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• Published: 03 June 2024

Evaluating competency-based medical education: a systematized review of current practices

• Nouf Sulaiman Alharbi 1 , 2 , 3  

BMC Medical Education volume  24 , Article number:  612 ( 2024 ) Cite this article

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Few published articles provide a comprehensive overview of the available evidence on the topic of evaluating competency-based medical education (CBME) curricula. The purpose of this review is therefore to synthesize the available evidence on the evaluation practices for competency-based curricula employed in schools and programs for undergraduate and postgraduate health professionals.

This systematized review was conducted following the systematic reviews approach with minor modifications to synthesize the findings of published studies that examined the evaluation of CBME undergraduate and postgraduate programs for health professionals.

Thirty-eight articles met the inclusion criteria and reported evaluation practices in CBME curricula from various countries and regions worldwide, such as Canada, China, Turkey, and West Africa. 57% of the evaluated programs were at the postgraduate level, and 71% were in the field of medicine. The results revealed variation in reporting evaluation practices, with numerous studies failing to clarify evaluations’ objectives, approaches, tools, and standards as well as how evaluations were reported and communicated. It was noted that questionnaires were the primary tool employed for evaluating programs, often combined with interviews or focus groups. Furthermore, the utilized evaluation standards considered the well-known competencies framework, specialized association guidelines, and accreditation criteria.

This review calls attention to the importance of ensuring that reports of evaluation experiences include certain essential elements of evaluation to better inform theory and practice.

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Medical education worldwide is embracing the move toward outcome-based education (OBME) [ 1 , 2 ]. One of the most popular outcome-based approaches being widely adopted by medical schools worldwide is competency-based medical education (CBME) [ 3 ]. CBME considers competencies as the ultimate outcomes that should guide curriculum development at all steps or stages—that is, implementation, assessment, and evaluation [ 3 , 4 , 5 ]. To embrace CBME and prepare medical students for practice, medical educators usually utilize an organized national or international competency framework that describes the abilities that physicians must possess to meet the needs of patients and society. There are numerous global competency frameworks that reflect the characteristics of a competent doctor, for example, CanMEDS, Scottish Doctor, Medical School Projects, ACGME Outcome Project, the Netherlands National Framework, and Saudi Meds [ 1 , 6 , 7 , 8 ].

With the worldwide implementation of CBME and availability of different competency frameworks, educators are expected to evaluate various modifications made to existing medical curricula [ 9 , 10 ]. Such evaluation is intended to explore whether the program is operating as planned and its outcomes are achieved as intended in comparison to predetermined standards as well as to ensure improvement [ 11 , 12 , 13 ]. Furthermore, program evaluation revolves around two main concepts, that is, merit and worth [ 12 , 14 ]. In 1981, Guba and Lincoln explained that the merits of a program are intrinsic, implicit, and independent and do not refer to a specific context or application, while evaluating a program’s worth entails judging the value of any aspect of it in reference to a certain context or precise application [ 12 , 14 ].

To enable educators to determine the merits and worth of an educational program or curriculum, evaluation experts have proposed several models [ 14 , 15 ]. Evaluation models are guiding frameworks that demonstrate what appropriate evaluation looks like and detail how it should be designed and implemented [ 16 ]. Although almost all evaluation models focus on exploring whether a program attains its objectives, they vary in numerous aspects, including their evaluation philosophy, approaches, and the specific areas that they encompass [ 17 ].

It is essential that educators choose a suitable evaluation model when they implement CBME, as the right model will enable them to pinpoint [ 15 , 18 , 19 ]. In other words, a program helps identify areas of success, challenges, and opportunities for improvement in CBME implementation, leading to a deeper comprehension of CBME strategies and their effectiveness. Moreover, implementing CBME demands significant efforts and a wide range of financial, human, time, and infrastructure resources [ 20 ]. Thus, ensuring that these efforts and resources are well utilized to enhance educational and healthcare outcomes is crucial. In addition, evaluation provides valuable evidence for accreditation, quality assurance, policies, and guidelines. Otherwise put, it supports informed decision-making on many levels [ 21 ]. On another front, sharing evaluation results and being transparent about evaluation processes can enhance public trust in available programs, colleges, and universities [ 19 ]. However, deciding which evaluation model to adopt can be challenging [ 9 ].

Not only can it be difficult to select an appropriate model to evaluate a CBME program, but CBME evaluation itself has numerous challenges, particularly given the lack of a common definition or standardized description of what constitutes a CBME program [ 9 , 22 , 23 ]. The complexity of CBME further tangles evaluation efforts, given the multilayered nature of CBME’s activities and outcomes and the need to engage a wide variety of stakeholders [ 11 ]. Moreover, the scarcity and variable quality of reporting in studies focusing on the evaluation of CBME curricula exacerbate these challenges [ 24 ]. Furthermore, few published articles provide a comprehensive overview of available evidence on the topic.

This review is therefore designed to synthesize the findings of published studies that have reported CBME evaluation practices in undergraduate and postgraduate medical schools and programs. Its objective is to explore which CBME program evaluation practices have been reported in the literature by inspecting which evaluation objectives, models, tools, and standards were described in the included studies. In addition, the review inspects the results of evaluations and how they were shared. Thus, the review will serve in supporting educators to make evidence-based decisions when designing a CBME program. In addition, it will provide a useful resource for educators to embrace what was done right, learn from what was done wrong, improve many current evaluation practices, and compare different CBME interventions across various contexts.

Following a preliminary search within relevant journals for publications addressing evaluation practices utilized to assess competency-based curricula in medical education, the researcher used the PEO (participant, educational aspect, and outcomes) model to set and formulate the search question [ 24 ] as follows: participants : healthcare professionals and healthcare profession students; educational aspect : CBME curricula; outcome : program evaluation practices.

Next, the researcher created a clear plan for the review protocol. This review is classified as a systematized review rather than a systematic review [ 25 ]. While it does not meet the criteria for a systematic review because it relies on a single researcher and does not evaluate the quality of the studies included, it adheres to most of the steps outlined in the “Systematic Reviews in Medical Education: A Practical Approach: AMEE guide 94” [ 26 ]. Moreover, the researcher met with a medical educator with a strong background in CBME, an expert in review methods, and a librarian who is an expert in available databases and provided guidance and support for navigating such databases. Feedback was obtained from all three and used to finalize the review protocol. The protocol was followed to ensure that the research progressed in a consistent and systematized manner.

For this review, full-text articles published in peer-reviewed journals in English from 1 January 2000 to 31 December 2022 were searched within the following electronic data bases: PubMed, ERIC, Education Source, and CINHAL. The following terms were utilized to conduct the search: (Competency Based Medical Education OR Outcome Based Medical Education) AND (Evaluation OR assessment) AND (Undergraduate OR Postgraduate) AND (Implementing OR Performance OR Framework OR Program* OR Project OR Curriculum OR Outcome) (Additional file 1 ).

The researcher included articles that were published in English and reported evaluation practices for CBME or OBME curricula whether for undergraduate or postgraduate healthcare professionals. The researcher did not consider research reviews, commentaries, perspective articles, conference proceedings, and graduate theses in this review. In addition, articles that addressed students’ assessments rather than program evaluation were not included. Furthermore, articles that focused on teaching a particular skill (e.g., communication skills) or specific educational strategies (e.g., the effectiveness of Problem Based Learning) were excluded from this review.

To facilitate the screening of articles and ensure the process was properly documented, an online review software that streamlines the production of reviews (Covidence) was utilized, and all the lists of articles retrieved from the specified databases were uploaded to the tool website (available at www.covidence.org ). The tool set the screening to start with the titles and abstracts then to proceed to full texts. During these stages, the reasons for excluding an article were precisely noted. Moreover, the PRISMA diagram (available at http://www.prisma-statement.org/ ) was produced by Covidence to illustrate the process of screening and including articles in this review.

After the decision was made to include an article, a data extraction tool created for the purpose of this review was used (Additional file 2 ). Since the term “program evaluation practices” is general and does not clearly define the method or focus of the analysis involved in critiquing evaluation efforts, the analysis of available evaluation practices in this review was based on the Embedded Evaluation Model (EEM) provided by Giancola (2020) for educators to consider when embedding evaluations into educational program designs and development [ 27 ]. The EEM outlines several steps. In the first step, “Define,” educators are expected to build an understanding of the evaluated program, including its logic and context. In the second step, “Plan,” educators must establish the evaluation-specific objectives and questions and select the model or approach along with the methods or tools that will be utilized to achieve those objectives. The next step, “Implement and Analyze,” requires educators to determine how the data will be collected, analyzed, and managed. In the fourth step, “Interpret the Results,” educators are expected to derive insights from the results in terms of how the evaluation can help with resolving issues and improving the program as well as how the results should be communicated and employed. Finally, in the “Inform and Refine” step, educators should focus on applying the results to realize improvements to the program and promote accountability [ 27 ].

