Challenges faced by health professions educationists en route to educational reforms in Pakistan

Abstract

BACKGROUND:

Since the field of health professions education (HPE) is an emerging trend in the country, educationists face considerable challenges in their workplaces while proposing any changes in the existing systems of academic institutions. The challenges affect the quality of work, hinder innovation, and create a dysfunctional work environment, non-conducive for both personal and professional progress. The study was conducted to explore the various kinds of challenges faced by educationists while bringing changes to the existing systems of academic institutions in Pakistan.

MATERIALS AND METHODS:

A qualitative exploratory research design was used to explore the challenges faced by health professions educationists in Pakistan during their efforts to bring about changes in the existing systems and structures. Thirteen health professions educationists working in various academic institutions of Pakistan were interviewed through one-to-one semi-structured interviews from March to May 2022. The data obtained were analyzed through manual thematic analysis, and themes and subthemes were identified.

RESULTS:

Four themes emerged after qualitative data analysis explaining the predominant challenges faced by educationists. These included challenges related to faculty and staff, institutional constraints, challenges from leadership, and stakeholders’ apprehension.

CONCLUSION:

Challenges are inevitable at every workplace but the field of health professions education in Pakistan faces significant challenges in institutions, leading to hindrance in positive developments and innovations in the field. Educationists should be skilled at recognizing the predominant challenges in the workplace and be equipped with strategies to manage conflicts to achieve productive results and to promote the long-overdue reforms in the field.

Introduction

Challenges and conflicts are inevitable in human interactions. While working in academic institutions, medical educationists come across conflicts and challenges, especially when leading the change in the existing structures. Medical educators face challenges of management, resources, and training in their workplaces.[1] The infrastructure and financial support for development is also a big challenge for health professions education institutes.[2] Workplace conflicts affect employee satisfaction and morale.[3] Unresolved conflict within interprofessional healthcare teams has been linked to detrimental consequences at the workplace.[4] Effective resolution of conflicts and management of challenges leads to positive work dynamics. In a study conducted to explore the challenges and stress faced by educational deans, it was concluded that among the major challenges for deans include, promoting positive changes, balancing financial resources, and dealing with personal matters among and within the faculty involving conflicts, jealousy, personal vendettas.[5] In another study conducted in Pakistan, medical educationists described that educators and administrators face and overcome challenges of time management, lack of resources, lack of infrastructure, and trained faculty while working in their fields.[1]

The present study will explore the various kinds of challenges that are unique to the workplace of health professions education and provide an insight into the real-life experiences of medical educationists in dealing with challenges at workplaces.

Materials and Methods

Study design and study setting

A qualitative research was conducted to explore the challenges faced by health professions educationists working in various academic (medical and dental) institutions of Pakistan during their efforts to bring about changes in the existing systems and structures. Educationists working in various academic institutions, of Pakistan, were interviewed through one-to-one semi-structured interviews from March to May 2022.

Study participants and sampling

A purposive sample of health professions educationists working in academic institutions was used to collect data. Purposeful sampling includes the selection of people and sites, which can best help in understanding the research question and phenomenon and provide a detailed understanding of the central research question.[6] The inclusion criteria included health professions educationists currently working in academic institutions. The sampling strategy was homogenous, and interviews were conducted till data saturation was reached and no new themes were identified. A total of 13 educationists specializing in health professions education and currently working in health professions education department, either part time or full-time capacity, in various institutes of country were interviewed.

Data collection tool and technique

Open-ended one-to-one interviews were conducted to collect the qualitative data. The interview questions were designed after a thorough literature search and aligned with the objective of the study. The interview guide was sent to three health professions educationists for expert validation. Two pilot interviews were conducted to check the understanding of the questions and any ambiguity and biases in the interview questions were removed.

The participants were briefed about the study and informed consent was taken from the participants before interviews. The primary researcher conducted each interview. The interviews were conducted online through Zoom Meeting Software and some through the WhatsApp application and were recorded with the permission of the interviewees. The recordings were used to transcribe the interviews by the primary researcher.

Data analysis

The researchers manually analyzed the collected data. Each interview was proofread, and the recording was played multiple times to ensure that the transcription reflects the exact thoughts of the participants. Open coding was done. Open codes were checked for redundancy it was followed by axial coding to generate categories or subthemes. The subthemes were merged to form main themes.

