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A Qualitative Evaluation of a Clinical Faculty Mentorship Program Using a Realist Evaluation Approach
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A Qualitative Evaluation of a Clinical Faculty Mentorship Program Using a Realist Evaluation Approach Corrie E. McDaniel, DO; Sahar N. Rooholamini, MD, MPH; Arti D. Desai, MD, MSPH; Sandeep Reddy, MBBS, PhD; Susan G. Marshall, MD From the Department of Pediatrics (CE McDaniel, SN Rooholamini, AD Desai, and SG Marshall), University of Washington, Seattle, Wash; and School of Medicine (S Reddy), Deakin University, Australia The authors have no conflicts of interest to disclose. Address correspondence to Corrie E. McDaniel, DO, Department of Pediatrics, University of Washington, Seattle Children’s Hospital, 4800 Sandpoint Way NE, M/S FA.2.115, Seattle, WA 98105 (e-mail: [email protected]). Received for publication August 27, 2018; accepted August 10, 2019.
TAGEDPABSTRACT OBJECTIVE: Clinically focused faculty (full-time clinical faculty and clinician educators) comprise an increasing proportion of academic faculty, yet they underutilize mentorship nationally. The aims of this study were to test and refine a program theory for an institutional mentorship program for junior clinically focused faculty and to understand the facilitators and barriers of sustained participation. METHODS: We conducted a qualitative study using a realist evaluation approach. Between July and December 2017, we performed in-depth semistructured interviews of 2 participant groups from a junior faculty mentorship program at our institution: 1) those who attended more than two thirds of the program sessions; and 2) those who only attended 1 session. We used inductive thematic analysis to identify key context and program mechanisms that led to meaningful outcomes for faculty mentorship. RESULTS: We interviewed 23 junior faculty representing 15 pediatric specialties. We identified 4 contextual themes (past personal experience, current competing priorities, institutional
culture, and gaps in support and resources), 3 mechanisms (connecting with faculty, sharing ideas and strategies, and self-reflecting), and 3 outcomes (sense of community, acquired tools and skills, and broadened perspectives), which we organized into a programmatic theory representing the program’s impact on participants. Themes that emerged were consistent between both groups. CONCLUSIONS: A mentorship program that provided junior faculty with opportunities to connect, share ideas and strategies, and self-reflect led to improvement in meaningful outcomes for clinically focused faculty. Our program theory provides a basis for institutions seeking to build a mentorship program targeted towards this increasing proportion of junior faculty.
TAGEDPKEYWORDS: clinical faculty; faculty development; junior faculty; mentorship; realist evaluation ACADEMIC PEDIATRICS 2019;XXX:1−9
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expectation nationally underutilize and have fewer opportunities for mentorship than research-focused colleagues.6,7 Clinically focused faculty, whose primary roles are teaching and advancing clinical care, consistently identify unique mentorship needs, including defining a purpose, identifying a niche, finding work-life balance, and transforming educational activities into scholarship.6,8 These needs do not readily fit within mentorship structures designed to support grant writing and funded academic production.8,9 When compared to clinician-investigators, clinically focused faculty report less familiarity with the promotion process,10,11 unclear departmental or divisional expectations,6,12 slower academic advancement,9 and less opportunity for mentorship by senior mentors on similar tracks.13 While multiple models have been proposed to address absent or suboptimal mentorship for clinically focused faculty,1,9,14 these models target specific mentorship
Currently there is a limited understanding of how institutions should address the mentorship needs of clinically focused junior faculty. This study provides a programmatic basis for those seeking to build a mentorship program targeting this increasing proportion of junior faculty.
TAGEDPMENTORSHIP, A CRUCIAL component for career development within academic medicine, improves job satisfaction, leads to enhanced individual perception of institutional belonging, improves academic productivity, and increases retention.1−4 Clinically focused faculty (eg, full-time clinical [FTCF] and clinician-educator [CE] faculty) represent an expanding proportion of faculty within academic centers, increasing from 30% of faculty in 1984 to 60% in 2008.5 Yet, faculty with more than 50% clinical
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needs within a particular division or focus on a problembased model (eg, academic writing groups). They do not address mentorship improvements at an institutional level. In 2014, the University of Washington Department of Pediatrics launched the Junior Faculty Mentorship Program at Seattle Children’s Hospital in order to improve mentorship for clinical faculty within the institution. In this study, we aimed to 1) test and refine a program theory for an institutional mentorship program for clinically focused junior faculty by exploring the contextual factors and program mechanisms that led to meaningful outcomes through participation in the program, and 2) explore the facilitators and barriers for sustained participation in the program.
TAGEDH1METHODSTAGEDEN TAGEDH2CONCEPTUAL FRAMEWORKTAGEDEN We applied realist evaluation (RE), a philosophy used to develop theories as to how and why programs lead to specific outcomes.15 RE is driven by the idea that participants within an intervention are functioning within a specific social context. This context influences a participant’s behavior toward the intervention; this then impacts how the participant responds to the intervention.16 A RE elucidates the underlying theory driving an intervention with the presupposition that achieving successful outcomes is only possible if the appropriate ideas are applied to the correct context with the social and cultural conditions.17 A realist program theory encapsulates not only which outcomes are linked to the intervention, but also what mechanisms generate these outcomes and how the social context affects those mechanisms. The use of theory development within RE is not meant to capture all possible patterns of outcomes. Rather, it explains the “on the ground” workings of a program, which may drive additional programmatic refinement. Conceptually, RE is not a method or technical procedure; it is a process of inquiry to identify what is working in a program, for whom, and in what context(s). Analytically, this causal mechanism is illustrated as the ContextMechanism-Outcome (CMO) configuration. Context is composed of the background conditions in which an intervention operates.15 Mechanisms are the underlying processes that lead to specific outcomes within a given context.15 These mechanisms help to address questions of how an intervention worked and what it triggered. Lastly, Outcomes are the practical effects produced by the mechanism(s), triggered in a given context.15 They are the explicit results of the program that can be seen or observed. As mechanisms according to RE may be identified through feelings or changes in thought, these are best elicited through interviews. For this reason, we chose a qualitative approach. Consistent with RE, we undertook a 3phase evaluation process: 1) initial program theory development, 2) testing of the theory using empirical data, and 3) theory refinement.
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TAGEDH2THE JUNIOR FACULTY MENTORSHIP PROGRAMTAGEDEN Seattle Children’s Hospital is comprised of multiple medical and surgical faculty departments. The Department of Pediatrics is comprised of 530 academic faculty in more than 20 divisions and is the largest Department within the institution. Of the faculty, 75% are clinically focused and 70% of these are junior faculty, defined as Instructor, Acting Assistant, Clinical Assistant, or Assistant Professor. FTCF have predominantly clinical duties without protected scholarship time or expectation of peerreviewed scholarship for promotion. CEs are provided with 20% protected time to engage in scholarly activities with publishing expectations for promotion. In 2013 and 2015, we conducted surveys to assess faculty perceptions of mentorship. Initial results in 2013 revealed that only 59% of faculty believed that mentorship had advanced their career. Subsequent targeted needs assessment of junior clinical faculty showed that 30% could not identify a mentor and 35% had not set longterm professional goals. Of those who identified having a mentor, 37% had not communicated their goals to them. Given the importance of mentorship in early career development, the Junior Faculty Mentorship Committee (JFMP) was designed as a topic-driven, peer-oriented program, highlighting small group collaboration based on models from the education literature.18,19 As clinical faculty are often faced with nebulous issues such as worklife integration, finding institutional fit, and defining a purpose, JFMP sessions were designed to maximize social interaction with focused discussions. Topics include finding the right mentor, tips for successful publication, time management, and resilience. The JFMP structure consists of a featured speaker, often a senior faculty member with significant leadership and mentorship experience, followed by 45 minutes of small group work targeted toward the specific session topic. Each small group has 3 to 8 junior faculty and 1 senior faculty facilitator. Groups are unassigned and rotate facilitators every 10 to 15 minutes. The program meets quarterly in the afternoon (3:30−5 pm), preceding a required faculty meeting at the hospital. Sessions have an average attendance of 40 to 50 faculty. Junior faculty are encouraged to block regularly scheduled clinic hours in order to attend. A volunteer planning committee of 2 senior faculty, 3 junior faculty from different divisions, and an administrative assistant plans the sessions. Although the program is hosted by the Department of Pediatrics, it is open to all faculty within the institution. T EVELOPMENT OF INITIAL AGEDH2D
PROGRAM THEORYAGEDNTE Applying RE, we developed an initial program theory based on the research team’s understanding of the mentorship and faculty development literature and our experience with the programmatic development of the JFMP. This initial program theory included potential mechanisms by which the JFMP led to relevant outcomes: Clinically focused junior faculty under-utilize mentorship and often feel unsupported in academic
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structures created for physician-scientists or faculty with research-focused careers (Context). The JFMP creates an environment for networking with peers (junior faculty) and mentors (senior faculty) allowing for the sharing of knowledge, experience, and shared learning (Mechanism). This leads to improved job satisfaction, institutional belonging, academic productivity, and collaboration (Outcomes). T TUDY AGEDH2S
POPULATION AND RECRUITMENTTAGEDEN Faculty were eligible for the study if they were on the FTCF or CE track and had participated between January 2015 and June 2017 in either two thirds or more of the JFMP sessions or attended a single session and did not return, with a total possible attendance of 8 sessions. Eligibility was determined based on JFMP attendance records. We approached eligible faculty to participate in this study via email using a standardized template. We used purposive sampling to recruit a heterogeneous mix of faculty across subspecialties, years of experience, race and ethnicity, and whether they trained at our institution. We continued enrollment until we reached thematic saturation, where subsequent interviews revealed few new concepts or themes. Faculty received a $25 gift card for participation.