In addition to supporting the aim of the current review, the theoretical insights from Giancola (2020) help to ensure alignment with best practices in curriculum evaluation. Thus, for each article, the extraction tool collected the following information: the author, the publication year, the country and name of the institution that implemented the CBME curriculum, the aim and method of the article, the type of curriculum based on the health profession specialty (e.g., medicine, nursing), the level of the curriculum (postgraduate or undergraduate), the evaluation objective, the approach/model or tool, the evaluation standard, the evaluation results, and the sharing of the evaluation results. The extracted information points are essential to contextualize the evaluation and allow educators to make sense of it and adapt or adjust it to their own situations. Understanding the context of an evaluation is important considering the wide variety of available educational environments, the diversity of evaluators, and the differences in goals, modes, and benchmarks for evaluation, all of which influence how an evaluation is framed and conducted [ 27 ].

The author, publication year , and name and country of the institution that implemented the CBME curriculum provide identifiers for the original article and enable educators to seek further information about a study. The aim and method of the article were highlighted because they clarify the general context in which the evaluation was conducted. For example, this information can help educators understand whether an evaluation was carried out as a single action in response to a certain problem or was a phase or part of a larger project. The type of curriculum based on the health profession specialty (e.g., medicine, nursing) along with the level of the curriculum (postgraduate or undergraduate) have specific implications related to the nature of each specialty and the level of the competencies associated with the advancement of the program. All of the previously mentioned information is vital for educators to define and understand the program they are aiming to evaluate, which is the first step in the EEM. The evaluation objective , approach/model or tool , evaluation standard , evaluation results , and sharing of the evaluation results help to answer the research question of the current review by dissecting various aspects of the evaluation activities. In addition, the reporting of these aspects provides valuable insight into evaluation directives, plans, and execution. For educators, the evaluation objective usually clarifies the focus of the evaluation (e.g., how the program was implemented, the action done to execute education or outcomes of the program, and its effectiveness). The approach/model or tool of an evaluation is a core element of the design and implementation of the evaluation, as it determines the theoretical guidelines that underlie the evaluation and the practical steps for its execution. Based on the evaluation standard, which refers to the target used to compare the evidence or results of the evaluation, educators can judge the relevance of the evaluation to their own practices or activities. This information aligns with steps two and three of the EEM. The evaluation results are the results of the evaluation, which form the cornerstone for emerging solutions or future improvements. Finally, sharing the evaluation results , or communicating the evaluation, is a key part of handling the results and working toward their application. This information is aligned with steps four and five of the EEM.

Search results

Searching the identified databases revealed a total of 640 articles, and 183 total duplicates were removed. A total of 457 articles was considered for screening (371 PubMed, 13 ERIC, 23 Education Source, 50 CINHAL) (Fig.  1 ). Of those articles, 87 were retrieved for full-text screening. Ultimately, 38 studies met the inclusion criteria and were considered eligible to be included in the current review.

Flowchart illustrating the process of including articles in the review

Findings of the included studies

The 38 studies that met the inclusion criteria were published between 2010 and 2021, and the majority (15%; n  = 6) were published in 2019. The studies represented the following countries: Canada (37%, n  = 14) [ 10 , 11 , 28 , 29 , 30 , 31 , 32 , 33 , 34 , 35 , 36 , 37 , 38 , 39 ], USA (27.5%, n  = 11) [ 40 , 41 , 42 , 43 , 44 , 45 , 46 , 47 , 48 , 49 , 50 ], Australia (5%, n  = 2) [ 51 , 52 ], China (5%, n  = 2) [ 53 , 54 ], Dutch Caribbean islands (2.5%, n  = 1) [ 55 ], Germany (2.5%, n  = 1) [ 56 ], Guatemala (2.5%, n  = 1) [ 57 ], Korea (2.5%, n  = 1) [ 58 ], the Netherlands (2.5%, n  = 1) [ 59 ], New Zealand (2.5%, n  = 1) [ 60 ], The Republic of Haiti (2.5%, n  = 1) [ 61 ], Turkey (2.5%, n  = 1) [ 62 ], and the region of West Africa (2.5%, n  = 1) [ 63 ].

According to the evidence synthesized from the included studies, most of the evaluation practices were reported in competency-based curricula that targeted the level of postgraduate professionals (57%, n  = 22) and were medical in nature (71%, n  = 27) (Fig.  2 ).

Curricula specialties in included articles

The findings showed that 37% ( n  = 14) of the articles did not report the precise objective of evaluating the curriculum. Moreover, 84% ( n  = 32) did not report the evaluation approach or model used to assess the described curricula. The approaches or models reported include Pawson’s model of realist program evaluation [ 37 ], theory-based evaluation approaches [ 10 ], Stufflebeam’s context, inputs, processes, and products (CIPP) model [ 62 ], the concerns-based adoption model, sensemaking and outcome harvesting [ 33 ]the CIPP model [ 48 ], and quality improvement (QI) for program and process improvement [ 50 ]. On the other hand, a wide variety of evaluation tools was reported including observations (3%, n  = 1) [ 28 ] surveys or questionnaires (58%, n  = 22) [ 10 , 28 , 29 , 31 , 34 , 35 , 36 , 38 , 39 , 41 , 42 , 45 , 49 , 50 , 51 , 52 , 53 , 55 , 56 , 58 , 59 , 63 ] interviews (16%, n  = 6) [ 10 , 28 , 37 , 41 , 47 , 62 ], focus groups (13%, n  = 5) [ 35 , 37 , 41 , 50 , 59 ], historical document review or analysis (8%, n  = 3) [ 10 , 29 , 33 ], educational activity assessment or analysis of the activity by separate reviewers (5%, n  = 2) [ 55 , 61 ], stakeholder discussions or reports about their inputs (5%, n  = 2) [ 43 , 44 ], curriculum mapping (3%, n  = 1) [ 32 ], feedback from external reviews from accrediting bodies (3%, n  = 1) [ 32 ], the Dundee Ready Education Environment Measure (DREEM) (3%, n  = 1) [ 56 ], and students’ or participants’ assessments (5%, n  = 2) [ 38 , 46 ].

Of the studies, 37% ( n  = 14) utilized multi methods [ 10 , 28 , 29 , 30 , 32 , 34 , 35 , 37 , 38 , 41 , 48 , 52 , 56 , 59 ]. Furthermore, 7.8% ( n  = 3) of the studies reported the nature of the tool, for example, quantitative or qualitative, without specifying the exact tool utilized [ 57 , 60 ]. Moreover, 63% ( n  = 24) of the studies included in this review did not report the evaluation standards applied while assessing the competency-based curricula addressed. Yet, those studies that reported their standards were stated in various ways as follows: some publications referred to the standards of specific specialized associations or societies, such as the American Academy of Family Physicians and College of Family Physicians Canada [ 61 ], Royal Australian and New Zealand College of Psychiatrists [ 60 ], and The American Association of Occupational Health Nurses [ 45 ]. Other publications utilized known competency frameworks as their standards, such as CanMED [ 36 , 37 , 59 ], or the competencies of the American Board of Surgery [ 43 ] Association of Canadian Faculties of Dentistry [ 31 ], Royal College of Ophthalmologists [ 52 ], The Florida Consortium for Geriatric Medical Education [ 50 ], or the Dutch Advisory Board for Postgraduate Curriculum Development for Medical Specialists [ 59 ]. Furthermore, many of the publications referred to accreditation standards, such as the Accreditation Standards of the Australian Medical Council [ 51 ], Competencies of Accreditation Council for Graduate Medical Education [ 43 ], Accreditation Body in the Competency-based Curriculum [ 32 ], and the Commission on Dental Accreditation of Canada [ 31 ]. All the publications included in the review reported the results of their evaluations.

Finally, the results revealed that almost half (52.6%, n  = 20) of the authors of the articles mentioned that they were publishing their experience with the intent of sharing lessons learned, yet they did not refer to any other means of sharing the results of their evaluations. In contrast, the other half did not mention any measures taken to communicate and share the evaluation results. Additional file 3 includes the characteristics and details of the data extracted from the studies included addressing evaluation practices in healthcare professionals’ education.