To ensure the quality of data analysis procedures, few quality markers were employed during data analysis process including member checking, triangulation, and external audit. Member Checking was done to approve the accurate meaning of the participant as perceived by the researcher. After the interviews were transcribed, the transcripts were sent to the participants to ensure that the transcription is done correctly and if any information has been misinterpreted. The participants were asked about their feedback and if any corrections were suggested they were incorporated after confirmation. Triangulation of data was done by using multiple sources of data. The recording of the interviewee was listened to twice to ensure the accuracy of transcriptions. The data obtained were compared with existing literature and themes were compared with each other to triangulate the data. External Audit was carried out through a discussion of thematic analysis and results including themes, subthemes, and codes with two other medical educationists. Their input on the interpretation and perception of results was considered and analysis was finalized by both the researchers.

Ethical considerations

The ethical approval was obtained from the Institutional Review Committee (Reference # Riphah/IIMC/IRC/21/23). The participants were briefed about the study and informed consent was recorded prior to interviews. To maintain the confidentiality of data and participants, all interview transcriptions were labeled with a participant's number before analysis. The names of institutions and any individuals taken during the interviews were removed and denoted as ABC, XYZ for anonymity.

Results

After the collection of data, qualitative thematic analysis was done manually. The demographic details of the participants of the study [n = 13] are given in Table 1.

Table 1.

Demographic details of the participants

Participant No.	Gender	Years of experience in HPE	Frequency
1	M	3-5 years	Gender:
2	F	3-5 years
3	F	3-5 years	Female	9
4	F	3-5 years	Male	4
5	F	1-3 years
6	M	1-3 years	Years of experience
7	F	>10 years
8	F	5-10 years	1-3 years	3
9	F	3-5 years	3-5 years	5
10	M	>10 years	5-10 years	3
11	M	5-10 years	>10 years	2
12	F	1-3 years
13	F	5-10 years

After qualitative data analysis, four themes emerged for challenges faced by health professions educationists. These included (a) faculty and staff challenges, (b) institutional constraints, (c) challenges from leadership, and (d) apprehension of stakeholders. An overview of the themes and subthemes is given in Table 2 along with representative quotes from the participants. The main themes have been briefly described below:

Table 2.

Themes obtained from data analysis along with their representative quotes

Theme	Category	Representative quotes
Faculty and staff challenges	Faculty resistance	Very renowned professors though very much renowned in their subjects always put barriers because of two things. One they did not want to limit their content and second, they do not want to mingle with other subjects. [P#2]
		The traditional faculty is very resistant and does not want to change so we need patience for that. The university administration says that whatever it may be, make the integrated curriculum and we will implement it. But it cannot be implemented without the consent of stakeholders, which shows resistance. [P# 8]
	Attitude problems	Since they are working for so many years and you are the new one, they think, who are you to guide them and things like that, so they think that they know everything, and they do not want to change. They do not want to learn new things. [P# 5]
	Lack of awareness	When they do not think that this change is essential, or this change will bring some positive impact then it is useless to bring change. [P# 3]
Institutional constraints	Infrastructure constraints	Every year when I write something in my budget details, I never get the one that I wanted. [P# 3]
		There was lack of resources, there was no place for students to self-study, the library was very small [P# 7]
	Human resource constraints	Resource constraints are there, if you do not have resources, you cannot do an innovative job. If I want to bring some innovation in my teaching and learning and I have some resource constraints, I cannot implement anything [P#3]
		They [institutions] provide barricades and they do not provide resources much easily. If they fulfill our human resources, things could be different. Logistic and infrastructure support is one thing but still, we can work around it, but the human resource is not facilitated by institutions. If you want to run medical education in true spirit for integration specifically then you must fulfill human resources. [P# 2]
	Lack of financial support	It was extremely challenging to convince the administration for investment both financially and for bringing about the change in the infrastructure which may be required for small group discussions or distinct types of active learning activities. [P#9]
		Faculty resists especially when they have to do additional work without training, and they do not understand why they are doing it without any incentives. [P# 9]
Challenges from Leadership	Resistance from hierarchy	Administrations resist when they do not understand why certain changes are needed when the older traditional system in their opinion is working perfectly well. [P# 9]
		My previous institutes’ leadership was not even aware of the emerging role and need for innovation in medical education and they gave no support toward change, which was the reason I left the job and came to this institute. [P# 6]
		The incompetency of senior professional colleagues, occupying key positions has been the biggest challenge for me [P# 11]
	Indecisiveness	When the university does not have a strong mindset that what they want actually. They say they want to have a win-win situation and try to make everyone happy. In that situation, every college faced and showed institutional resistance. [P#2]
Stakeholders’ Apprehensions	Faculty’s Fear of the unknown	Leadership generally seems to be threatened by anyone who is trying to bring about change and they feel that their position will be challenged or their position. [P# 9]
		Faculty also have their fears, maybe they think their authoritative power would decrease or there is fear of the unknown because they do not know what education is. So, they did not know what it is about. so, they perceived it as a threat of some kind, and even before any intervention was done, they were in a defensive mode [P#8]
	Students’ response to change	People were saying the student will be the challenge in these reforms, but they did not give any challenge to us. They were just like a blank slate We piloted a portion of the integrated curriculum on some students and later collected the feedback from the students. They enjoyed this session, and they were ready to come up with a change to shift to problem-centered learning instead of traditional [P# 7]

