A Study on the Challenges of Morning Report in Clinical Education : A Phenomenological Study

1School of Medical Education, Student’s Research Office, Shahid Beheshti University of Medical Sciences, Tehran, Iran 2Department of Medical Education, School of Medical Education, Shahid Beheshti University of Medical Sciences, Tehran, Iran 3Research Fellow at Department of Learning, Informatics, Managementand Ethics, Karolinska Institutet, Stockholm, Sweden 4School of Medicine, Kashan University of Medical Sciences, Kashan, Iran 5Iranian Research Center on Aging, University of Social Welfare and Rehabilitation Sciences, Tehran, Iran.

Clinical teaching which lies at the heart of medical education, focuses on patients and their problems 1 .One of the clinical teaching methods is morning report which is also called ''one-room schoolhouse'' It is designed to monitor the quality of the procedures done for patients in the previous night.It can ensure continuity of care, provide a mutual learning experience for residents and medical students and give doctors the opportunity to assess the quality of the night shifts 2,3 .The purposes of morning reports are diverse but usually include case-oriented teaching, evaluation of the residents' knowledge, discussion of management dilemmas, and supervision of medical staff by the chief of service 4 .
Since morning reports play a crucial role in training it deserves a special attention 5 .In recent years, some educators have reported high risk iatrogenic complications 6 , decline of supervision 7 ,and lack of adequate evaluation and feedback mechanisms in academic medical services 8 .Lately, it was reported that many clinical skills could be better evaluated in the course of residency training 9-11.Morning report is considered as an important tool for documenting clinical competence too 11 .Such documentation is becoming increasingly important for graduates who enter the medical professions 12 where more accurate verification of clinical skills is required in the letters of recommendation.In this regard, morning reports can provide a good opportunity for learning practical tips in the issue of patient management 3,6 .Obviously, due to the lack of time, just purposeful and planned use of this opportunity, can lead to learning 13 .Unfortunately, in most cases, morning report procedure is not designed properly and it is not matched with the objectives.On the other hand, it cannot meet the expectations of different learner groups 4,14 and the results of its process are rarely evaluated 15 .Many studies have reported the features and goals of morning report and attitudes of the stakeholders 5,13 .However, there is no enough evidence about the experiences of medical students and residents who participate in morning report sessions.Therefore the researchers of the present study decided to conduct a qualitative research with purpose of describing medical students and resident's experiences about morning report.

MATERIALS AND METHODS
In this study a descriptive phenomenological approach was used to explore the challenges of morning report sessions.Data were gathered by interviewing informant persons and were analyzed by the Colaizzi's seven step method.Colaizzi (1978) developed a descriptive phenomenological method in order 'to achieve a description of the meaning of an experience from the participant's point of view.As each person has an understanding of the world which is based upon his/her own experiences, one way to ascertain the perceptions of the person about his/her experiences is interview 16 .
Data were collected during May to August 2015 and the study populations consisted of medical students and residents who participated in morning reports.They were 6 residents and 3 medical students studying in 6 th year.The participants were interviewed after obtaining informed consent.The place for individual interviews was Taleghani hospital in Tehran.Each interview lasted about 35 min.The interview started with an open question such as "What does come to your mind when you hear morning report?"and it continued with probing questions.Sampling was Purposive and data collection continued until the researcher found out that data saturation was reached.The data were saturated with 9 interviews.Interviews were digitally audio recorded and transcribed verbatim .Personal identifications weres replaced by a participant ID number to ensure confidentiality (Project Registration Number : 47812).
As mentioned above, the Colaizzi' s seven-step phenomenological method was used to analyze the interview data 16 1.Each participant's transcript was read several times to achieve a deep understanding and make sense of the description.2. The sentences and phrases of each individual transcript that were directly related to the under investigation phenomenon were highlighted and extracted, 3. Formulated meanings of each significant statement were created.4. The researcher repeated these steps for each transcript immediately after the interviews and then aggregated formulated meanings into clusters of themes and then into emergent themes 5. Three emergent themes were identified and an exhaustive description was developed.6.The essential structure of the description of the experience was identified.7. Finally, the essential structure was validated by the participants.
Trustworthiness: The researcher and supervisors had sessions regularly to discuss and verify the accuracy of the emerging themes and the meaning of each theme.A theme was not accepted unless there was a general consensus on it.The researcher had a long engagement with data during the period of research.The analysis was checked and confirmed by 4 other experts (peer check).To ensure the rigor of the analysis "member check" was used too.The themes and concepts which were extracted from medical students and resident's experiences were sent back through emails to all the participants for verification and confirmation of the researcher's interpretation 17 .All of the participants agreed that the results of study reflect their point of views about morning reports.

RESULTS
Nine participants were participated in the face to face in-depth interviews.All of the participants were originally from Tehran and the majority of them were married.The mean age of the participants was 34.3 and included 5 female and 4 male students.The following three major themes emerged from the findings: (1) anxiety-provoking (2) faculty's competency (3) organization of morning report.

Anxiety-provoking
Anxiety-provoking was one of the important emergent themes in the study which had three theme clusters: (1) Inappropriate behavior (2) education with stress (3) Interaction between faculty and students.
Most participants including residents and interns emphasized that the environment of morning report is not suitable for effective learning.They believed that it is a fearful place which prevent them of a good learning and asking free questions.It was described as a trial in court.

A participant describes morning reports in this way
"The only thing you can think about the morning report after a night shift is stress.and normally you can study the same lessons without stress, but as you go to present you patients in a morning report, suddenly the simple things you do every day, become big and difficult." Another resident states "Presenting in morning report looks like a divine punishment.Some teachers fail students, what is associated with aggression, asking why didn't you study?go and study.Stress is one of the important issues we always have in presenting patients.The stress morning reports makes students reluctant to introduce freaking and complicated cases.Morning report is a place where we can learn, not a place for fighting or quarrelling."