T ATA AGEDH2D
COLLECTIONTAGEDEN In-depth, semistructured interviews lasting 20 to 53 minutes (average 41 minutes) were completed by one of the research team members (C.M.). Interviews were audio-recorded and transcribed in their entirety. The interview guide included open-ended questions regarding the faculty’s past experiences with mentorship, participation in the JFMP, format of the program itself, and opportunities to improve the program (Supplement A). The interview guide was reviewed and piloted by the research team prior to its official use to optimize comprehensiveness of the content and clarity. As data collection occurred concurrently with data analysis, we iteratively revised the interview guide to reflect new patterns that emerged from our analysis. We also asked participants to complete a demographic questionnaire at the end of the interview, which included items noted to have a significant impact on junior faculty mentorship experiences, such as selfidentified gender,20 race, and ethnicity.20,21 The Seattle Children’s Institutional Review Board approved this study. AGEDH2D T ATA
ANALYSISTAGEDEN We applied a thematic analysis approach using the RE framework. First, 2 research team members (C.M. and S. R.) read and open-coded 3 transcripts to identify prominent codes. The full research team discussed and developed definitions and examples for each of these codes. We also determined whether the majority of these codes fit within the general CMO framework. Codes that were related to facilitators and barriers of program participation were coded separately.
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The 2 research members then open-coded 3 additional transcripts to identify additional prominent codes and to verify the CMO framework was applicable to these new codes. The team then met to discuss all of the codes and create a codebook (where each code is defined and illustrative excerpts identified). The codebook allowed for coding consistency through the remaining analytic process. The 2 research team members independently recoded the initial 6 interviews and then prospectively continued to independently read and code subsequent interviews. Between rounds of 3 to 4 transcripts, the team met to discuss new codes, further define codes, and revise the coding scheme. As coding progressed, research team meetings focused on combining codes into themes. We explored if and how each of the themes within the individual CMO categories was connected to each other and whether these themes and their relationships differed between the 2 groups. We compared excerpts for each theme and the overall thematic structure between the 2 groups. Additionally, we organized codes related to facilitators/barriers to program participation into overarching themes. Interviews were continued until the data reached thematic saturation in each participating group as well as a whole for the data sample. Working from the organized themes, we subsequently developed a revised program theory. We then met with 2 prior participants to review their transcripts and the revised theory as member checking to ensure that our program theory was consistent with their experiences.22 We used Dedoose Version 7.0.23 qualitative software for data analysis.23
TAGEDH1RESULTSTAGEDEN We conducted interviews with 23 faculty in 15 pediatric specialties (Table 1). Fifty seven percent (N = 13) of participants attended two thirds or more of the JFMP sessions, and 43% (N = 10) only attended 1 session. Seven faculty (30%) were within 2 years of being promotion-eligible to Associate Professor, and 1 faculty member who had attended the JFMP while junior faculty rank had undergone promotion to Associate Professor within the previous 2 months. All of the faculty in the group with sustained attendance identified as women. The majority of interviews (74%, N = 17) were conducted with faculty on the CE track, which is representative of our institution’s CE-to-FTCF ratio. The majority of participants completed a fellowship (87%) and over half (56%, N = 13) identified as non-Caucasian. We identified 10 themes, which we categorized within the CMO configuration (Table 2). Themes were consistent across the 2 attendance groups. T ONTEXTTAGEDEN AGEDH2C We identified 4 main themes within the context domain: past personal experiences, current competing priorities, institutional culture, and gaps in support and resources. First, participants described how past personal experiences during medical school, residency, fellowship, and in
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Table 1. Participant Demographics N (%) Total number of participants
Faculty track Fellowship training Years as an attending physician
Self-Identified Gender Race/Ethnicity
Specialties
Attended ≥2/3 of sessions Attended 1 session Full Time Clinical Faculty Clinical Educator Completed a fellowship program 0−2 3−5 6−8 >8 Women Men White/Caucasian Asian Black or African American Hispanic Other Adolescent Medicine, Craniofacial, Developmental and Behavioral Pediatrics, Endocrinology, Genetics, General Pediatrics, Hematology and Oncology, Hospital Medicine, Infectious Disease, Neonatology, Nephrology, Pediatric Emergency Medicine, Pulmonology, Rehabilitation Medicine, Rheumatology
23 (100) 13 (57) 10 (43) 6 (26) 17 (74) 20 (87) 3 (13) 10 (43) 7 (30) 3 (13) 19 (83) 4 (17) 10 (43) 10 (43) 2 (9) 1 (4) 0
Table 2. Illustrative Quotes Within the Context-Mechanism-Outcome Configuration Domain Context
Theme Past personal experiences Current competing priorities
Institutional culture
Gaps in support and resources
Mechanism
Connect with faculty
Share ideas and strategies
Self-reflect Outcomes
Sense of community
Acquired tools and skills
Broadened perspectives
Illustrative Quote It was hard for me to find any one person or team of people who really said, “Here’s how you sculpt your career.” B.1 Time is always against us. As junior faculty we’re asked to do lots of things and be in lots of places. A.2 I remember honestly when I was coming out here, [a colleague] made an aside comment about, “Well, in general, we’re only successful for the things we do on nights and weekends.” B.2 I think every junior faculty works individually, and they’re sort of like an island. . .even if you are in the same program, you know their research, but you really don’t get to know them. A.12 It would be nice to have someone within academic medicine that I could describe my academic position to: my medical director position, the [clinical standard] pathway work that I do, and my clinical work too, and have somebody look at me as a whole. A.9 I feel like there should be more mentorship about what does advancing mean? What does that look like? What is expected of me, especially as a clinical faculty, besides just [clinical] work? I feel like I’ve never been able to get a solid answer. B.8 I feel like the junior faculty meetings are the only place where I have gotten to know more senior members of the faculty and the junior faculty people as well. I think that is probably literally the only place, and it’s been good. A.4 I remember hearing conversations about choosing when to say yes and when to say no to things. That’s been really helpful because I sometimes think about that when I’m deciding. It feels ok to say no in some situations based on stories I’ve heard from other people. A.5 I think that in each one of the sessions, I’ve found something valuable that made me rethink how I’m functioning. A.9 I feel part of this community and that we can support each other morally and also on the research and on the clinical side, because a lot of times you share patients and it’s a lot easier to talk to your friends than someone you’ve never met. A.12 I think that starting to diagram and map my goals has been something that I can actually articulate and do, which I definitely had no idea about back when I started. A.10 What I didn’t know is that other people were having the same challenges. I was like, “Whoa! Everybody else needs this too? Oh, good! I’m so glad!” I wasn’t the only one this whole time that was feeling awash on the iceberg not knowing what to do. B.1
A, Participant who had attended ≥ two thirds of the program sessions. B, Participant who had attended one session.
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their early faculty years influenced their current perspectives on and expectations for mentorship. These included positive and negative prior mentorship connections, perceptions about optimal work-life integration, and self-perceived strengths and weaknesses. A second theme was the struggle to balance current competing priorities. Participants articulated stress around balancing time pressures, clinical requirements, academic obligations (eg, scholarship or administrative responsibilities), and personal obligations. Participants also described our local institutional culture as impacting their work experience. Some expressed feelings of isolation or lack of connection to the institution, positive and negative connections with colleagues, and perceived inequities. Inequities were anything with a value-differential, including disparities by gender, seniority, and perceived respect based on academic track. Lastly, participants identified gaps in the support and resources required to succeed and gain promotion. Some of these were unmet professional needs, perceived barriers to advancement, a lack of social support, and fragmented mentorship. TAGEDH2MECHANISMSTAGEDEN We elicited 3 main mechanisms to describe how the JFMP led to outcomes and what it triggered for participants individually. The JFMP provided opportunities to connect with faculty, share ideas and strategies, and self-reflect. One of the strongest mechanisms we identified was the opportunity to connect with other faculty within the institution. Finding camaraderie and having shared experiences with peers facing similar challenges motivated faculty to participate. Second, attending the program provided an opportunity to share ideas and strategies. During these sessions, participants noted they had the opportunity to exchange ideas and strategies with peers and senior faculty on topics such as career negotiation, navigating new opportunities, hearing practical tips on time-management techniques, and strengthening teaching skills. Third, the program provided an opportunity for faculty to self-reflect. This often came in the form of hearing the stories of other faculty and relating these to their own experiences.