Evaluating a curriculum appropriately is important to ensure that the program is operating as intended [ 13 ]. The present study aimed to review the available literature on the evaluation practices of competency-based undergraduate and postgraduate health professionals’ schools and programs. This review inspected which evaluation objectives, models, tools, and standards were described as well as the results of evaluations and how the results were shared. The synthesized evidence indicates that most of the programs reporting evaluation practices were postgraduate-level medical programs. This focus on CMBE among postgraduate programs can be related to the fact that competency-based education is organized around the most critical competencies useful for health professionals after graduation. Thus, they are better judged at practice [ 64 , 65 , 66 ]. Moreover, although competency-based curricula were introduced to many health professions over 60 years ago, such as pharmacology and chiropractic therapy, within the medical field they have only evolved in the last decade [ 67 ].

Furthermore, the data revealed that there is a discrepancy in how evaluation practices were reported in the literature in terms of evaluation objectives, approaches/models, tools, standards, documenting of results, and communication plans. Each area will be further discussed in the following paragraphs considering the ten-task approach and embedded evaluation model [ 27 , 68 ]. Both guide evaluation as an important step in curriculum development in medical education, detail the evaluation process, and outline many important considerations from design to execution [ 27 , 68 ].

Evaluation is a crucial part of curriculum development, and it can serve many purposes, such as ensuring attaining educational objectives, identifying areas of improvement, improving decision-making, and assuring quality [ 13 , 27 ]. Consequently, when addressing evaluation, it is important for educators to start by explaining the logic of the curriculum by asking, for example, what the program’s outcomes are and whether it is designed for postgraduates or undergraduates [ 27 ]. Moreover, educators must be precise in setting evaluation objectives, which entails answering certain questions: who will use the evaluation data; how will the data be used at both the individual and program level; will the evaluation be summative or formative; and what evaluation questions must be answered [ 27 , 68 , 69 ] However, many of the studies included in this review did not clearly explain the context of the curricula or report the objectives of their evaluation endeavors; rather, they settled for clarifying the objectives of the study or of the publication itself. One reason for this is that evaluation and educational research have many similarities [ 13 ] Nevertheless, the distinction between the two should be clarified, as doing so will enable other medical educators to better understand and benefit from the evaluation experience shared. Moreover, since CBME outcomes are complicated and should be considered on many levels, evaluation plans should include a focus, level, and timeline. The focus of an evaluation can be educational, with outcomes relevant to learners, or clinical, with health outcomes relevant to patients. The level of an evaluation can be micro, meso, or macro, targeting an individual, a program, or a system, respectively. The timeline of an evaluation can investigate outcomes during the program, after the program (i.e., how well learners have put what they learned in a CBME program into practice), and in the long term (i.e., how well learners are doing as practicing physicians) [ 70 ].

Once the evaluation objectives are clearly identified and prioritized, it is logical to start considering the evaluation approach or model that is most appropriate to attain these objectives considering the available resources. In other words, evaluation design should be outlined [ 27 , 68 ]. The choice of an evaluation approach or model affects the accuracy of assessing certain tasks carried out by or to specific subjects in a particular setting [ 68 , 71 , 72 , 73 , 74 , 75 ] This accuracy is referred to as an evaluation’s internal validity. Yet, the external validity of an evaluation entails that the evaluation results are generalizable to other subjects and other settings [ 68 ]. Each model has its own strengths and weaknesses, which require careful examination when planning an evaluation [ 14 , 73 , 74 , 75 ]. Explaining and justifying why a particular evaluation approach was chosen for a specific curriculum can enrich the lessons learned from the evaluation and aid other educators. Furthermore, some of the available models were more utilized within various educational contexts than others [ 17 ] that calls for a continuous documentation of the evaluation approaches or models used to inform theory and practice. Considering the importance of reporting the approaches and models used, it is unfortunate that most of the publications did not indicate the approach/model they used for evaluation, which limits educators’ abilities to utilize the plans and build on their evidence.

Another critical task in the evaluation process is deciding on the measurement tool or instrument to be used. The tool choice will determine what data will be gathered and how they will be collected and analyzed [ 27 , 68 ]. Thus, the choice should consider the evaluation objective as well as the uses, strengths, and limitations of each tool. The evidence in this review indicates that questionnaires or surveys were the most utilized tools in evaluating competency-based curricula. This result can be attributed to the advantages of this method (for example, it is a convenient and economical tool that is easy to administer and analyze and can be utilized with many individuals) [ 27 , 68 ]. Nevertheless, it is important to highlight that questionnaires and surveys usually target attitudes and perceptions, which usually entails only a surface-level evaluation, according to the Kirkpatrick model [ 76 ]. The results also showed that in around 50% of the mixed-methods evaluations, the questionnaires were combined with another tool, such as interviews or focus groups. Understandably, utilizing an additional tool aims to deepen the level of the evaluation focus to include learning, behaviors, or results [ 76 ].

The evaluation evidence must be compared with a standard or target for educators to judge the program and make decisions [ 12 ]. Standards can be implicit or explicit, but they usually provide an understanding of what is ideal [ 12 ]. Worryingly, the results of this review revealed that many of the included studies did not clarify the standards they used to judge different CBME curricula. However, the studies that reported their standards used accreditation criteria or broad competencies frameworks, such as CanMeds, which consider the guides of specialized associations, such as family physicians or nursing. Although deciding what standard to use can be challenging to those designing and evaluating programs, evaluating without an understanding of the level of quality desired can lead to many complications and a waste of resources.

Communicating and reporting evaluation results are crucial to attaining the evaluation objectives [ 27 , 68 , 75 ]. Moreover, effective communication strategies have many important functions, such as providing decision makers with the necessary data to make an informed decision. Informing other stakeholders about the results is also important to achieve their support in implementing program changes and nourish a culture of quality [ 77 , 78 ]. Around half of the authors of studies included in this review indicated that they were publishing to share their own evaluation experiences, while the other half did not. Regardless, none of the studies shared or indicated how their results were reported and communicated, which is an important part of the evaluation cycle that should not be overlooked when sharing evaluation lessons within the scientific community. Reporting the results also ensures quality transformation by closing the evaluation cycle and encourages future engagement in evaluation among different stakeholders [ 78 , 79 , 80 ]. Moreover, the results of the evaluation should be shared publicly to contribute to increasing public trust in educational programs and their outcomes [ 19 , 69 ].

In summary, this review of evaluation practices within competency-based curricula for undergraduate and postgraduate health professional programs provides valuable insight into the current landscape. The results of the review show that most evaluation practices published pertain to postgraduate medical programs. In addition, by examining the objectives, models, tools, standards, and communication of evaluation results, this study exposes a discrepancy between the reported evaluation practices and identified evaluation elements. This discrepancy extends to the data that are reported, which makes it even more difficult to synthesize a holistic picture and definitively fulfill the aim of the review. Moreover, the issue of missing information poses serious challenges for educators who try to leverage existing knowledge to inform their curriculum development and improvement efforts, and it highlights the need for a more systematic and transparent approach to evaluation within CBME.

This review illustrates the importance of agreeing on the main evaluation elements to be reported when publishing a CBME evaluation. Establishing a shared understanding of these fundamental elements will give educators a framework for enhancing the practical utility of evaluation methodologies. In addition, educators and practitioners can ensure that the evaluation process yields more insightful outcomes and is better tailored to meet the needs of the educational context.

Data availability

The datasets used during the current study are available from the corresponding author on reasonable request.

Abbreviations

Outcome-Based Medical Education

Competency-Based Medical Education

Embedded Evaluation Model

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Acknowledgements

The author would like to acknowledge the support that Prof. Ahmad Alrumayyan and Dr. Emad Masuadi gave this research by reviewing its protocol and providing general feedback. In addition, the author would like to acknowledge Dr. Noof Albaz for the discussions about educational program evaluation, which contributed to improving the final version of this manuscript. Thanks, are also due to Mr. Mohammad Alsawadi for reviewing the utilized search terminologies and participating in the selection of appropriate databases and searching them to obtain the needed lists of articles.

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Alharbi, N.S. Evaluating competency-based medical education: a systematized review of current practices. BMC Med Educ 24 , 612 (2024). https://doi.org/10.1186/s12909-024-05609-6

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Heuristic evaluation: Definition, case study, template

Imagine yourself faced with the challenge of assembling a tricky puzzle but not knowing where to start. Elements such as logical reasoning and meticulous attention to detail become essential, requiring an approach that goes beyond the surface level to achieve effectiveness. When evaluating the user experience of an interface, it is no different.