One of the interns says
In morning report, sometimes the insistence on learning is so extreme that the teachers insult.Sometimes, unfortunately, the instructor cannot control himself and mistreat the student.

Faculty's competency
Based on the data analysis, this emergent theme was specified with two theme clusters of: 1. Teacher's responsibility for training 2. Role of competent professor in clinical education.
Most residents and interns believed that faculty members had a significant role in the morning report, selecting cases and mastering discussions.On the other hand, faculty members' qualifications, such as communication skills, flexibility, skills to guide discussions, skills to ask questions, are effective in the success of morning report.

A participants explains this issue
There are some days that professors select the topics which are not too important.If the morning report is well held, it has a learning value.

Another resident says
In morning reports, it is better to explain the important measures.That is very useful to say what the next action is, rather than just talking about the patient's details.It is not necessary to start explaining an unnecessary thing, morning report is not a proper place for it.They should be discussed in regular classes.

One of the interns mentions to the competency of instructor in this way
It happened for me that although we were awake during a night shift, we went to the next morning report and learnt something new.That is so good if the professor comes and calls the student to start a scientific discussion.

Organization of Morning Reports
Based on data analysis, the emergent theme of "Organization of morning reports" was specified with four theme clusters: 1. Moderate quality of morning reports, 2. Lack of attention to the training of interns, 3. Absence of other specialists and 4. Limited opportunities for study.
Most students stated that the method of holding morning reports should be preferred to its contents.They believe that presenting cases with a good preparation, limited number of cases, adequate discussions, and problem oriented discussions are preferred.Interactive discussions, active participation, step by step presentation, comprehensive approaches, and considering the training of interns, as well as the presence of an expert in morning report meetings were also highlighted by the participants.

One of the participants says
It is better to have fellowship students in morning report sessions to use their experiences.We can learn what they say.It is better to invite them to morning report sessions so they can talk about the subjects too.

The other resident state
The quality of morning report is average, because they don't hold CT or X-ray classes.Depending on the case and whether the professor knows the issue, they discuss.We sometimes see that professors speak for themselves, students are not engaged in discussions, and we are busy with our mobiles.

Another student says
In some morning reports, we don't achieve a certain diagnosis.Or they don't tell us the way of diagnose it.Sometimes, morning report a place to raise several differential diagnosis and there is no conclusion.

DISCUSSION
The findings of this research, which describes the experiences of medical students about morning report meetings, represented some desirable and undesirable experiences.The important concepts in experiences of residents and medical interns were: "anxiety-provoking, faculty`s competency and organization of morning report".The results indicate that the environment of morning reports is stressful for students and it can have negative effect on the learning process.In this research, the experiences of residents and medical interns demonstrated a lack of desirable communication in the morning reports; hence the competency of the instructors including his/her communication skills is very important for students.In comparison with other studies, it is revealed that there were similarities between the participants' experiences of present study and the results other investigations.It has been suggested that a suitable professional communication contributes to recognition of both individuals and professional identity (18).In his contribution, Harris refers to establishment of a positive and enjoyable environment as a pleasant learning atmosphere and achieving good experiences (15).In another study, Sacher and Durning pointed out that instructions result in better learning when a more pleasurable communication and a friendly atmosphere is felt by students (19, 20).In the Brancati's study (14), the defensive reactions and emotional harassment resulting from fear have been reported, which had a massive effect on the quality of learning and experiences of the students.Thus, a clinical teacher must have a good mutual communication with his/her students.Learning process does not occur well unless the teacher establishes a friendly relationship with the students.A respectful treatment for students will lead to self-confidence, providing a support for learners.
Another experience of residents and medical interns reported in this study was the potency of professor for managing the sessions.The presence of an empowered and enthusiastic teacher who has enough managing skills and acts as a facilitator provides a good experience for students.These finding are consistent with Houghhtalen and James's study too 21,22 .
Most of the participants in the present study have emphasized on the interactive conversations and managing step-by-step discussions which is also consistent with Ways and Gross's study 4,23 .In this study, paying attention to the needs of medical staff as a whole has been emphasized.In the other words, if all of the learners have to be engaged in morning report, it should meet their learning requirements.Review of the literature reveals that some believe the participants should be at the same level (e.g.only residents), whereas others support the presence of various groups (students, interns in addition to residents).However, in order to improve the morning report process in a clinical setting, the needs of various learner groups with different levels should be considered.Our study showed that organization of morning report was another issue reported by students particularly interns.Non-specified goals, lack of agenda and the absence of an schedule for morning report sessions, unsuitable organization of morning report, described by participants are in line with the studies of Harris and Gross 15,23 .In fact one of the main objectives of the morning report is a "medical training" 24 .The method of proper diagnosis and treatment, clinically reasoning during evaluation and administration of complicated condition 25 , getting information about the newly hospitalized cases, and 21 , solving the blurred problems, recognition and enhancement of skills, appraisal of clinical performance as a mean for promotion in clinical services 5,26 are other specific goals which have been reported by participants in this study too.
In the present study, most of residents believe that the presence of specialists from other disciplines can improve the morning report quality.According to other results, the presence of specialists from other disciplines such as nutritionists, clinical pharmacists and radiologists can increase the richness of contents and improve the treatment performance for patients (3, 27).So it can be said, the learning process in morning reports has several aspects but transforming into a more effective instructional activity is possible.

CONCLUSION
Considering the valuable role of morning report in medical training, it seems that more attention should be paid to improve its quality.The environment of morning report is described stressful by students, and they do not experience a good communication with instructors.This situation can negatively influence on learning.The process which can enhance the quality of morning report meetings, needs to be investigated in the further studies using other methods such as Grounded Theory.