by their mentors (usually by email). Most students completed the post-visit reflection sheet (80%), had a discussion with their fifth-year mentor (95%), and were signed off at the end of the day. In addition, most students attended a fifth-year teaching session (79%) and observed their mentor undertake some self-directed learning (76%) (Table 3). From free text responses, the most-valued aspects of the HOD were being able to interact with the fifth-year mentors and experiencing the hospital environment (Figure 1). The most important perceived educational benefits related to ‘gaining insight into future learning’ (Figure 2).

Figure 1. First-year perspective of the best aspects of the day.

Figure 2. First-year perspectives about what were the most important things they learned from the HOD.

Table 3.  Responses to closed questions in the online questionnaire about organisational and administrative aspects of the orientation day

Question	Yes^a	No^a
Did you complete the pre-visit planning sheet?	145 (64%)	82 (36%)
Did you make the initial contact with the 5th year?	127 (56%)	101 (44%)
Did you attend a planned 5th year teaching session?	181 (79%)	48 (21%)
Did you observe the 5th year engage in some self-directed learning?	173 (76%)	56 (24%)
Did you discuss the visit with your 5th year at the end of the day?	218 (95%)	11 (5%)
Did you complete the post visit reflection sheet?	183 (80%)	45 (20%)

Note: ^aNumber of responses (% of responses).

Many students thought the HOD should be included in the curriculum at Birmingham in the future (87%). When asked about problems during the day, 208 students (90%) reported that they had not encountered any significant problems. Problems highlighted were related to: identity cards (1%), travel to the hospital (1%), restrictions due to infection control (2%), being able to access to fifth-year teaching (1%) and not enough activities to do during the day (4%). The most common suggestions for improvement were to introduce more structure to the day (23%), increasing the time of the orientation period (16%) and improving fifth-year mentor preparation (13%).

Focus group responses

The following five themes were generated from the group interviews. Representative quotes from first-year students, for each theme, are included in Table 4.

Table 4.  Representative quotes from first year students for the individual focus group themes

Themes	Data extracts
Entering the hospital without fear	‘I did loads of work in a hospital before I came so it felt completely normal … I was a volunteer but I did it every weekend for two years. I knew all the staff! I know that is pretty extreme, but I think everybody, to some extent, has experience of a hospital’.
	‘Yeah I’d spoken to my 5th Year beforehand so he’d told me at least what he’d be doing and what ward he was on and what-not, so I went in knowing a bit more what I was going to do, but that's only because I’d contacted him and actually spoken to him about it’.
	‘Unlike on work experience where I’ve felt very uncomfortable, the 5th year introduced you to everyone and made it clear that you were a 1st Year and didn’t know very much and all of the doctors I was introduced to were very positive’.
Linking the present with the future	‘When the 3rd Years say that you’re in hospital the whole time you don’t have a clue what that means. So to spend a day in the life of a 5th Year, that was probably the most informative thing. Knowing how the next three years will take shape … that was more important than the experience of a hospital environment’.
	‘So it really brought it all home that it is important what we’re learning in the 1st Year, because sometimes, it feels like, none of this is relevant and I’m never going to remember it. Seeing that the 5th Years were being asked about things that we’ve already learned made us see that actually what we’re learning is really relevant. I found that really useful’.
	‘So for me, it [HOD] showed me that you need to sort yourself out now, in 1st and 2nd Year if you want to get the best out of the clinical years’.
	‘It motivated me probably by looking at the FY1s and the 5th Years and seeing how much more they knew than I did. It's quite astonishing, in a way, to see how far you do progress’.
	‘Also, it's really quite daunting, like you don’t know if you’re going to like the clinical years, it's like you’re doing two years of a degree and then you might find you don’t even like it. So it's quite reassuring to go and see it's good and most people end up liking it’.
Understanding the culture of learning in the clinical years	‘I found it quite strange that they [3rd Years] have to find their own teaching, and there's bartering- like if they do this for their 5th Year then the 5th Year would then teach them. It was quite cool ‘cause quite a lot of the 5th Years actually wanted to do the teaching, but I thought you have to be so proactive to sort out what you’re going to learn on the day- it's very much on you, whereas you have your lectures here’.
	‘I think you have to be one of those people who isn’t scared to say, ‘Do you mind if I do this?’, otherwise you’re going to get nowhere’.
	‘What I got out of it was that when you’re learning in hospital you get out what you put in and you’ve got to have good relationships with the F1s, F2s and the consultants so that they’ll teach you more. I don’t think I would have thought that before the HOD day’.
A ‘Backstage Pass’ to the clinical world	‘Yeah, I’ve borrowed a book off mine too and it's just nice to sort of know someone in the older years. Cause normally you wouldn’t socialise with people outside of your year, let alone 5th Years, but like it was quite nice to talk to a group of people that my 5th Year was with and we were talking about electives and I was just able to ask them questions about stuff like that and it was just quite nice to speak to them’.
	‘Watching them [the 5th Year students] doing what they did. I didn’t get to see any teaching, so watching them go around on the ward rounds and seeing what they actually do was interesting’.
	‘We talked quite a lot about how in a nine to five day how you handle 5th Year and the hospital years in general. They all just seemed to be fine in terms of managing their time and getting the stuff done. That was quite reassuring to see that it's manageable and there's quite a good social life’.
Peer mentors can make or break the day	‘He was really good. For me, the 5th Year made the day. You hear about different experiences, but he used it as a teaching experience for both of us in the way that F1s might mentor medical students, so I thought that was really good’.
	‘I think there was a lot of variety in the students that people were put with as well. Some people had students that took them under their wing and still give them textbooks- even now they stay in contact, whereas other people did feel left on their own’.
	‘[5th Year students] they’re more current and it's easier to talk to a 5th Year than it is a doctor for some of the questions you’re going to ask. I think they’re sometimes more honest as well. Their experience is more relevant to us than other doctors due to the changes in the structure of learning, and stuff like that’.
	‘And none of your questions were stupid questions … because they’d [5th Year students] all been there before and been completely clueless about how it all worked, so you could ask anything that you wanted really’.