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TAGEDH2OUTCOMESTAGEDEN We identified 3 outcomes that participants experienced as a result of the program: creation of a sense of community, acquisition of practical tools and skills, and broadened perspectives. Through participation within the JFMP, faculty experienced a sense of community that persisted beyond the individual programmatic sessions into stronger relationships with their peers and senior faculty across the institution. Faculty described this community as providing support and facilitating interpersonal communication and collaboration. Second, faculty acquired new tools and skills at the JFMP and subsequently applied them in their clinical practice or scholarly work. Participants described applying learned mentorship skills such as agenda setting and meeting follow-up. They also described using practical advice around technology for streamlining their work, establishing short- and long-term goals, and writing a career mission statement. Lastly, the program led to broadened perspectives in regards to faculty perceptions of their career, place within the institution, and potential opportunities for professional growth and collaboration. T EVISED AGEDH2R
PROGRAM THEORYTAGEDEN Based on the themes we identified, we developed a revised JFMP program theory: Clinically focused junior faculty approach the need for mentorship from a complex contextual milieu of competing priorities, personal experiences, institutional culture, and gaps in support and resources (Context). By providing opportunities to connect with other faculty, share ideas and strategies, and self-reflect (Mechanisms), the JFMP has led to a sense of community, the acquisition of tools and skills, and broadened perspectives (Outcomes). The Figure is a visual representation of this revised program theory, describing how through participation in the program participants’ mechanisms are influenced by contextual factors at our institution and subsequently lead to
Figure. Visual representation of the revised program theory using realist evaluation framework for the Junior Faculty Mentorship Program.
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meaningful outcomes. For example, for faculty who experience unmet mentorship needs (context), the program provided perspective on career options and paths (mechanism), which led to a change in mindset (outcome).
Table 3 provides illustrative quotes from participants to exemplify the relationships between the CMO configurations captured within individual interviews based on our RE approach.
Table 3. Illustrative Quotes Demonstrating Relationships Within the Context-Mechanism-Outcome Configuration C: Current competing priorities* M: Share ideas and strategies M: Self-reflect O: Sense of community O: Broadened perspectives
C: Current competing priorities M: Share ideas and strategies O: Acquired tools and skills
C: Institutional culture M: Share ideas and strategies M: Connect with faculty O: Sense of community
C: Gaps in support and resources M: Connect with faculty M: Share ideas and strategies O: Broadened perspective
C: Gaps in support and resources M: Self-Reflect O: Broadened perspective
It’s been hard to navigate that a bit and not feel guilty if I have to say no to one thing or another. There’s always more work to do and if you don’t get something done, then does that mean that one of your colleagues is going to have to pick up and do it for you? Or does it mean that you’re going to miss out on an opportunity to move things forward in another part of your career? And so I’m feeling guilty that I’m not taking advantage of all of the things at my disposal. . .and then on the flip side, I feel guilty if I miss out on something with my kids. . .I think [the program started me] thinking strategically about career. Not thinking, “ Oh my gosh, I’ve got to get promoted,” like big picture, but thinking more like the small steps along the way. So it’s changed my mindset in terms of the goals I’m trying to accomplish. . .I definitely have peers [outside of my division] who also participated in the program and it’s helped us hone in on what do we need to be successful instead of us just brainstorming our own ideas on what kind of tasks we should take or not. For example, it might come up that an opportunity was available to become clinical director of your division, and so before we’d just talk about it like, “Oh my gosh, what do you think this’ll mean? Oh, will I be able to pick up my kids from pre-school?” Those kind of things. But [now], we think more strategically about it, “Is this going to be a career move for me? Is this going to put me in a place where I’m going to be able to have more opportunities or not?” So it’s kind of shifted our conversations around opportunities that come up. A.2 It’s pretty much all clinical time, so if you ever want to do anything that’s outside of your clinical schedule, then you’re really having to just add it onto your plate of your clinical work. I think just the logistics of trying to do your shifts, especially when you’re a day shift and night shift worker, and to do other projects can be overwhelming. . .It just can be exhausting from a time perspective. I think there are sometimes when I feel burned out, even though I’m doing things that I like. . .I love hearing, or sharing ideas among faculty, because people are coming with so many different views, and day-to-day life experiences, and things they’re having to do, so sometimes someone has a great idea that works well for you. . . I think I’m more protective of what I do, and my time. Like I say no more than I used to, and that’s come from the sessions. Like really being mindful that you can’t be on every single committee. It’s important for me to pick things that I think will actually give to me just as much as I give to them. It goes back to being very intentional now about what I choose to do. A.10 Even though I had identified somebody as a mentor, I still didn’t feel like I was equivalent to someone who has trained here. I feel like I didn’t get the same opportunities. . .[In the program] I think it’s great to hear from senior members that have those “ A-ha!” moments. I think, it’s good to hear their stories because I think that, sometimes, it gives you clues on how to not make those things happen, and try to make the right choices. I would say the one helpful thing is it was nice to see colleagues there in that boat. [The program] promotes a little bit of collegiality. I think in that way it improves job satisfaction because it’s easier to email that person that you’ve already met to say, "Hey, let me ask this question about a patient.” It’s for the greater good. Sometimes, it’s for the greater good of your research, or research collaboration, or for your trainees’ collaboration. A.6 So [I was] going back and forth between different possible scholarly outputs or research experiences for myself. Quality improvement work versus trying to create a cohort of a certain group of patients, and then abstracting that data all myself. Things I did as a fellow when I had a ton more time for research, but to do now would be almost impossible. . .Then I got the email [about the program], and some of the other younger faculty said you should go to this. . .And so I went. I think I was anxious about some of these things that we’re talking about. Maybe this is going to be a place where I can get some answers to these things. Or at least be in the company of people who have similar concerns. . . We were at tables, and people rotated around and talked to us. People who were senior faculty were kind of sharing their experiences, and giving their advice on things, and we were asking questions. So that was helpful...It was helpful to hear them say, "Oh I was in that situation", or "I remember feeling overwhelmed", things like that. B.3 I don’t really have a mentor who I think that I’m like at all. I don’t have any full-time clinical faculty mentors. Everybody who is my mentor is a clinician educator, a clinician researcher. And then I think being the medical director of the clinic, I don’t have anybody who’s in a similar leadership position who I think of as a direct mentor . . .I think in particular, hearing women talk about being in this academic setting and their blend of teaching and research and clinical care makes me feel like I can do it. . . I think that each one of the sessions, I’ve found something valuable that made me rethink how I’m functioning. . . I think when I go into meetings, I, at the same time that I’m sharing problems, I’m also sharing solutions and so. . .I’m coming up with solutions for my own problems. A.9
A, Participant who had attended ≥ two thirds of the program sessions. B, Participant who had attended one session. *Lines in bold represent Context. Lines in italics represent Mechanisms. Lines in standard formatting represent Outcomes.
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Table 4. Barriers for Sustained Participation in the Junior Faculty Mentorship Program Time and location limitations
Perceived lack of fit
Individual priorities
And I really have been bummed that I haven’t made it to any of the other ones, and it’s purely been that I have clinic on Wednesdays a lot where I’m on service. And it’s challenging to go for that time. B.1 I have a kid who’s under five and child care is not provided for that group of kids and that’s right around the time when I have to relieve my child care for the day and I have to get home and be with him and start his bedtime. B.8 I do remember the issue of I’m not sure what side of this I fall on, because I am now mid-career. B.2 I’m not a big networking person, and I do think that some people really value those opportunities. I’m just not one of them, I’m not good at that, and it’s hard for me to take something out of those meetings, where that’s the goal. B.3 I feel like there’s people I can reach out to for mentorship, and with having a kid, honestly, meetings that I don’t have to go to are lower on the priority. B.9 I’m looking at some of these topics and most of them sound intriguing and I would have gone, or I would want to go, but then there’s a [specialty] meeting or there’s all the other stuff. I think that the balance of the lack of time that we have, I think we just have to be protective about this. This is one of the things where it would be good, but I’d rather get my stuff done so I can go home. Those become, sort of, the pragmatic things that get in the way. B.4
B, Participant who had attended one session and not returned.