1. Faculty and staff challenges: The most predominant challenge faced by all educationists was the major resistance offered by fellow faculty members and staff. The resistance was faced in varying forms including passiveness, reluctance, and open conflicts. The respondents shared that the resistance is primarily because of the faculty; especially the senior faculty has an orthodox mindset, and it was particularly challenging to bring any change in the traditional mindsets.

2. Institutional constraints: After faculty resistance, the institutional limitations in the form of resources constraints were the biggest challenge for the participants. These constraints included logistics, infrastructure, and human resources. It was the general perception of all the participants that no innovation could be done in the absence of optimum resources, both material and human.

3. Challenges from Leadership: The participants had a mixed experience related to the leadership role in the challenges provided at the workplace. The challenges presented by the institutional leadership included the reluctance to change which was attributed either to their lack of understanding or their disinterest in bringing about any change or both. Participants stressed upon the need of a supportive leadership at workplaces, as, without them, it is immensely difficult to make anything fruitful.

4. Apprehension of stakeholders: The fear of the unknown was seen as one driving factor behind the apprehension of stakeholders in the process of change. The faculty, staff, administration either failed to recognize the need for change or dreaded the anticipated consequences of moving out of the comfort zone for all involved stakeholders. The data showed that the administration and the senior staff were more concerned about their loss of authority which would put them into undue defensive mode as they anticipated that the changes proposed by educationists would undermine their authority if they did not resist.

Discussion

The emerging trend of health professions education has been challenging the traditional concepts and mindsets of individuals and institutions. Institutional cultures develop gradually and are remarkably resistant to efforts to change them. Studies on management sciences showed that any proposed change in organizations was faced with resistance from some employees that resulted in significant challenges.[7] This resistance was associated with the fear of losing control, reluctance to give-up old habits, and intolerance from the resistant colleagues,[7] lack of provided resources, lack of support and provision for continuous development activities,[8] and lack of institutional support from the management and leadership of organizations.[9]

In our study, the most prevalent challenges that health educationists encountered included challenges from the faculty and staff, institutional and infrastructure challenges, challenges from leadership, and apprehensiveness from the stakeholders of the process. In the perspective of the results of the study, it could be deducted that the challenges faced by health professions educationists were unique to their workplace. Since the educationists dealt with emerging changes and contemporary trends in health professionals, their job required immense social interactions and collaborations with students, staff, hierarchy, administration, and support staff. This high-end collaboration could be seen as one of the reasons for the unique challenges of faculty and institutional resistance faced by educationists.