Theme 1: Entering the hospital without fear

Almost unanimously, first-year students’ responses expressed little or no fear associated with going into clinical settings. Students reported that this was due to extensive medically related work experience prior to starting the course preparing them emotionally for entering the hospital environment. Pre-visit contact and travelling with the fifth-year mentor made going in to the hospital for the HOD much easier and was considered a key aspect of the preparation. During the HOD, first-year students had positive interactions with healthcare staff and patients which were reassuring to students. There were several examples of doctors who made an effort to make first-year students feel included, and there was only one reference to a ‘scary Consultant’. Several first-year students commented that as patients did not really distinguish between them and more senior medical students, they did not feel uncomfortable when interviewing patients.

Theme 2: Linking the present with the future

On the whole, students felt the day was beneficial because it gave them an insight into real life as a clinical student and made the learning in pre-clinical years more relevant. The need to retain knowledge for the clinical years was evident in fifth-year teaching sessions and independent learning on the wards. Generally, this experience motivated first years to reach the clinical years and provided reassurance about the future.

Theme 3: Understanding the culture of learning in the clinical years – unexpected learning outcome

First-year students became aware of the culture of learning in hospital and the behaviours required to get the most out of the clinical years. They commented on the need for clinical students to be autonomous, self-directed learners. A few first-year students also referred to the importance of having good relationships with those who had more knowledge (senior students, junior doctors and consultants) in order to gain more learning opportunities. Many acknowledged the ‘unstructured nature’ of educational opportunities in the hospital day and some made the link between this situation and the need for senior students to organise and seek out their own learning opportunities. Interactive learning, often on practical tasks, along with the use of patients for case presentations were noted as an ‘interesting’ approach to learning.

Theme 4: A ‘Backstage Pass’ to the clinical world

First-year students generally valued the day as it facilitated discussion with senior clinical students, allowing them to pass on their experiences and advice about how to succeed and survive the clinical years. It was widely acknowledged that this valuable ‘inside’ information and insight could never be gained from a textbook, medical school teaching, work experience prior to medical school, or CBM placements.

Theme 5: Peer mentors can make or break the day

First years’ overall opinion of the day seemed to be strongly dependent on the quality of the fifth-year mentor, with value being placed on effective peer mentors. Characteristics associated with effective mentors were being ‘friendly’, ‘helpful’, ‘interested’, ‘cheerful’ and ‘proactive’. The best performing mentors went beyond the remit laid out in the handbook providing additional learning opportunities through informal conversations and their own teaching. A few fifth years maintained a relationship with their mentee beyond the HOD. Those with ineffective mentors tended to see the day as a pointless or de-motivating experience. Mentors who were considered to have performed poorly were reported to be ‘not interested’, ‘quiet’ or ‘unprepared’. For this reason, a few first-year students suggested a volunteer system for mentor selection. First-year students confirmed that senior students, rather than doctors, should act as mentors to impart their personal experiences and ‘tips’ as clinical students because they were ‘less intimidating’, ‘more accommodating’ and ‘in a position to talk about the current medical degree course’.

Discussion

This study suggests that the inclusion of the HOD into the undergraduate curriculum is beneficial to first-year students. Senior student mentorship provided unique opportunities for junior students to gain insight into their future learning trajectory. In focus groups, students reported finding out about areas such as time management, exams, revision, electives and social life. An important finding was that the success of the day was significantly dependent on the fifth-year mentor, indicating that mentor selection procedures or academic (non-financial) incentives for mentors may be fundamental to maximising the success of this day in the future.