In this article, we will cover the fundamental concepts of heuristic evaluation, how to properly perform a heuristic evaluation, and the positive effects it can bring to your UX design process. Let’s learn how you can solve challenges with heuristic evaluation.

What is heuristic evaluation?

The heuristic evaluation principles, understanding nielsen’s 10 usability heuristics, essential steps in heuristic evaluation, prioritization criteria in the analysis of usability problems, communicating heuristic evaluation results effectively, dropbox’s heuristic evaluation approach, incorporating heuristic evaluation into the ux process.

The heuristic evaluation method’s main goal is to evaluate the usability quality of an interface based on a set of principles, based on UX best practices. From the identification of the problems, it is possible to provide practical recommendations and consequently improve the user experience.

So where did heuristic evaluation come from, and how do we use these principles? Read on.

Heuristic evaluation was created by Jakob Nielsen, recognized worldwide for his significant contributions to the field of UX. The method created by Nielsen is based on a set of heuristics from human-computer interaction (HCI) and psychology to inspect the usability of user interfaces.

Therefore, Nielsen’s 10 usability heuristics make up the principles of heuristic evaluation by establishing carefully established foundations. These foundations serve as a practical guide to cover the main usability problems of projects. These heuristics work as cognitive shortcuts used by the brain for efficient decision making, especially in redesign projects. Heuristics also help to complement the UX process when understanding user problems and supporting UX research and evaluation.

When you are getting ready to conduct a heuristic evaluation, the first step is to set clear goals. Then, during the evaluation, you should make notes on what you find considering usability issues, always based on the criteria. Once this is done, you can prepare a report that might include information on which issues to tackle first, which makes the evaluation even better. All these steps matter because they help make sure interfaces match what users want and expect, leading to better interactions overall.

Preparation for the heuristic evaluation: Defining usability objectives and criteria

As with the puzzle example in the intro, fully understanding the problem is critical to applying heuristic evaluation effectively. Thus, during the preparation phase, you need to establish the evaluation criteria, also defining how these criteria will be evaluated.

Select evaluators based on their experience. By involving a diverse set of evaluators, you can obtain different perspectives on the same challenge. Although an expert is able to point out most of the problems in a heuristic evaluation, collaboration is essential to generate more comprehensive recommendations.

Although it follows a set of heuristics, the evaluation is less formal and less expensive than a user test, making it faster and easier to conduct. Therefore, heuristic evaluation can be performed in the early stages of design and development when making changes is more cost effective.

Nielsen’s usability heuristics are like a tactical set for methodically making things work, providing valuable clues that designers and creators follow to piece together the usability puzzle. These heuristics act as master guides, helping us intelligently fit each piece of the puzzle together so that everything makes sense and is easy to understand to create amazing experiences in the products and websites we use.

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Here are Nielsen’s 10 usability heuristics, each with its own relevance and purpose:

1. System status visibility

Continuously inform the user about what is happening.

2. Correspondence between the system and the real world

Use words and concepts familiar to the user.

3. User control and freedom

Allow users to undo actions and explore the system without fear of making mistakes.

4. Consistency and standards

Maintain a consistent design throughout the system, so users can apply what they learned in one part to the rest.

5. Error prevention

Design in a manner that prevents users from committing mistakes or provides means to easily correct wrong decisions.

6. Recognition instead of memorization

Provide contextual hints and tips to help users accomplish tasks without needing to remember specific information.

7. Flexibility and efficiency of use

Allow users to customize keyboard shortcuts or create custom profiles to streamline their interactions.

8. Aesthetics and minimalist design

Keep the design clean and simple, focusing on the most relevant information to avoid overwhelming users using proper spacing, colors, and typography.

9. Help and documentation

Provide helpful and accessible support in case users need extra guidance.

10. User feedback

Give immediate feedback to users when they take an action.

Together, these pieces of the usability heuristics puzzle help us build a complete picture of digital experiences. Thus, by following these guidelines, evaluators can identify problems and prioritize them for correction at the evaluation stage.

In the evaluation phase, evaluators should look at the product or system interface and document any usability issues based on heuristics. By using heuristics consistently across different parts of the interface, it is still possible to balance conflicting heuristics to find optimal design solutions.

There may be challenges during the evaluation phase, which is why it is important that evaluators suggest strategies to overcome them from the definition of priorities. Evaluators should therefore, in consensus, discuss how these heuristics can be applied to identify and address usability problems.

One of the interesting ways to do heuristic evaluation is through real-time collaboration tools like Miro. On the template below, you will be able to collaborate in real-time to conduct heuristic evaluations of your project with your team, evaluating the problems by criteria and dividing them by colors, based on the level of complexity to be solved.

You can download the Miro Heuristic Evaluation template for free .

After performing a heuristic assessment, evaluators should analyze the findings and prioritize usability issues, trying to identify the underlying causes of usability issues rather than just addressing surface symptoms.

Usability issues discovered during the assessment can be given severity ratings to prioritize fixes.

Below is an example of categorization by severity according to the challenge presented:

• High severity : Prevents the user from performing one or more tasks
• Medium severity : Requires user effort and affects performance
• Low severity : May be noticeable to the user but does not impede execution or performance

The classification will help the team to have greater clarity regarding what is most relevant to be faced considering the impact on the user experience. By prioritizing the most critical issues based on their impact on the user experience, it will be easier to effectively allocate them throughout the project.

Finally, during the reporting phase, evaluators should present their findings and recommendations to stakeholders and facilitate discussions on identified issues.

Evaluators typically conduct multiple iterations of the assessment to uncover different issues in subsequent rounds based on the need for the project and the issues identified.

Heuristic evaluation provides qualitative data, making it important to interpret the results with a deeper understanding of user behavior. When reporting and communicating the results of a heuristic assessment, assessors should follow best practices by presenting findings in visual representations that are easy to read and understand, and that highlight key findings, whether using interactive boards, tables or other visuals.

Problem descriptions should be clear and concise so they can be actionable. Instead of generating generic problems, for example, break the problems into distinct parts to be easier to deal with. If necessary, try to analyze the interface component and its details, thinking not only analytically in an abstract way but also understanding that that problem will be solved by a UX Designer, considering all its elements. In this scenario, a well-applied context makes all the difference.

It is also important to involve stakeholders and facilitate discussions around identified issues. As a popular saying goes: a problem communicated is a problem half solved.

The Dropbox team really nails it when it comes to giving users a smooth and user friendly experience. Let’s dive into a few ways they have put these heuristic evaluation principles to work in their platform:

Dropbox keeps things clear by using concise labels to show the status of your uploaded files. They also incorporate a convenient progress bar that provides a time estimate for the completion of the upload. This real-time feedback keeps you informed about the ongoing status of your uploads on the platform:

The ease of moving, deleting, and renaming files between different folders and sharing with other people means that Dropbox offers users control over fundamental actions, allowing them to work in a personalized way, increasing their sense of ownership:

Making it a breeze for users to navigate no matter if they’re on a computer or a mobile device, Dropbox keeps things consistent in both: website and mobile app design:

To prevent errors from happening, Dropbox has implemented an interesting feature. If a user attempts to upload a file that’s too large, Dropbox triggers an error message. This message is quite helpful, as it guides the user to select a smaller file and clearly explains the issue. It’s a nifty feature that ensures users know exactly which steps to take next:

Dropbox cleverly employs affordances to ensure that users can easily figure out how to navigate the app. Take, for instance, the blue button located at the top of the screen — it’s your go-to for creating new files and folders. This is a familiar and intuitive pattern that users can quickly grasp:

Consider now flexibility and efficiency. On Dropbox, the user can access their files from any gadget, and they can keep working even when they are offline without worrying about losing anything. It makes staying productive a breeze, no matter where the users finds themselves:

Dropbox has a clean and minimalist design that’s a breeze to use and get around in. Plus, it’s available in different languages, ensuring accessibility for people all around the world:

Dropbox goes the extra mile by using additional methods alongside heuristic evaluation, demonstrating a high positive impact on their services. All this dedication to applying the best heuristics on their products has made Dropbox one of the most popular storage services globally.

Heuristic evaluation fits into the broader UX design process and can be conducted iteratively throughout the design lifecycle, despite being commonly used early in the design process.

It provides valuable insights to inform design decisions and improvements and enables UX designers to effectively identify and address usability issues.