TAGEDH2BARRIERS TO SUSTAINED PARTICIPATIONTAGEDEN We identified 3 main barriers for sustained participation: 1) time and location limitations, 2) perceived lack of fit within the program, and 3) individual priorities (Table 4). Participants identified practical limitations as the most common reason for lack of sustained participation, such as childcare constraints and clinical responsibilities. Suggestions from participants to mitigate these included offering sessions at different times during the day such as shorter lunchtime opportunities, providing childcare during the session, and expanding remote web-based participation options (both live and recorded). Second, the JFMP structure itself was a barrier for some participants. As some of the faculty were close to or had completed the promotions process from junior to midlevel faculty, they expressed concern whether the program still targeted their changing needs or if they would have a place in the program after promotion. Additionally, as the sessions are designed to facilitate group interaction and discussion, some expressed feelings of discomfort with large group interactions. Participants suggested incorporating newly promoted Associate Professors as small group mentors, tailoring specific small groups to be Associate Professors only, and having assigned rather than rotating small groups for discussion. As a reflection of the context of current competing priorities, some participants described prioritizing between multiple opportunities. Ongoing participation in the JFMP was not seen as a priority for participants who already had adequate mentorship support, immovable job conflicts, or personal work-life balance choices. To mitigate these barriers, participants suggested ways to stay connected to the JFMP such as receiving electronic notifications about upcoming sessions or social opportunities for connection with peers in the future.
TAGEDH1DISCUSSIONTAGEDEN Through the utilization of the RE approach, we developed a robust understanding of the relationships between
the social context from which clinical junior faculty approach mentorship and the underlying mechanisms for why and how JFMP participants responded to the program within that context. Participation in the JFMP created opportunities for faculty to connect with each other, share ideas and strategies, and self-reflect, leading to the creation of community, acquisition of practical tools and skills, and broadened perspectives. Barriers to the program included time and location limitations, perceived lack of fit, and competing priorities. By understanding these social dynamics and relationships within the CMO configuration,24 our revised program theory describes an institutional approach toward mentorship for clinically focused junior faculty. As participants included a diverse representation of faculty, spanning specialty, race/ethnicity, and training, the developed theory represents a potentially transferrable basis for other institutions seeking to build such programs. Through small group activities, the JFMP facilitated connection and the exchange of ideas between peers, providing a space for participants to address the more ill-defined issues that clinical junior faculty face. This is consistent within the literature where small-group collaboration that incorporates “think-aloud” interactions has been shown to lead to improved problem solving of nebulous problems, improved critical thinking, and increased development of positive attitudes.18,25 Other institutions of comparable size and complexity may consider the application of similar interventions specifically targeting the underlying mechanisms revealed through the revised program theory. This may help to address larger, similar contextual factors and ultimately lead to the improved creation of community, skills, and perspectives within their faculty. Our contextual themes (past experiences, competing priorities, institutional culture, and gaps in support and resources) reflect the struggle that clinically focused faculty experience between professional and personal obligations, clinical and nonclinical (research, administrative, and quality improvement) responsibilities, and trying to find a fit within a large academic institution. In many institutions, CE and FTCF tracks are new, often resulting
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in faculty attempting to navigate their own paths with various levels of support and mentorship towards career development.2,6,8−10 In building an institutional mentorship program, accounting for these contextual factors may increase sustainability and engagement. The JFMP program created an opportunity for both internal reflection and external engagement with colleagues. While it was not designed to replace in-depth dyadic mentoring relationships, the topic-targeted sessions and small-group exercises created opportunities for faculty to interact and learn from one another. These mechanisms are consistent with published literature around peer support groups, writing groups, and project collaboration.14,26,27 These examples engage faculty in communication, collaboration, and connection, ultimately leading to engagement, confidence, productivity, and mutual learning.14,26−28 Such published examples, however, are limited to specific populations, often a single division or group with a focused purpose such as a writing group. Building upon these, the JFMP further demonstrates transferability of these concepts onto a broader institutional level by spanning divisions and departments. Barriers to sustained participation reflect the reality of competing responsibilities that faculty balance. While the JFMP was not able to address every faculty member’s individual mentorship needs, faculty who only attended a single session described the same themes for how and why the program was impactful and expressed desire for the opportunity to be involved in the future. Ultimately, this underscores the strength of the revised program theory, as the context and mechanisms experienced by participants who attended even once represent concepts more broadly experienced by clinically focused junior faculty. Lastly, 80% of our participants were women. While this is representative of the pediatric workforce,29 gender remains an identified gap within academic mentorship.20 Women specifically identify challenges in finding research role models and the mixed-model structure of the JFMP with rotating senior and junior faculty interactions may directly address this. Next steps include expanding to medical or surgical specialties where there is not a predominance of women within the workforce in order to further delineate the potential role of such a program to target this known mentorship gap. Our study has several limitations. Our revised program theory may not be transferrable to institutions dissimilar in size, complexity, or contextual factors. This study focused only on clinical faculty and the program theory may not translate to research-focused faculty. We also did not interview clinical junior faculty who were invited to the program but never attended. These individuals may represent a population with differing needs within our institution that are not currently represented in our sample. We also were unable to look at long-term outcomes such as promotions or publications as a result of participation in this program. Although beyond the scope of this evaluation, ultimately we hope to demonstrate such outcomes for faculty attendance.
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TAGEDH1CONCLUSIONSTAGEDEN The mentorship experiences of clinically focused junior faculty stem from their unique context within academic medicine. Mentorship programs that provide opportunities for faculty to connect, share ideas and strategies, and selfreflect may help to cultivate community, practical skills, and broadened perspectives. Our revised program theory serves as a potential basis for building successful institutional mentorship programs that lead to meaningful outcomes for this growing population of junior faculty.
TAGEDH1ACKNOWLEDGMENTSTAGEDEN We thank Drs Leslie Walker-Harding, Richard Shugerman, Thida Ong, Yongdong Zhao, and Bruder Stapleton for their incredible vision and support of the University of Washington JFMP. Human Subjects: This study was formally reviewed and approved by the Institutional Review Board at Seattle Children’s Hospital, STUDY00000571. Funding: This project was supported through the 2017 Small Grants Fund through the Center for Learning in Medical Education at the University of Washington. The funding source had no involvement in study design, data collection, analysis, writing of this manuscript, or decision to submit for publication. Dr. Desai’s time was supported by Agency for Healthcare Research and Quality grant K08 HS024299 (PI Desai).
TAGEDH1SUPPLEMENTARY DATATAGEDEN Supplementary data related to this article can be found online at https://doi.org/10.1016/j.acap.2019.08.008.
TAGEDH1REFERENCESTAGEDEN 1. Johnson KS, Hastings SN, Purser JL, et al. The Junior Faculty Laboratory: an innovative model of peer mentoring. Acad Med. 2011; 86:1577–1582. 2. Ries A, Wingard D, Morgan C, et al. Retention of junior faculty in academic medicine at the University of California, San Diego. Acad Med. 2009;84:37–41. 3. Sambunjak D, Straus SE, Marusic A. Mentoring in academic medicine: a systematic review. JAMA. 2006;296:1103–1115. 4. Straus SE, Chatur F, Taylor M. Issues in the mentor-mentee relationship in academic medicine: a qualitative study. Acad Med. 2009;84:135–139. 5. Bunton SA, Mallon WT. The continued evolution of faculty appointment and tenure policies at U.S. medical schools. Acad Med. 2007;82:281–289. 6. Buckley LM, Sanders K, Shih M, et al. Attitudes of clinical faculty about career progress, career success and recognition, and commitment to academic medicine. Results of a survey. Arch Intern Med. 2000;160:2625–2629. 7. Chew LD, Watanabe JM, Buchwald D, et al. Junior faculty’s perspectives on mentoring. Acad Med. 2003;78:652. 8. Castiglioni A, Aagaard E, Spencer A, et al. Succeeding as a Clinician Educator: useful tips and resources. J Gen Intern Med. 2013; 28:136–140. 9. Levinson W, Rubenstein A. Integrating clinician-educators into Academic Medical Centers: challenges and potential solutions. Acad Med. 2000;75:906–912. 10. Lowenstein SR, Fernandez G, Crane LA. Medical school faculty discontent: prevalence and predictors of intent to leave academic careers. BMC Med Educ. 2007;7:37. 11. Atasoylu AA, Wright SM, Beasley BW, et al. Promotion criteria for clinician-educators. J Gen Intern Med. 2003;18:711–716. 12. Girod SC, Fassiotto M, Menorca R, et al. Reasons for faculty departures from an academic medical center: a survey and comparison across faculty lines. BMC Med Educ. 2017;17:8.