Sharing experiences with medical staff and other students is also recognised as being an important method of assimilating work-based knowledge (Sommers et al. 1994). Having a peer mentor as a role model to interact with during the HOD, was found to bolster student enthusiasm as it showed them the ‘light at the end of the tunnel’. Other reports of ECE also show that it improves student motivation (Nathanson et al. 1987).

The students interviewed in our study were very clear that they did not feel stressed or emotionally unprepared to enter the hospital which is in agreement with past research (McLean 2004). Without exception, all of the students who took part in the focus groups had undertaken medical-related work experience ranging from 2 weeks to over a year. The duration and depth of this work experience, which they felt was an unofficial pre-requisite of entry into the course, was an unexpected finding of the focus groups.

Our study revealed that uncertainty about what lies ahead in the course causes students a good deal of anxiety. We found that experiencing how students learn in the hospital was an important outcome of the HOD. The ‘learning trajectory’ in the transition from Medical Student to physician has many stages (Slotnick 2001) and the HOD provided valuable insight into this process, helping to calm the uncertainty amongst many of the students. Students reported that the HOD made them feel more comfortable about future clinical placements, an outcome that has also been found using other forms of ECE (Jacobs et al. 2005). The HOD has a limited role in reducing the stress of entering the hospital environment but may have a major role in reducing stress from the uncertainty of what lies ahead. Pre-clinical learning has been shown to be more comprehensible if it is done in context (Prince et al. 2000; Alford et al. 2001; Fernald et al. 2001) and ECE allows this (Hopayian et al. 2007). ‘Vertical integration’ contextualises learning, promotes self-awareness and teaches students about health professional roles (Dornan & Bundy 2004). Confirmation of medicine as a career choice is another important benefit of this approach (McLean 2004). The HOD showed first-year students the level of knowledge that would be expected of them in the final years of their studies. This appreciation helped make their preclinical studies more relevant to their future jobs. The HOD contextualised pre-clinical learning as a whole, rather than specific subject areas, and this was a major benefit.

The approach of introducing first-year students to the hospital under the mentorship of senior students proved to be a success. Talking about experiences with other students has been received positively by students previously (Jacobs et al. 2005). However, opinion was divided as to whether it should be third-, fourth- or fifth-year students who acted as peer mentors for the HOD. This depended on whether first-year students wanted to know what it was like to enter the hospital as a third year or wanted guidance from a more experienced student. The majority of mentoring programmes in the literature, however, involve physician/faculty mentoring of students and they have been shown to improve interest, reduce stress by providing psychological support, and provide help with career choice (Tekian et al. 2001; Murr et al. 2002; Goldstein et al. 2005; Macaulay et al. 2007; Coates et al. 2008; Kalén et al. 2010).

Within ‘Tomorrow's Doctor 2009’ there is now an expectation that doctors perform mentoring roles (General Medical Council 2009). Students clearly felt comfortable observing and questioning fifth-year mentors who were perceived as approachable and non-judgmental. It was suggested that there should be a selection process as it seemed that the success of the day, was significantly dependent on the quality of the fifth-year mentor. Although logistically more difficult, the use of a selection procedure to recruit student mentors remains a potential improvement for future years. Alternatively, the use of incentives, such as introducing teaching portfolios where feedback from the mentee could be collated, may improve the quality of the mentors’ performance. Extra courses on how to be an effective teacher may be useful, as other studies have shown this to be welcomed by medical students (Pasquale & Pugnaire 2002).

There are several limitations to this study. Although the response rate for the questionnaire was high (61%), focus groups included 32 first-year students from a total of 377 in the year. More students in the interviews would have added to the reliability of the conclusions, although we do feel that themes were developed based on consistent responses from most students who participated. A single researcher facilitated the group interviews, and although reflexivity was exercised by utilising an independent adviser to minimise researcher bias, using a second researcher in the process could have added extra validity to the results. Finally, this study did not evaluate the experience from the mentor's perspective and future research should concentrate on this aspect of the HOD.

Conclusions

We conclude that the HOD was a successful addition to the first-year curriculum at the University of Birmingham Medical School. The major benefits included making students aware of their learning trajectory, providing an appreciation of the self-directed culture of learning in the hospital environment and also showing them that pre-clinical knowledge is directly relevant to their future careers. On the whole, all of these benefits improved motivation and interest for students. Finally, the quality of the fifth-year mentor determined the success of the day and future improvements in the course should be focused on mentor selection and training with a means of selected mentors recording this in an educational portfolio as an incentive.

Acknowledgements

The authors would like to thank Nina Williams for the useful discussion with relation to the thematic analysis. In addition, our thanks also go to Megan Thacker for assistance in organising the focus groups and Roy Bevan for advice during manuscript preparation.

Declaration of interest: The authors report no declarations of interest.