Conclusion and key takeaways

In this article, we have seen that heuristic evaluation is a systematic and valuable approach to identifying usability problems in systems and products. Through the use of general usability guidelines, it is possible to highlight gaps in the user experience, addressing areas such as clarity, consistency and control. This evaluation is conducted by a multidisciplinary team, and the problems identified are recorded in detail, allowing for further prioritization and refinement.

Much like a complex puzzle, improving usability and user experience requires identifying patterns and providing instructive feedback when working collaboratively.

Checking interfaces using heuristic evaluation can uncover many issues, but it’s not a replacement for what you learn from watching actual users. Think of it as an extra tool to understand users better.

Remember that heuristic evaluation not only reveals challenges but also empowers you as a UX professional to create more intuitive and impactful solutions.

When you mix in heuristic evaluation while making your designs, you can end up with products and systems that are more helpful and user-friendly without spending too much. This helps make your products or services even better by following good user experience tips.

So don’t hesitate: make the most of the potential of heuristic evaluation to push usability to the next level in your UX project.

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Article Contents

1 introduction, 2 case study: shunde polytechnic, 3 methodology, 4 results and discussion, 5 conclusions, acknowledgements, author contributions.

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Study on the effects of low-carbon education on the carbon emissions of college students: a case study in Guangdong Province

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Zhang Junting, Lyu Shun, Chen Zefeng, Study on the effects of low-carbon education on the carbon emissions of college students: a case study in Guangdong Province, International Journal of Low-Carbon Technologies , Volume 19, 2024, Pages 1425–1431, https://doi.org/10.1093/ijlct/ctae097

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College students are the main force in low-carbon society and social governance, and therefore, their awareness of low-carbon is of vital importance. This article indicates a case study about the effects of low-carbon education on the carbon emissions of college students. In 2019, low-carbon education was promoted on the campus of Shunde Polytechnic and questionnaire survey and interview method were used to study the carbon emissions and low-carbon behaviors of college students after 3 years. Based on the results, the carbon emissions of college students in the aspects of food and daily use accounted for 53.8% and 40.8%, respectively, of the total carbon emissions. In the aspect of food, wine and staple foods accounted for a higher proportion. Their per capital carbon emissions were 291.536 kg and 454.651 kg, respectively. The main contributor to daily use was laptops, which emitted 530.351 kg of carbon per capital. The carbon emissions of clothing, housing, and transportation were relatively low. It is found that low-carbon facilities and measures and low-carbon living environments in colleges have a very positive effect on the reduction of carbon emissions of college students. But the disunity between knowing and doing is still common among college students. Therefore, further measures must be taken to improve the situation.

Over the past decades, China’s economy has achieved rapid development, accompanied by the increasing consumption of fossil energy such as oil and coal. In this process, the ecological environment has suffered serious damage, such as global warming, sea level rise, and many other hazards [ 1 ]. These problems are contrary to the direction of realizing sustainable economic and social development.

According to the latest analysis data from the International Energy Agency (IEA), China has become the largest carbon emitter. In 2021, China’s carbon dioxide emissions exceeded 12.9 billion tons, accounting for 33% of the global total and twice that of the USA. According to the China Energy Big Data Report (2022), China’s coal consumption in 2021 was 4.87 billion tons, an increase of 4% year-on-year, and coal accounted for 47.7% of the total energy consumption, which is related to the coal-dominated energy consumption structure in China [ 2 ]. In the long run, the traditional energy production and consumption structure is not sustainable, and the damage caused to the ecological environment is irreversible. In this case, many countries begin to attach importance to low-carbon economies and use various fiscal and tax policies to promote the development of low-carbon economies. The development of low-carbon economy has become a new direction for China’s economic transformation [ 3 ].

In light of its economic development, the Chinese government has proposed to build and improve a green, low-carbon, and circular economic system and achieve the commitment of “carbon peak” by 2030 and “carbon neutrality” by 2060 at an early date. In October 2021, the Chinese government proposed to establish a green and low carbon development economic system and promote the transformation of economic and social development to green and low carbon, which is the long-term strategy to realize sustainable development [ 4 ].

College students are important driving forces for environmental protection and sustainable development. Their understanding of the environment will determine the development trend of social environment and ecology in the future. Improving their environmental literacy has become a strategic task for the whole society. As a special group, college students have strong plasticity and influence [ 5 ]. On the one hand, there are still high carbon behaviors in college students’ living habits, but based on their plasticity. It is feasible to study and analyze college students’ behaviors and give them correct guidance. On the other hand, the behavioral concept of college students can produce a demonstration effect, which has a strong social radiation effect. Therefore, improving the low-carbon literacy of college students is an important aspect of accelerating the formation of low-carbon environmental protection lifestyle and consumption mode in the public, which is conducive to the formation of a low energy, low consumption, and low-expenditure lifestyle in the whole society and promoting the construction of ecological civilization [ 6 ].

Low-carbon work has gradually shifted from the macro perspective to individual lifestyle carbon emissions. Shui and Dowlatabadi [ 7 ] propose the consumer lifestyle model law to explore the impact of consumer lifestyle on the environment in 2005. In 2006, Britain’s environment minister proposed a personal carbon cap [ 8 ]. Rahman et al. [ 9 ] introduced the Carbon Footprint Calculator app in 2009 as a basis for dynamically tracking individual carbon footprints. In 2009, Riddell et al . [ 10 ] estimated that college students each produced nearly 4 t carbon emissions per year. In 2013, Larsen et al. [ 11 ] calculated the carbon footprint of the Norwegian University of Science and Technology by applying the environment extended I/O model, showing that the average student contribution to carbon emissions was 4.6 t/a.

The current research on college students’ carbon emissions mainly focuses on four aspects: (i) The analysis of college students’ carbon footprint and the research on emission reduction measures. Yixin et al. ’s research [ 12 ] shows that the carbon emissions of college students in Beijing have different proportions in different aspects of clothing, food, housing, and transportation; (ii) Research on low carbon lifestyle of college students. Zeguang et al . [ 13 ] studied the cognition and practice of low carbon consumption among college students and pointed out that college students should establish a correct consumption concept, put forward a series of measures to practice low carbon lifestyle and (iii) explore the relevant influencing factors of college students’ low-carbon consumption behavior. Ma Xiaoxu’s research [ 14 ] shows that environmental responsibility awareness, environmental impact concern, and low carbon concern have a significant impact on college students’ low carbon consumption intention; (iv) Research on college students’ low-carbon life education. Xin and Zhendong’s research [ 15 ] shows that low-carbon life education aims to cultivate low-carbon values, develop ecological morality, establish a correct view of nature, and disseminate low-carbon ideas, popularize low-carbon knowledge, develop low-carbon behavior content, and cultivate group and individual autonomy and consciousness of low-carbon life. In a word, the current research on college students’ carbon emissions shows multiangle and multilevel development, which has guiding significance for the research in this article.

In this article, a college in Guangdong, China was taken as a case study, which lasted for 3 years (from 2019 to 2022). In this study, the students’ carbon emission behavior was firstly investigated and suggestions for carbon reduction at campus were given, and the college adopted several measures of low-carbon education to improve the students’ carbon emission behavior, then an investigation was conducted again to know the students carbon footprints. By comparing the results before and after college’s activity, the effects of low-carbon education could be fully understood, and effective suggestion could also be provided. The investigation and research in this article not only grasp an important aspect of college students’ culture, moral quality, and sense of mission but also have important academic value and extensive social significance.

Shunde Polytechnic is a public college in Guangdong Province which is located in the south China. According to the statistical data for the year 2022, the campus covers an area of 1.2 million m 2 , with a construction area of more than 600 000 m 2 . It has 11 secondary colleges and 53 majors, with a total of 16 000 full-time students, 2781 adult education students, and 1086 faculty and staff members.

Figure 1 shows the CO 2 emission of university students from different countries compared to other countries. The Chinese students have much smaller CO 2 emission. But there is still space for CO 2 emission reduction among the Chinese university students. In order to better understand the students’ carbon footprints, a survey has been conducted in Shunde Polytechnic to investigate the students’ energy behavior in 2019. Figure 2 shows the composition of students’ energy consumption. It can be seen that students consume more electricity in dorms and research building, and the electricity in these two places can easily be affected by students’ behavior.

The CO 2 emission of university students from different countries [ 16 ].

The composition of students’ energy consumption in 2019.

To further reduce the CO 2 emission of students at Shunde Polytechnic, the college proposed several low-carbon education measures, e.g. low-carbon seminar, poster, low-carbon behavior evaluation, etc. After 3 years of adjustment, a carbon footprint investigation was conducted again to obtain an in-depth understanding on the effects of low-carbon education on the carbon footprint of college students, and corresponding measures for further carbon reduction were proposed based on the research.