The most common challenge seen from our findings was the resistance from the faculty. This resistance manifested itself in the form of reluctance, passivity, holding on to strong existing boundaries, and refusal to change. Literature also provided evidence that resistance was one of the biggest challenges in any work environment, especially ones that were promoting change. Resistance is the reason attributed to the failure of change initiatives. Change initiatives are usually faced with opposition characterized by behaviors that delay and disrupt the change process and the outcomes desired from it.[10] Individuals resist change due to the fear of losing their controls, cognitive rigidity, lack of psychological resilience, intolerance, and reluctance to give up old habits.[7] Resistant employees tend to distance themselves from their supervisors and coworkers and instead of collectively focusing on the strategic direction of their organization they focus on themselves and distrust the management and leadership of the organization.[11] Change is also resisted due to a lack of management and leadership support in the process.[9] When like-minded people come together and resist the changes being proposed collectively, this kind of resistance is harder to target and manage as it results from combined group efforts that share the same goal. Forming more inclusive groups and encouraging participation among different groups can help manage such intergroup conflicts.[12] Inclusive practice enables collaborations and encourages social bonding and mutual connectedness.[13] A significant way to address resistance in the workplace is by acknowledging and cultivating spiritual elements in the employees including listening, facilitating, meaningful teamwork, and supporting and rewarding employees.[13] Giving importance to stakeholders of the process inculcates a feeling of confidence and trust. Experts from health professions education have enforced in literature the importance of senior stakeholders and how the senior stakeholders should be seen as role models and collaborators during the journey of innovation in medical education which is in itself a complex process.[14] By giving due importance to stakeholders and valuing their expertise, not only can an individual learn from their years of experience and wisdom but also can improve the quality of the relationship between them, hence reducing the resistance.

The changing trends and innovations that are expected from an educationist in their workplace require unwavering institutional support in terms of resources. These resources account for human resources, material resources, training of stakeholders, and financial support for training and activities. A study conducted in Africa stated that their health professions education suffered challenges in the form of; infrastructure, accreditation systems of professional schools, faculty recruitment and retention including the pay structures and faculty development. Keeping in mind the institutional organization, the educationists propose changes and innovations in the existing structures of organizations which require material, human, and financial resources for their effective implementation. All the ideas and innovations are dependent on how well their execution is facilitated. In the absence of resources, innovations could not be brought. The role of leadership has a huge impact on the experiences of employees and their performance.[15] When employers and leaders in the workplace facilitate and empower their employees, they nurture meaningful teamwork.[16] One participant shared the experience of paying financial incentives and dedicated time to faculty members involved in reforming the curriculum and teaching strategies; the results were favorable as the members were motivated and were comfortable while doing the additional tasks and reached their goals efficiently and productively. The provision of resources and support from the institutional is important in bringing readiness and acceptability to the faculty members.[17] Institutions that recognize the needs of their employees and provide opportunities for their growth and development promote an environment and mutual feeling of trust in the organization.[18] When the educationist is equipped with tools to fight off the challenges, they can focus more on innovation and bring about reforms that are needed in the system. Once the challenges and conflicts are reduced and tacked well, the progress of innovation and reform in the existing health professions education field will take speed.

Limitations and Recommendations

The study addresses the challenges faced by health professions educationists in their workplaces. The presence of these challenges has been ever obvious, but no work had been done to chart down the predominant factors causing these challenges. The authors of the present study sought the real-life experiences of educationists working in different academic institutions to elaborate the various challenges encountered in the field. The study was not without limitations. Th authors believe that the challenges related to teaching were not discussed in the study and could be probed further as those challenges also affect the workplace of health professions education.

Conclusion

As the field of health professions education is developing in our country, there are enormous challenges that the novice practicing educationists face in their workplaces. The quality of work and innovative perspectives are sometimes sidelined in the face of the resistance offered by the existing organizational structures and dominant faculty members The long-overdue changes in the structures of health professions education in our country are halted by enormous personal and professional challenges. Educationists should be acquainted with the predominant challenges of the field and equipped with strategies and tools to work effectively in the practical field.

Institutional ethical approval

The Ethical Approval of the study was taken from Institutional review Committee of Riphah International University, Islamabad, Pakistan. The current study is part of a larger study in which first level of social intelligence of educationists was explored followed by the experiences of challenges in the same target population. The reference number is Ref No. Riphah/IIMC/IRC/21/23.

Declaration of patient consent

The authors certify that they have obtained all appropriate patient consent forms. In the form the patient (s) has/have given his/her/their consent for his/her/their images and other clinical information to be reported in the journal. The patients understand that their names and initials will not be published and due efforts will be made to conceal their identity, but anonymity cannot be guaranteed.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.