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13. Chung KC, Song JW, Kim HM, et al. Predictors of job satisfaction among academic faculty members: do instructional and clinical staff differ? Med Educ. 2010;44:985–995. 14. Fleming GM, Simmons JH, Xu M, et al. A facilitated peer mentoring program for junior faculty to promote professional development and peer networking. Acad Med. 2015;90:819–826. 15. Pawson R, Tilley N. Realistic Evaluation. London; Thousand Oaks, Calif.: Sage; 1997. 16. Marchal B VBS, Westhorp G. Realist evaluation. Vol 2018: Better Evaluation. 2014. 17. Nurjono M, Shrestha P, Lee A, et al. Realist evaluation of a complex integrated care programme: protocol for a mixed methods study. BMJ Open. 2018;8:e017111. 18. Cohen E. Restructuring the classroom: conditions for productive small groups. Rev Educ Res. 1994;64:1–35. 19. King A. Verbal interaction and problem-solving within computer-assisted cooperative learning groups. J Educ Comput Res. 1989;5:1–15. 20. Steele MM, Fisman S, Davidson B. Mentoring and role models in recruitment and retention: a study of junior medical faculty perceptions. Med Teach. 2013;35:e1130–e1138. 21. Pololi L, Cooper LA, Carr P. Race, disadvantage and faculty experiences in academic medicine. J Gen Intern Med. 2010;25:1363–1369.
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22. Angen MJ. Evaluating interpretive inquiry: reviewing the validity debate and opening the dialogue. Qual Health Res. 2000;10:378– 395. https://doi.org/10.1177/104973230001000308. 23. Dedoose Version 7.0.23. Web Application for Managing, Analyzing, and Presenting Qualitative and Mixed Method Research Data. 7.0.23 ed Los Angeles, CA: SocioCultural Research Consultants, LLC; 2014. 24. Tilley N. Realistic evaluation: an overview. Vol 2018. In: Presented at the Founding Conference of the Danish Evaluation Society; September 2000. 2000. 25. McKeachie WJ, Chism NVN. Teaching Tips: Strategies, Research, and Theory for College and University Teachers. 9th ed. Lexington, MA: D.C. Heath; 1994. 26. Brandon C, Jamadar D, Girish G, et al. Peer support of a faculty "writers’ circle" increases confidence and productivity in generating scholarship. Acad Radiol. 2015;22:534–538. 27. Lord JA, Mourtzanos E, McLaren K, et al. A peer mentoring group for junior clinician educators: four years’ experience. Acad Med. 2012;87:378–383. 28. DeCastro R, Sambuco D, Ubel PA, et al. Mentor networks in academic medicine: moving beyond a dyadic conception of mentoring for junior faculty researchers. Acad Med. 2013;88:488–496. 29. Demographics of Women Physicians and Pediatricians. Vol 2018: American Academy of Pediatrics.
A Qualitative Evaluation of a Clinical Faculty Mentorship Program Using a Realist Evaluation Approach Corrie E. McDaniel, DO; Sahar N. Rooholamini, MD, MPH; Arti D. Desai, MD, MSPH; Sandeep Reddy, MBBS, PhD; Susan G. Marshall, MD From the Department of Pediatrics (CE McDaniel, SN Rooholamini, AD Desai, and SG Marshall), University of Washington, Seattle, Wash; and School of Medicine (S Reddy), Deakin University, Australia The authors have no conflicts of interest to disclose. Address correspondence to Corrie E. McDaniel, DO, Department of Pediatrics, University of Washington, Seattle Children’s Hospital, 4800 Sandpoint Way NE, M/S FA.2.115, Seattle, WA 98105 (e-mail: [email protected]). Received for publication August 27, 2018; accepted August 10, 2019.
TAGEDPABSTRACT OBJECTIVE: Clinically focused faculty (full-time clinical faculty and clinician educators) comprise an increasing proportion of academic faculty, yet they underutilize mentorship nationally. The aims of this study were to test and refine a program theory for an institutional mentorship program for junior clinically focused faculty and to understand the facilitators and barriers of sustained participation. METHODS: We conducted a qualitative study using a realist evaluation approach. Between July and December 2017, we performed in-depth semistructured interviews of 2 participant groups from a junior faculty mentorship program at our institution: 1) those who attended more than two thirds of the program sessions; and 2) those who only attended 1 session. We used inductive thematic analysis to identify key context and program mechanisms that led to meaningful outcomes for faculty mentorship. RESULTS: We interviewed 23 junior faculty representing 15 pediatric specialties. We identified 4 contextual themes (past personal experience, current competing priorities, institutional
culture, and gaps in support and resources), 3 mechanisms (connecting with faculty, sharing ideas and strategies, and self-reflecting), and 3 outcomes (sense of community, acquired tools and skills, and broadened perspectives), which we organized into a programmatic theory representing the program’s impact on participants. Themes that emerged were consistent between both groups. CONCLUSIONS: A mentorship program that provided junior faculty with opportunities to connect, share ideas and strategies, and self-reflect led to improvement in meaningful outcomes for clinically focused faculty. Our program theory provides a basis for institutions seeking to build a mentorship program targeted towards this increasing proportion of junior faculty.
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expectation nationally underutilize and have fewer opportunities for mentorship than research-focused colleagues.6,7 Clinically focused faculty, whose primary roles are teaching and advancing clinical care, consistently identify unique mentorship needs, including defining a purpose, identifying a niche, finding work-life balance, and transforming educational activities into scholarship.6,8 These needs do not readily fit within mentorship structures designed to support grant writing and funded academic production.8,9 When compared to clinician-investigators, clinically focused faculty report less familiarity with the promotion process,10,11 unclear departmental or divisional expectations,6,12 slower academic advancement,9 and less opportunity for mentorship by senior mentors on similar tracks.13 While multiple models have been proposed to address absent or suboptimal mentorship for clinically focused faculty,1,9,14 these models target specific mentorship
Currently there is a limited understanding of how institutions should address the mentorship needs of clinically focused junior faculty. This study provides a programmatic basis for those seeking to build a mentorship program targeting this increasing proportion of junior faculty.
TAGEDPMENTORSHIP, A CRUCIAL component for career development within academic medicine, improves job satisfaction, leads to enhanced individual perception of institutional belonging, improves academic productivity, and increases retention.1−4 Clinically focused faculty (eg, full-time clinical [FTCF] and clinician-educator [CE] faculty) represent an expanding proportion of faculty within academic centers, increasing from 30% of faculty in 1984 to 60% in 2008.5 Yet, faculty with more than 50% clinical
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needs within a particular division or focus on a problembased model (eg, academic writing groups). They do not address mentorship improvements at an institutional level. In 2014, the University of Washington Department of Pediatrics launched the Junior Faculty Mentorship Program at Seattle Children’s Hospital in order to improve mentorship for clinical faculty within the institution. In this study, we aimed to 1) test and refine a program theory for an institutional mentorship program for clinically focused junior faculty by exploring the contextual factors and program mechanisms that led to meaningful outcomes through participation in the program, and 2) explore the facilitators and barriers for sustained participation in the program.
TAGEDH1METHODSTAGEDEN TAGEDH2CONCEPTUAL FRAMEWORKTAGEDEN We applied realist evaluation (RE), a philosophy used to develop theories as to how and why programs lead to specific outcomes.15 RE is driven by the idea that participants within an intervention are functioning within a specific social context. This context influences a participant’s behavior toward the intervention; this then impacts how the participant responds to the intervention.16 A RE elucidates the underlying theory driving an intervention with the presupposition that achieving successful outcomes is only possible if the appropriate ideas are applied to the correct context with the social and cultural conditions.17 A realist program theory encapsulates not only which outcomes are linked to the intervention, but also what mechanisms generate these outcomes and how the social context affects those mechanisms. The use of theory development within RE is not meant to capture all possible patterns of outcomes. Rather, it explains the “on the ground” workings of a program, which may drive additional programmatic refinement. Conceptually, RE is not a method or technical procedure; it is a process of inquiry to identify what is working in a program, for whom, and in what context(s). Analytically, this causal mechanism is illustrated as the ContextMechanism-Outcome (CMO) configuration. Context is composed of the background conditions in which an intervention operates.15 Mechanisms are the underlying processes that lead to specific outcomes within a given context.15 These mechanisms help to address questions of how an intervention worked and what it triggered. Lastly, Outcomes are the practical effects produced by the mechanism(s), triggered in a given context.15 They are the explicit results of the program that can be seen or observed. As mechanisms according to RE may be identified through feelings or changes in thought, these are best elicited through interviews. For this reason, we chose a qualitative approach. Consistent with RE, we undertook a 3phase evaluation process: 1) initial program theory development, 2) testing of the theory using empirical data, and 3) theory refinement.