3.1 Carbon emission calculation

At present, there are two authoritative methods for the calculation of carbon emissions, one is from a macro perspective, and the other is from a micro perspective. For the calculation from the macro perspective, the guidance document is mainly based on the ‘National Greenhouse Gas Inventory’ guidelines issued by the United Nations. In the calculation of carbon emissions, it is necessary to first classify carbon emission sources and establish a subset until all carbon emission sources are covered. For the calculation from the micro perspective, the most critical step is to calculate the carbon emission factor of different products, obtain the unit carbon emission of the product, and obtain the total carbon emissions. In this article, the calculation method from the bottom to the top microlevel is used to determine the carbon emission factors and calculate the total carbon emission. The expression is as follows:

where CE is the carbon emissions of a certain lifestyle; A x means the activity level of one detail in the lifestyle; and EF x refers to the carbon emission factor of one detail in the lifestyle. The carbon emission factors of different items are shown in Table 1 .

Carbon emission factors [ 17 ] .

3.2 Data collection

This research follows three basic principles: the combination of theoretical analysis and practice, the combination of qualitative analysis and quantitative research, and interdisciplinary research. In terms of specific methods of data collection, it mainly adopts the literature analysis method, questionnaire survey method, and interview method.

(1) Literature analysis  

The literature analysis method is a theoretical method of modern science and technology research, that deeply consults, analyzes, and sorts out the scientific data of the literature of related things and uses it to find the physical nature and scientific attributes of related things. In terms of this research, literature related to carbon emission assessment, low carbon environmental protection education for college students, and low carbon environmental protection social governance was collected and sorted out, and some relevant literature was reviewed.

(2) Questionnaire survey  

Questionnaire survey is a research method that collects relevant information by asking questions in written form. Students from a college in Guangdong, China were selected as key respondents and totally 1200 students were investigated randomly by questionnaires and 1097 valid questionnaires were collected. Considering the impact of age and gender on the research results, the age and gender of the respondents are both generally equally distributed.

The purpose of the questionnaire survey was to understand the low-carbon environmental awareness and behavior of college students, and the survey object was mainly college students. The students who participated in the survey were freshman, sophomore, junior, and senior, accounting for 22.17%, 23.22%, 33.48%, and 21.13%, respectively. Among the students who participated in this questionnaire survey, male students accounted for 49.5% of the total number, while female students accounted for 50.5%. From this data, it can be seen that the students participating in the survey come from different genders and grades, and the questionnaire had certain rationality.

The questionnaire mainly consisted of two parts. The first part was about carbon emissions of college students. From the aspects of clothing, food, housing, transportation, daily use, and environmental protection behavior, the differences in carbon emission behavior of college students were analyzed from four aspects: consumption characteristics, individual characteristics, consciousness characteristics and behavior characteristics. The main influencing factors of carbon emission were found. The detailed contents information of this part of questionnaire is shown in Table 2 . The second part of the questionnaire was about environmental protection awareness, attitude to low-carbon living, low-carbon education in college, and importance of low-carbon education for social governance. The main aim of this part was to obtain an in-depth understanding of students’ environmental protection behavior.

(3) Interview  

Detailed contents of different aspects in the questionnaire .

The interview method mainly refers to a method of collecting other relevant resources and literature in a purposeful, reasonable, and systematic way, in which the investigator conducts oral conversations with other respondents and asks them about their feelings or views about the phenomenon in a specific time or situation. In this actual research, the authors first prepared an interview outline on the basis of fully understanding the research content, and then conducted in-depth interviews with college students, college teachers, and social personnel. The interview could help the authors to gain a well understanding of the status of low-carbon education among college students from a more comprehensive perspective and help us further understand the importance of low carbon education for the development of students and social governance. Finally, the interview results are helpful to provide reasonable suggestions for further improvement of low-carbon education for college students.

4.1 Preliminary statistics of questionnaire survey

Data observed from the questionnaire were firstly collected and analyzed. It can be observed from the data that from the aspect of water usage, the number of college students taking a shower less than 100 minutes per week accounted for 66.5%, 100–200 minutes accounted for 26.8%, and more than 200 minutes accounted for 6.7%. Most students used water for a reasonable time, but there were some students who used water for a long time, resulting in a waste of resources. The electricity in the dormitory was limited by the objective conditions of the dormitory, which were basically limited to lighting electricity and low-power electrical appliances, and the most important high-power electrical facilities were air conditioners. In this respect, carbon emissions have not changed significantly from before.

According to public statistics, the carbon emissions of private transportation in China show an increasing trend year by year. Among public transportation, taxis account for the largest proportion of carbon emissions. The survey found that more than 86.2% of college students chose low-carbon emission transportation modes, such as buses and bicycles, when traveling. Due to the reasons of COVID-19, most college students only had activities near the college, and even if they need to travel, the travel time was short. In terms of the choice of travelling tools, most college students were more inclined to choose public transportation, so the carbon emissions caused by traveling are relatively small.

In terms of the use of disposable tableware, 55.6% of the students used disposable tableware between 0 and 20 times per week, and the carbon emissions generated by disposable tableware accounted for 48.3% of the survey group. More than 42.2% of students used disposable tableware more than 20 times a week, accounting for a high proportion, indicating that there was a large space for improving students’ low-carbon awareness.

4.2 Carbon emission structure analysis

According to the data obtained from the survey, the selection of main activity data in the analysis is introduced: The quantity of clothing purchased and the laundry behavior will have a great impact on the carbon emissions of clothing. In the aspect of clothing, the excessive carbon emission was obvious, so the quantity of clothing and the amount of laundry detergent were selected as the main factors affecting clothing. The amount of food has an important impact on carbon emissions. In terms of food, staple food, auxiliary food, and daily consumption of fruit, milk, wine, and tobacco were selected as the measurement criteria. Water resources are widely used in the life of college students, and the resulting carbon emissions cannot be underestimated. Therefore, the water that college students frequently use in daily life was selected for consideration. For daily consumption products, express delivery, plastic bags, disposable chopsticks, laptops, and paper products that had a greater impact on carbon emissions were selected for analysis. In terms of transportation, the variables of subway, bus, taxi, electric vehicle, and bicycle were selected for analysis. Through the above analysis, the numerical characteristics of carbon emissions from students’ life in Shunde Polytechnic can be found, and the distribution of carbon emissions from the investigated objects can be better reflected.

According to the analysis results for each variable, it can be seen that the distribution basically conforms to the sampling requirements. The total carbon emission of college students at Shunde Polytechnic was 18201.72 kg, of which the per capital carbon emission of clothing, food, housing, transportation, and daily use were 819.08, 9592.31, 91.01, 418.64, and 7280.69 kg, respectively.

The proportions of carbon emissions from different aspects of college students are shown in Fig. 3 . It can be seen that the life carbon emissions of college students at Shunde Polytechnic are mainly concentrated in the aspects of food and daily use, with the total proportion of about 94%. Carbon emissions from food occupy the first place in all aspects of life. The shares of carbon emissions from different food types in colleges are shown in Fig. 4 , among them, vegetables, eggs, fruits, milk, meat, tobacco, drinks, staple food, and other carbon emissions accounted for 0.19%, 2.16%, 0.32%, 1.86%, 21.44%, 1.07%, 28.49%, and 44.47% of the food carbon emissions, respectively. Alcohol and staple foods accounted for 72.96% of food’s total carbon emissions. It can be seen that the unreasonable diet structure of students in Shunde Polytechnic was very serious, and there were generally bad habits such as picky eating and drinking drinks. In this aspect, there is a large space for carbon emission reduction. From the perspective of per capital carbon emissions of specific behaviors, carbon emissions from clothing purchased during the school year accounted for a relatively large proportion in the aspect of clothing, whose per capital carbon emissions are 40.597 kg. In terms of food, drinks and staple foods occupied a relatively large proportion of carbon emissions (291.536 kg and 454.651 kg, respectively). In the daily use aspect, which accounted for a relatively large of carbon emissions was the laptop with a per capital carbon emissions as high as 530.351 kg, plastic bags released less carbon emissions with a per capital carbon emissions of only 0.0002 kg. It can be seen that most of the college students have a healthy and good living habits. In terms of transportation, the carbon emission is relatively small due to the influence of COVID-19 in recent years. The proportion of carbon emissions from food and daily use is closely related to the higher education environment received by college students, but there is still a large part of the room for emission reduction.