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TAGEDH2THE JUNIOR FACULTY MENTORSHIP PROGRAMTAGEDEN Seattle Children’s Hospital is comprised of multiple medical and surgical faculty departments. The Department of Pediatrics is comprised of 530 academic faculty in more than 20 divisions and is the largest Department within the institution. Of the faculty, 75% are clinically focused and 70% of these are junior faculty, defined as Instructor, Acting Assistant, Clinical Assistant, or Assistant Professor. FTCF have predominantly clinical duties without protected scholarship time or expectation of peerreviewed scholarship for promotion. CEs are provided with 20% protected time to engage in scholarly activities with publishing expectations for promotion. In 2013 and 2015, we conducted surveys to assess faculty perceptions of mentorship. Initial results in 2013 revealed that only 59% of faculty believed that mentorship had advanced their career. Subsequent targeted needs assessment of junior clinical faculty showed that 30% could not identify a mentor and 35% had not set longterm professional goals. Of those who identified having a mentor, 37% had not communicated their goals to them. Given the importance of mentorship in early career development, the Junior Faculty Mentorship Committee (JFMP) was designed as a topic-driven, peer-oriented program, highlighting small group collaboration based on models from the education literature.18,19 As clinical faculty are often faced with nebulous issues such as worklife integration, finding institutional fit, and defining a purpose, JFMP sessions were designed to maximize social interaction with focused discussions. Topics include finding the right mentor, tips for successful publication, time management, and resilience. The JFMP structure consists of a featured speaker, often a senior faculty member with significant leadership and mentorship experience, followed by 45 minutes of small group work targeted toward the specific session topic. Each small group has 3 to 8 junior faculty and 1 senior faculty facilitator. Groups are unassigned and rotate facilitators every 10 to 15 minutes. The program meets quarterly in the afternoon (3:30−5 pm), preceding a required faculty meeting at the hospital. Sessions have an average attendance of 40 to 50 faculty. Junior faculty are encouraged to block regularly scheduled clinic hours in order to attend. A volunteer planning committee of 2 senior faculty, 3 junior faculty from different divisions, and an administrative assistant plans the sessions. Although the program is hosted by the Department of Pediatrics, it is open to all faculty within the institution. T EVELOPMENT OF INITIAL AGEDH2D
PROGRAM THEORYAGEDNTE Applying RE, we developed an initial program theory based on the research team’s understanding of the mentorship and faculty development literature and our experience with the programmatic development of the JFMP. This initial program theory included potential mechanisms by which the JFMP led to relevant outcomes: Clinically focused junior faculty under-utilize mentorship and often feel unsupported in academic
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structures created for physician-scientists or faculty with research-focused careers (Context). The JFMP creates an environment for networking with peers (junior faculty) and mentors (senior faculty) allowing for the sharing of knowledge, experience, and shared learning (Mechanism). This leads to improved job satisfaction, institutional belonging, academic productivity, and collaboration (Outcomes). T TUDY AGEDH2S
POPULATION AND RECRUITMENTTAGEDEN Faculty were eligible for the study if they were on the FTCF or CE track and had participated between January 2015 and June 2017 in either two thirds or more of the JFMP sessions or attended a single session and did not return, with a total possible attendance of 8 sessions. Eligibility was determined based on JFMP attendance records. We approached eligible faculty to participate in this study via email using a standardized template. We used purposive sampling to recruit a heterogeneous mix of faculty across subspecialties, years of experience, race and ethnicity, and whether they trained at our institution. We continued enrollment until we reached thematic saturation, where subsequent interviews revealed few new concepts or themes. Faculty received a $25 gift card for participation.
T ATA AGEDH2D
COLLECTIONTAGEDEN In-depth, semistructured interviews lasting 20 to 53 minutes (average 41 minutes) were completed by one of the research team members (C.M.). Interviews were audio-recorded and transcribed in their entirety. The interview guide included open-ended questions regarding the faculty’s past experiences with mentorship, participation in the JFMP, format of the program itself, and opportunities to improve the program (Supplement A). The interview guide was reviewed and piloted by the research team prior to its official use to optimize comprehensiveness of the content and clarity. As data collection occurred concurrently with data analysis, we iteratively revised the interview guide to reflect new patterns that emerged from our analysis. We also asked participants to complete a demographic questionnaire at the end of the interview, which included items noted to have a significant impact on junior faculty mentorship experiences, such as selfidentified gender,20 race, and ethnicity.20,21 The Seattle Children’s Institutional Review Board approved this study. AGEDH2D T ATA
ANALYSISTAGEDEN We applied a thematic analysis approach using the RE framework. First, 2 research team members (C.M. and S. R.) read and open-coded 3 transcripts to identify prominent codes. The full research team discussed and developed definitions and examples for each of these codes. We also determined whether the majority of these codes fit within the general CMO framework. Codes that were related to facilitators and barriers of program participation were coded separately.
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The 2 research members then open-coded 3 additional transcripts to identify additional prominent codes and to verify the CMO framework was applicable to these new codes. The team then met to discuss all of the codes and create a codebook (where each code is defined and illustrative excerpts identified). The codebook allowed for coding consistency through the remaining analytic process. The 2 research team members independently recoded the initial 6 interviews and then prospectively continued to independently read and code subsequent interviews. Between rounds of 3 to 4 transcripts, the team met to discuss new codes, further define codes, and revise the coding scheme. As coding progressed, research team meetings focused on combining codes into themes. We explored if and how each of the themes within the individual CMO categories was connected to each other and whether these themes and their relationships differed between the 2 groups. We compared excerpts for each theme and the overall thematic structure between the 2 groups. Additionally, we organized codes related to facilitators/barriers to program participation into overarching themes. Interviews were continued until the data reached thematic saturation in each participating group as well as a whole for the data sample. Working from the organized themes, we subsequently developed a revised program theory. We then met with 2 prior participants to review their transcripts and the revised theory as member checking to ensure that our program theory was consistent with their experiences.22 We used Dedoose Version 7.0.23 qualitative software for data analysis.23
TAGEDH1RESULTSTAGEDEN We conducted interviews with 23 faculty in 15 pediatric specialties (Table 1). Fifty seven percent (N = 13) of participants attended two thirds or more of the JFMP sessions, and 43% (N = 10) only attended 1 session. Seven faculty (30%) were within 2 years of being promotion-eligible to Associate Professor, and 1 faculty member who had attended the JFMP while junior faculty rank had undergone promotion to Associate Professor within the previous 2 months. All of the faculty in the group with sustained attendance identified as women. The majority of interviews (74%, N = 17) were conducted with faculty on the CE track, which is representative of our institution’s CE-to-FTCF ratio. The majority of participants completed a fellowship (87%) and over half (56%, N = 13) identified as non-Caucasian. We identified 10 themes, which we categorized within the CMO configuration (Table 2). Themes were consistent across the 2 attendance groups. T ONTEXTTAGEDEN AGEDH2C We identified 4 main themes within the context domain: past personal experiences, current competing priorities, institutional culture, and gaps in support and resources. First, participants described how past personal experiences during medical school, residency, fellowship, and in
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Table 1. Participant Demographics N (%) Total number of participants
Faculty track Fellowship training Years as an attending physician
Self-Identified Gender Race/Ethnicity
Specialties
Attended ≥2/3 of sessions Attended 1 session Full Time Clinical Faculty Clinical Educator Completed a fellowship program 0−2 3−5 6−8 >8 Women Men White/Caucasian Asian Black or African American Hispanic Other Adolescent Medicine, Craniofacial, Developmental and Behavioral Pediatrics, Endocrinology, Genetics, General Pediatrics, Hematology and Oncology, Hospital Medicine, Infectious Disease, Neonatology, Nephrology, Pediatric Emergency Medicine, Pulmonology, Rehabilitation Medicine, Rheumatology
23 (100) 13 (57) 10 (43) 6 (26) 17 (74) 20 (87) 3 (13) 10 (43) 7 (30) 3 (13) 19 (83) 4 (17) 10 (43) 10 (43) 2 (9) 1 (4) 0
Table 2. Illustrative Quotes Within the Context-Mechanism-Outcome Configuration Domain Context
Theme Past personal experiences Current competing priorities
Institutional culture
Gaps in support and resources
Mechanism
Connect with faculty
Share ideas and strategies
Self-reflect Outcomes
Sense of community
Acquired tools and skills
Broadened perspectives
Illustrative Quote It was hard for me to find any one person or team of people who really said, “Here’s how you sculpt your career.” B.1 Time is always against us. As junior faculty we’re asked to do lots of things and be in lots of places. A.2 I remember honestly when I was coming out here, [a colleague] made an aside comment about, “Well, in general, we’re only successful for the things we do on nights and weekends.” B.2 I think every junior faculty works individually, and they’re sort of like an island. . .even if you are in the same program, you know their research, but you really don’t get to know them. A.12 It would be nice to have someone within academic medicine that I could describe my academic position to: my medical director position, the [clinical standard] pathway work that I do, and my clinical work too, and have somebody look at me as a whole. A.9 I feel like there should be more mentorship about what does advancing mean? What does that look like? What is expected of me, especially as a clinical faculty, besides just [clinical] work? I feel like I’ve never been able to get a solid answer. B.8 I feel like the junior faculty meetings are the only place where I have gotten to know more senior members of the faculty and the junior faculty people as well. I think that is probably literally the only place, and it’s been good. A.4 I remember hearing conversations about choosing when to say yes and when to say no to things. That’s been really helpful because I sometimes think about that when I’m deciding. It feels ok to say no in some situations based on stories I’ve heard from other people. A.5 I think that in each one of the sessions, I’ve found something valuable that made me rethink how I’m functioning. A.9 I feel part of this community and that we can support each other morally and also on the research and on the clinical side, because a lot of times you share patients and it’s a lot easier to talk to your friends than someone you’ve never met. A.12 I think that starting to diagram and map my goals has been something that I can actually articulate and do, which I definitely had no idea about back when I started. A.10 What I didn’t know is that other people were having the same challenges. I was like, “Whoa! Everybody else needs this too? Oh, good! I’m so glad!” I wasn’t the only one this whole time that was feeling awash on the iceberg not knowing what to do. B.1
A, Participant who had attended ≥ two thirds of the program sessions. B, Participant who had attended one session.