Carbon emission of college students from different aspects.

The shares of carbon emissions from different food types in colleges.

In terms of environmental behavior, students at Shunde Polytechnic are analyzed in four aspects: waste clothing disposal method, daily traveling method, meal surplus, and disposable container use. Among them, 15.4% of students chose to discard their old clothing, 23.4% chose to donate them, 5.6% chose others, and 55.6% chose to leave them idle. Among the daily travel modes, 82.4% of college students choose walking, 7.1% choose electric vehicles, 6.8% choose bicycles, 1.4% choose buses, and nearly 1.0% choose taxis, rail transit, and motor vehicles. 57.9% of students have little surplus, 37.9% have little surplus, and 4.2% have a lot of surplus. In terms of takeaway containers, 61.2% of college students used plastic bags, 27.9% used disposable plastic cutlery, 0.9% used paper bags, and 10.0% used self-catering cutlery.

According to the results of relevant analysis, 68.1% of college students in Foshan choose to discard or idle old clothing, indicating that college students still have not completed the effective use of clothing in the disposal of old clothing. In terms of daily travel, 89.2% of college students chose walking and cycling to travel, indicating that the students possess low-carbon behavior in traveling. In terms of meal leftovers, 95.8% of college students have little leftovers, and their overall behavior is good. In terms of disposable container, 89.1% of college students choose to use plastic bags and disposable plastic tableware. The main reason is that most students give priority to the convenience of take-out food, resulting in the lack of environmental protection behavior.

4.3 Low-carbon awareness analysis

In the following research, the authors investigated the low-carbon awareness of college students by questionnaires, and the main results are presented and discussed in this part.

In the respondents, 42% of the students think that individuals play a very large role in low-carbon process, while 48% of the students think individuals play a relatively large role. However, there are still 10% of the students think that individuals play no role in low-carbon process. As to whether they pay attention to the news about environmental protection and carbon reduction, 26% of the students answered often, 62% chose occasionally, and 12% never pay attention to the news about environmental protection. This shows that college students’ attention to low-carbon issues needs to be strengthened.

About the understanding level of the concept of low carbon and environmental protection, 58.60% of the students knew roughly the meaning and content, 25.15% of the students were familiar with the meaning and content, 12.12% of the students had heard but did not know the meaning, and 4.13% of the students had never heard. Only nearly 25% of students are familiar with the content and meaning of ‘low-carbon and environmental protection’, which is worth our deep thought. The college, government, and relevant groups should strengthen the publicity of the concept of ‘low-carbon environmental protection’ in colleges. Only by letting more people know this knowledge, we can achieve low-carbon environmental protection better.

What are the main channels through which college students learn about the concept of low carbon and environmental protection? According to the survey data, it is mainly through the Internet, accounting for 79.8%. In fact, this channel also reflects the contemporary college students contact with the Internet for lots of time. Most of the time is with computers and mobile phones. 55.6% of college students learn about it through TV and radio. The rest of the students learn mainly through newspapers, magazines, and other channels. Therefore, if colleges and relevant government departments want to increase the spread of the concept of low carbon and environmental protection among college students, releasing this knowledge on the Internet can be a good means of publicity.

In terms of students’ attitude toward low-carbon and environmental protection, we designed ‘Do you think the promotion and practice of low carbon and environmental protection are closely related to college students?’. According to the statistics, 66.70% of the students think it is relevant, college students are the main force in environmental protection; 9.09% of the students think it is irrelevant and think it is the government’s business; 24.21% of the students are not clear. It can be seen from this set of data that most students hold a positive attitude toward it, believing that the promotion of ‘low carbon and environmental protection’ is related to themselves. For those students whose attitude is not clear or negative, they should be guided positively and improve their understanding.

4.4 Interview analysis

To understand the status of low-carbon education in colleges, several college students and tutors were interviewed. The main aim of the interview was to collect the low-carbon activities and measures in colleges and suggestions from college students and tutors.

In terms of low-carbon activities and measures in colleges, about 55% interviewees thought it was not enough. The colleges put more attention on professional education, but less on low-carbon education as the main job of colleges is to solve the employment problem of students. Based on the interview of tutors, they were not forced to add low-carbon education to their courses because they had heavy teaching tasks. Besides, only little college associations are about low-carbon environmental protections, thus the opportunities for tutors and students to participate in low-carbon environmental activities are very limited, resulting in limited low-carbon propagandizing and popularizing.

Low-carbon living environment in colleges should be further built. For example, several students mentioned that they had limited methods to dispose waste cloths, based on previous questionnaire. 68.1% of college students choose to discard or idle old clothing. Based on the interview, the interviewees indicated that the handling facilities were not enough, and they had no way to sell or donate their clothes even they wished to. In the canteens, disposable plastic food container, cutlery, and plastic bags usually severed to students due to the severe take-out demand, but unfortunately, most of the students would not bring their own food containers. Furthermore, the canteens usually interfere with students’ meal choices very little, even the students waste much food, they do not need to take responsibility for your actions.

Last but not least, the disunity of knowing and doing is very common among college students. For example, nearly all the students know that the disposable cutlery has negative effects on the low-carbon process and environmental protection, 61.2% of college students will use plastic bags and 27.9% use disposable plastic cutlery because of the convenience and low cost of disposable cutlery. When questioned ‘would you support the ban on using disposable cutlery and plastic bags in the college canteen’, only 56% of the interviewees support it, which showed that there is still a distance between having environmental awareness and actually taking action to protect the environment.

4.5 Suggestions

Based on the research, several suggestions are proposed for the promotion of low-carbon education in colleges.

Firstly, we will promote the improvement of college students’ environmental literacy and normalize environmental science popularization. Specifically, measures can be taken from the following two aspects. Firstly, national environmental protection education, the annual ‘World Environment Day’, ‘National Tree Planting Week’, and other special activity days are used to organize various forms of activities to promote environmental protection. Secondly, it is necessary to create an environment protection atmosphere in the whole society and to guide young people to take an active part in environmental protection activities such as planting trees. Besides, it is urgent to improve and strengthen the organization of large-scale voluntary activities, as well as the training, incentive, guarantee, feedback, and supervision mechanism of volunteers.

Secondly, various activities should be taken to enhance public environmental awareness. First, public courses on environmental protection should be offered. Colleges and universities should set up courses related to ecological and environmental protection to improve the cognitive ability of environmental protection of college students and actively guide them to establish scientific ecological and environmental awareness. Second, various forms of environmental protection activities should be organized. By organizing environmental protection activities, college students can understand the importance of keeping the environment clean and maintaining the balance of the ecological environment and develop the good habit of protecting the environment. Thirdly, research on environmental protection should be encouraged. Colleges and universities can organize students to carry out research on environmental protection topics, so that students can ask questions, decide the direction of research, collect and sort out data, draw conclusions, and take social actions in the process of implementing project plans. By doing environmental protection research, the students’ environmental awareness could be improved.

Thirdly, students themselves should learn more about low-carbon life and eliminate the behavior of comparison and waste. From the perspective of the school, it is necessary to create a good low-carbon environment, provide students with low-carbon life as far as possible, and integrate low-carbon into their daily life.

Based on the collection and collation of 1097 valid questionnaires, this article conducted an in-depth exploration of different aspects of college students’ carbon emissions in Shunde Polytechnic. Based on the research, the following conclusions can be drawn:

(1) The carbon emissions of college students in the aspects of food and daily use accounted for 53.8% and 40.8%, relatively in the total carbon emissions. In the aspect of food, wine and staple food accounted for a higher proportion. Their per capital carbon emissions are 291. 536 kg and 454.651 kg, respectively. The main contributor to daily use is laptops, which emit 530.351 kg of carbon per capital.

(2) The carbon emissions of clothing, housing, and transportation are relatively low, respectively, accounting for 3.3%, 0.3%, and 1.8% of the total carbon emissions.

(3) It is found that the low-carbon facilities and measures and low-carbon living environments in colleges have a very positive effect on the reduction of carbon footprint of college students. But the disunity of knowing and doing is still common among college students. Therefore, further measures must be taken to improve the situation.

The authors would appreciate The Plan of Philosophy and Social Science of Guangdong Province 2023 Annual Discipline Co-Constructive Project (Project No. GD23XGL121), 2023 Young Innovative Talent Category of Colleges and Universities in Guangdong Province (Project No. 2023WQNCX255), Special Funds for the Cultivation of 2023 Guangdong College Students’ Scientific and Technological Innovation. (‘Climbing Program’ Special Funds Project No.pdjh2023b1077).