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their early faculty years influenced their current perspectives on and expectations for mentorship. These included positive and negative prior mentorship connections, perceptions about optimal work-life integration, and self-perceived strengths and weaknesses. A second theme was the struggle to balance current competing priorities. Participants articulated stress around balancing time pressures, clinical requirements, academic obligations (eg, scholarship or administrative responsibilities), and personal obligations. Participants also described our local institutional culture as impacting their work experience. Some expressed feelings of isolation or lack of connection to the institution, positive and negative connections with colleagues, and perceived inequities. Inequities were anything with a value-differential, including disparities by gender, seniority, and perceived respect based on academic track. Lastly, participants identified gaps in the support and resources required to succeed and gain promotion. Some of these were unmet professional needs, perceived barriers to advancement, a lack of social support, and fragmented mentorship. TAGEDH2MECHANISMSTAGEDEN We elicited 3 main mechanisms to describe how the JFMP led to outcomes and what it triggered for participants individually. The JFMP provided opportunities to connect with faculty, share ideas and strategies, and self-reflect. One of the strongest mechanisms we identified was the opportunity to connect with other faculty within the institution. Finding camaraderie and having shared experiences with peers facing similar challenges motivated faculty to participate. Second, attending the program provided an opportunity to share ideas and strategies. During these sessions, participants noted they had the opportunity to exchange ideas and strategies with peers and senior faculty on topics such as career negotiation, navigating new opportunities, hearing practical tips on time-management techniques, and strengthening teaching skills. Third, the program provided an opportunity for faculty to self-reflect. This often came in the form of hearing the stories of other faculty and relating these to their own experiences.
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TAGEDH2OUTCOMESTAGEDEN We identified 3 outcomes that participants experienced as a result of the program: creation of a sense of community, acquisition of practical tools and skills, and broadened perspectives. Through participation within the JFMP, faculty experienced a sense of community that persisted beyond the individual programmatic sessions into stronger relationships with their peers and senior faculty across the institution. Faculty described this community as providing support and facilitating interpersonal communication and collaboration. Second, faculty acquired new tools and skills at the JFMP and subsequently applied them in their clinical practice or scholarly work. Participants described applying learned mentorship skills such as agenda setting and meeting follow-up. They also described using practical advice around technology for streamlining their work, establishing short- and long-term goals, and writing a career mission statement. Lastly, the program led to broadened perspectives in regards to faculty perceptions of their career, place within the institution, and potential opportunities for professional growth and collaboration. T EVISED AGEDH2R
PROGRAM THEORYTAGEDEN Based on the themes we identified, we developed a revised JFMP program theory: Clinically focused junior faculty approach the need for mentorship from a complex contextual milieu of competing priorities, personal experiences, institutional culture, and gaps in support and resources (Context). By providing opportunities to connect with other faculty, share ideas and strategies, and self-reflect (Mechanisms), the JFMP has led to a sense of community, the acquisition of tools and skills, and broadened perspectives (Outcomes). The Figure is a visual representation of this revised program theory, describing how through participation in the program participants’ mechanisms are influenced by contextual factors at our institution and subsequently lead to
Figure. Visual representation of the revised program theory using realist evaluation framework for the Junior Faculty Mentorship Program.
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meaningful outcomes. For example, for faculty who experience unmet mentorship needs (context), the program provided perspective on career options and paths (mechanism), which led to a change in mindset (outcome).
Table 3 provides illustrative quotes from participants to exemplify the relationships between the CMO configurations captured within individual interviews based on our RE approach.
Table 3. Illustrative Quotes Demonstrating Relationships Within the Context-Mechanism-Outcome Configuration C: Current competing priorities* M: Share ideas and strategies M: Self-reflect O: Sense of community O: Broadened perspectives
C: Current competing priorities M: Share ideas and strategies O: Acquired tools and skills
C: Institutional culture M: Share ideas and strategies M: Connect with faculty O: Sense of community
C: Gaps in support and resources M: Connect with faculty M: Share ideas and strategies O: Broadened perspective
C: Gaps in support and resources M: Self-Reflect O: Broadened perspective
It’s been hard to navigate that a bit and not feel guilty if I have to say no to one thing or another. There’s always more work to do and if you don’t get something done, then does that mean that one of your colleagues is going to have to pick up and do it for you? Or does it mean that you’re going to miss out on an opportunity to move things forward in another part of your career? And so I’m feeling guilty that I’m not taking advantage of all of the things at my disposal. . .and then on the flip side, I feel guilty if I miss out on something with my kids. . .I think [the program started me] thinking strategically about career. Not thinking, “ Oh my gosh, I’ve got to get promoted,” like big picture, but thinking more like the small steps along the way. So it’s changed my mindset in terms of the goals I’m trying to accomplish. . .I definitely have peers [outside of my division] who also participated in the program and it’s helped us hone in on what do we need to be successful instead of us just brainstorming our own ideas on what kind of tasks we should take or not. For example, it might come up that an opportunity was available to become clinical director of your division, and so before we’d just talk about it like, “Oh my gosh, what do you think this’ll mean? Oh, will I be able to pick up my kids from pre-school?” Those kind of things. But [now], we think more strategically about it, “Is this going to be a career move for me? Is this going to put me in a place where I’m going to be able to have more opportunities or not?” So it’s kind of shifted our conversations around opportunities that come up. A.2 It’s pretty much all clinical time, so if you ever want to do anything that’s outside of your clinical schedule, then you’re really having to just add it onto your plate of your clinical work. I think just the logistics of trying to do your shifts, especially when you’re a day shift and night shift worker, and to do other projects can be overwhelming. . .It just can be exhausting from a time perspective. I think there are sometimes when I feel burned out, even though I’m doing things that I like. . .I love hearing, or sharing ideas among faculty, because people are coming with so many different views, and day-to-day life experiences, and things they’re having to do, so sometimes someone has a great idea that works well for you. . . I think I’m more protective of what I do, and my time. Like I say no more than I used to, and that’s come from the sessions. Like really being mindful that you can’t be on every single committee. It’s important for me to pick things that I think will actually give to me just as much as I give to them. It goes back to being very intentional now about what I choose to do. A.10 Even though I had identified somebody as a mentor, I still didn’t feel like I was equivalent to someone who has trained here. I feel like I didn’t get the same opportunities. . .[In the program] I think it’s great to hear from senior members that have those “ A-ha!” moments. I think, it’s good to hear their stories because I think that, sometimes, it gives you clues on how to not make those things happen, and try to make the right choices. I would say the one helpful thing is it was nice to see colleagues there in that boat. [The program] promotes a little bit of collegiality. I think in that way it improves job satisfaction because it’s easier to email that person that you’ve already met to say, "Hey, let me ask this question about a patient.” It’s for the greater good. Sometimes, it’s for the greater good of your research, or research collaboration, or for your trainees’ collaboration. A.6 So [I was] going back and forth between different possible scholarly outputs or research experiences for myself. Quality improvement work versus trying to create a cohort of a certain group of patients, and then abstracting that data all myself. Things I did as a fellow when I had a ton more time for research, but to do now would be almost impossible. . .Then I got the email [about the program], and some of the other younger faculty said you should go to this. . .And so I went. I think I was anxious about some of these things that we’re talking about. Maybe this is going to be a place where I can get some answers to these things. Or at least be in the company of people who have similar concerns. . . We were at tables, and people rotated around and talked to us. People who were senior faculty were kind of sharing their experiences, and giving their advice on things, and we were asking questions. So that was helpful...It was helpful to hear them say, "Oh I was in that situation", or "I remember feeling overwhelmed", things like that. B.3 I don’t really have a mentor who I think that I’m like at all. I don’t have any full-time clinical faculty mentors. Everybody who is my mentor is a clinician educator, a clinician researcher. And then I think being the medical director of the clinic, I don’t have anybody who’s in a similar leadership position who I think of as a direct mentor . . .I think in particular, hearing women talk about being in this academic setting and their blend of teaching and research and clinical care makes me feel like I can do it. . . I think that each one of the sessions, I’ve found something valuable that made me rethink how I’m functioning. . . I think when I go into meetings, I, at the same time that I’m sharing problems, I’m also sharing solutions and so. . .I’m coming up with solutions for my own problems. A.9
A, Participant who had attended ≥ two thirds of the program sessions. B, Participant who had attended one session. *Lines in bold represent Context. Lines in italics represent Mechanisms. Lines in standard formatting represent Outcomes.
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Table 4. Barriers for Sustained Participation in the Junior Faculty Mentorship Program Time and location limitations
Perceived lack of fit
Individual priorities
And I really have been bummed that I haven’t made it to any of the other ones, and it’s purely been that I have clinic on Wednesdays a lot where I’m on service. And it’s challenging to go for that time. B.1 I have a kid who’s under five and child care is not provided for that group of kids and that’s right around the time when I have to relieve my child care for the day and I have to get home and be with him and start his bedtime. B.8 I do remember the issue of I’m not sure what side of this I fall on, because I am now mid-career. B.2 I’m not a big networking person, and I do think that some people really value those opportunities. I’m just not one of them, I’m not good at that, and it’s hard for me to take something out of those meetings, where that’s the goal. B.3 I feel like there’s people I can reach out to for mentorship, and with having a kid, honestly, meetings that I don’t have to go to are lower on the priority. B.9 I’m looking at some of these topics and most of them sound intriguing and I would have gone, or I would want to go, but then there’s a [specialty] meeting or there’s all the other stuff. I think that the balance of the lack of time that we have, I think we just have to be protective about this. This is one of the things where it would be good, but I’d rather get my stuff done so I can go home. Those become, sort of, the pragmatic things that get in the way. B.4
B, Participant who had attended one session and not returned.
TAGEDH2BARRIERS TO SUSTAINED PARTICIPATIONTAGEDEN We identified 3 main barriers for sustained participation: 1) time and location limitations, 2) perceived lack of fit within the program, and 3) individual priorities (Table 4). Participants identified practical limitations as the most common reason for lack of sustained participation, such as childcare constraints and clinical responsibilities. Suggestions from participants to mitigate these included offering sessions at different times during the day such as shorter lunchtime opportunities, providing childcare during the session, and expanding remote web-based participation options (both live and recorded). Second, the JFMP structure itself was a barrier for some participants. As some of the faculty were close to or had completed the promotions process from junior to midlevel faculty, they expressed concern whether the program still targeted their changing needs or if they would have a place in the program after promotion. Additionally, as the sessions are designed to facilitate group interaction and discussion, some expressed feelings of discomfort with large group interactions. Participants suggested incorporating newly promoted Associate Professors as small group mentors, tailoring specific small groups to be Associate Professors only, and having assigned rather than rotating small groups for discussion. As a reflection of the context of current competing priorities, some participants described prioritizing between multiple opportunities. Ongoing participation in the JFMP was not seen as a priority for participants who already had adequate mentorship support, immovable job conflicts, or personal work-life balance choices. To mitigate these barriers, participants suggested ways to stay connected to the JFMP such as receiving electronic notifications about upcoming sessions or social opportunities for connection with peers in the future.
TAGEDH1DISCUSSIONTAGEDEN Through the utilization of the RE approach, we developed a robust understanding of the relationships between
the social context from which clinical junior faculty approach mentorship and the underlying mechanisms for why and how JFMP participants responded to the program within that context. Participation in the JFMP created opportunities for faculty to connect with each other, share ideas and strategies, and self-reflect, leading to the creation of community, acquisition of practical tools and skills, and broadened perspectives. Barriers to the program included time and location limitations, perceived lack of fit, and competing priorities. By understanding these social dynamics and relationships within the CMO configuration,24 our revised program theory describes an institutional approach toward mentorship for clinically focused junior faculty. As participants included a diverse representation of faculty, spanning specialty, race/ethnicity, and training, the developed theory represents a potentially transferrable basis for other institutions seeking to build such programs. Through small group activities, the JFMP facilitated connection and the exchange of ideas between peers, providing a space for participants to address the more ill-defined issues that clinical junior faculty face. This is consistent within the literature where small-group collaboration that incorporates “think-aloud” interactions has been shown to lead to improved problem solving of nebulous problems, improved critical thinking, and increased development of positive attitudes.18,25 Other institutions of comparable size and complexity may consider the application of similar interventions specifically targeting the underlying mechanisms revealed through the revised program theory. This may help to address larger, similar contextual factors and ultimately lead to the improved creation of community, skills, and perspectives within their faculty. Our contextual themes (past experiences, competing priorities, institutional culture, and gaps in support and resources) reflect the struggle that clinically focused faculty experience between professional and personal obligations, clinical and nonclinical (research, administrative, and quality improvement) responsibilities, and trying to find a fit within a large academic institution. In many institutions, CE and FTCF tracks are new, often resulting
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in faculty attempting to navigate their own paths with various levels of support and mentorship towards career development.2,6,8−10 In building an institutional mentorship program, accounting for these contextual factors may increase sustainability and engagement. The JFMP program created an opportunity for both internal reflection and external engagement with colleagues. While it was not designed to replace in-depth dyadic mentoring relationships, the topic-targeted sessions and small-group exercises created opportunities for faculty to interact and learn from one another. These mechanisms are consistent with published literature around peer support groups, writing groups, and project collaboration.14,26,27 These examples engage faculty in communication, collaboration, and connection, ultimately leading to engagement, confidence, productivity, and mutual learning.14,26−28 Such published examples, however, are limited to specific populations, often a single division or group with a focused purpose such as a writing group. Building upon these, the JFMP further demonstrates transferability of these concepts onto a broader institutional level by spanning divisions and departments. Barriers to sustained participation reflect the reality of competing responsibilities that faculty balance. While the JFMP was not able to address every faculty member’s individual mentorship needs, faculty who only attended a single session described the same themes for how and why the program was impactful and expressed desire for the opportunity to be involved in the future. Ultimately, this underscores the strength of the revised program theory, as the context and mechanisms experienced by participants who attended even once represent concepts more broadly experienced by clinically focused junior faculty. Lastly, 80% of our participants were women. While this is representative of the pediatric workforce,29 gender remains an identified gap within academic mentorship.20 Women specifically identify challenges in finding research role models and the mixed-model structure of the JFMP with rotating senior and junior faculty interactions may directly address this. Next steps include expanding to medical or surgical specialties where there is not a predominance of women within the workforce in order to further delineate the potential role of such a program to target this known mentorship gap. Our study has several limitations. Our revised program theory may not be transferrable to institutions dissimilar in size, complexity, or contextual factors. This study focused only on clinical faculty and the program theory may not translate to research-focused faculty. We also did not interview clinical junior faculty who were invited to the program but never attended. These individuals may represent a population with differing needs within our institution that are not currently represented in our sample. We also were unable to look at long-term outcomes such as promotions or publications as a result of participation in this program. Although beyond the scope of this evaluation, ultimately we hope to demonstrate such outcomes for faculty attendance.
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TAGEDH1CONCLUSIONSTAGEDEN The mentorship experiences of clinically focused junior faculty stem from their unique context within academic medicine. Mentorship programs that provide opportunities for faculty to connect, share ideas and strategies, and selfreflect may help to cultivate community, practical skills, and broadened perspectives. Our revised program theory serves as a potential basis for building successful institutional mentorship programs that lead to meaningful outcomes for this growing population of junior faculty.
TAGEDH1ACKNOWLEDGMENTSTAGEDEN We thank Drs Leslie Walker-Harding, Richard Shugerman, Thida Ong, Yongdong Zhao, and Bruder Stapleton for their incredible vision and support of the University of Washington JFMP. Human Subjects: This study was formally reviewed and approved by the Institutional Review Board at Seattle Children’s Hospital, STUDY00000571. Funding: This project was supported through the 2017 Small Grants Fund through the Center for Learning in Medical Education at the University of Washington. The funding source had no involvement in study design, data collection, analysis, writing of this manuscript, or decision to submit for publication. Dr. Desai’s time was supported by Agency for Healthcare Research and Quality grant K08 HS024299 (PI Desai).
TAGEDH1SUPPLEMENTARY DATATAGEDEN Supplementary data related to this article can be found online at https://doi.org/10.1016/j.acap.2019.08.008.
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