Junting Zhang (Formal analysis [equal], Investigation [equal], Methodology [equal]), Shun Lyu (CRediT contribution not specified), Shun Lyu (Conceptualization [lead], Funding acquisition [lead], Resources [lead], Supervision [lead]), Chen Zefeng (Data curation [equal], Software [equal], Validation [equal]).

None declared.

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• Published: 04 June 2024

Clinical competency of nurses trained in competency-based versus objective-based education in the Democratic Republic of the Congo: a qualitative study

• Mari Nagai   ORCID: orcid.org/0000-0001-6731-5064 1 ,
• Miyuki Oikawa 2 ,
• Tomoko Komagata 3 ,
• Josué Désiré Bapitani Basuana 4 ,
• Gérard Kahombo Ulyabo 4 ,
• Yui Minagawa 1 ,
• Sadatoshi Matsuoka 1 ,
• Yuriko Egami 1 ,
• Mari Honda 1 &
• Toyomitsu Tamura 1  

Human Resources for Health volume  22 , Article number:  38 ( 2024 ) Cite this article

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Designing competency-based education (CBE) programmes is a priority in global nursing education for better nursing care for the population. In the Democratic Republic of the Congo (DRC), object-based education (OBE) remains mainstream in pre-service nursing education programmes. Recently, the Ministry of Health developed a self-assessment tool and quantitatively compared the clinical competency of CBE- and OBE-trained nurses. This study aimed to qualitatively triangulate the results of self-evaluation by exploring perception of supervisors, incumbent CBE-, and OBE-trained nurses in comparison with the competence of the two types of nurses, and to identify influential factors or barriers to their competence in clinical settings.

A qualitative descriptive approach with conventional content analysis was applied. Twenty interviews with clinical supervisors who oversaw both CBE- and OBE-trained nurses, 22 focus group discussions (FGDs) with CBE-trained nurses, and 21 FGDs with OBA-trained nurses currently working in health facilities were conducted. Participants of the FGDs were selected from the participants of the DRC self-assessment competency comparison study where there was no statistically significance between CBE- and OBE-trained nurses in the demographic characteristics. Data were analysed in terms of the competencies identified by the Ministry of Health.

The supervisors recognised that the CBE-trained nurses had stronger competencies in professional communication, making decisions about health problems, and engaging in professional development, but were weak in clinical skills. This study identified challenges for supervisors in assuring standardised care in health facilities with OBE- and CBE-trained nurses, as well as barriers for CBE-trained nurses as a minority in the workplace in demonstrating their competencies.

Conclusions

The study results support the Ministry of Health’s policy to expand CBE in pre-service education programmes but reveal that its slow implementation impedes full utilisation of the acquired competencies at health facilities. Implementation could be accelerated by strengthening cooperation among the Ministry of Health’s three human resource departments, and developing and implementing a well-planned, legally binding, long-term CBE reform strategy, including an approach to the Continuing Professional Development system.

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Primary healthcare (PHC) is the cornerstone of universal health coverage (UHC). Its implementation requires a diverse workforce, including nurses who have acquired competencies to address people’s health needs [ 1 ]. As an outcome-based and learner-centric approach, competency-based education (CBE) enhances the clinical performance of healthcare providers [ 2 ]. CBE is expected to produce a health workforce that can provide optimal care by making comprehensive decisions based on acquired competencies [ 3 ]. The shift from traditional object-based education (OBE) to CBE has been a key trend in health professional education worldwide [ 4 , 5 ]. The Global Strategic Direction for Nursing and Midwifery also identifies CBE as a priority in creating policies in the global nursing education sector [ 6 ].

The achievement of UHC is a salient health policy in the Democratic Republic of the Congo (DRC) [ 7 ]. There, PHC is primarily available in health districts where health centres (HCs) provide frontline health services and general hospitals (GHs) serve as referrals. Most of the health service provisions in health facilities, especially at HCs, rely on nurses, as the health workforce regulation does not require allocation of a doctor due to shortages. Pre-service nursing education is provided through different systems by two ministries; the Ministry of Higher and University Education governs bachelor’s and advanced diploma courses in nursing education, while the Ministry of Public Health (MoH) governs secondary nursing education institutions and certificate courses for secondary nurses. As of 2019, nurses accounted for 47.1% (93,218) of all health personnel registered by the MoH, of which 37.0% (34,449) of nurses were secondary nurses [ 8 ]. While primary nurses are expected to work in health administration or take managerial responsibility in health facilities, secondary nurses play a critical role in the DRC to perform multiple nursing tasks, including providing PHC in lower-level health facilities [ 9 ]. Based on a 2002 survey which identified the gap between the outcomes of pre-service secondary nursing education and the competencies required for clinical practice [ 7 ], the MoH issued a ministerial decree in 2005 for introducing CBE in secondary nursing education institutions to strengthen pre-service education and provide secondary nurses with the competencies required for providing PHC [ 10 ]. Twenty-six decentralised provincial health departments are responsible for managing the health workforce, including secondary nursing education institutions. As of 2019, only 110 (21%) of the 526 secondary nursing education institutions nationwide implement CBE [ 8 ]. Despite support from external partners such as a nursing education partnership initiative to expand access to CBE programmes [ 11 ], seven out of the 26 provinces have not introduced CBE at all. In the provinces that partially introduced CBE, some nursing education institutions continued to offer OBE simultaneously. Thus, in some HCs and GHs, both newly qualified CBE- and OBE-secondary nurses work together. CBE implementation challenges have been reported in the DRC and other African countries, with obstacles including lack of teachers, capital, and planning [ 11 , 12 ].

Secondary nurses in the DRC must have five competencies for clinical practice: (1) establishing professional communication, (2) making decisions about health problems, (3) performing nursing interventions, (4) managing resources, and (5) engaging in professional development. Nursing students must acquire skills such as collecting patient data, identifying the patient's health problems, and planning a nursing care plan [ 13 ]. The scope of CBE goes beyond mere skill development; it entails mastering comprehensive nursing skills [ 5 ]. It integrates acquired knowledge, skills, and attitudes, which can enhance clinical performance [ 14 , 15 , 16 , 17 , 18 , 19 , 20 , 21 ]. The CBE programmes in secondary nursing education institutions allocate 358 h to integrate vertical knowledge and skills into optimal care over four years, whereas OBE programmes do not provide this opportunity [ 22 ].

After more than 10 years since CBE-trained secondary nurses started working in health facilities in the DRC, the MoH developed a DRC self-assessment competency scale and compared the competencies of CBE-trained with those of OBE-trained secondary nurses, both having 2–5 years of clinical experience. The result showed that the former has statistically higher competency in communication, decision making, and nursing interventions [ 23 ]. However, it was unclear how their supervisors perceive their competence, and how these two types of nurses interact with each other in clinical settings [ 24 ]. This study aimed to qualitatively triangulate the results of self-evaluation by exploring perception of supervisors, incumbent CBE-, and OBE nurses in comparison with the competence of the two types of nurses, as well as to identify influential factors or barriers to their competence in clinical settings.

Design, setting, and participants

A qualitative descriptive approach with conventional content analysis was applied to achieve the aims of the study. The target population and the selection criteria were: (1) secondary nurses with 2–5 years of clinical experience, who had graduated after 2012 from nursing education institutions using CBE in the DRC and currently worked in lower level health facilities such as HCs or GHs providing PHC (CBE-nurses); (2) secondary nurses with 2–5 years of clinical experience, who had graduated after 2012 from nursing education institutions using OBE and currently worked in lower level health facilities such as HCs or GHs providing PHC (OBE-nurses); and (3) clinical supervisors who oversaw both the CBE- and OBE-nurses in the health facilities. For this qualitative study, we randomly selected CBE- and OBE-nurses from participants of the DRC self-assessment competency comparison study [ 23 ] where there was no statistically significance between the two groups in demographic characteristics such as gender, age, years of experience, type of health facility, and position in the health facilities. For the comparison study, nine of the 26 provinces in DRC (Sud-Kivu, Nord-Kivu, Kasai-Central, Kongo-Central, Lualaba, Haut-Katanga, Kwilu, Kasai-Oriental, and Kinshasa) were selected based on transport accessibility and safety considerations for the research team to visit from Kinshasa [ 25 ]. Next, to compare OBE and CBE in similar conditions, a total of 10 cities (two from Kwilu and one from other 8 provinces) were selected where nursing education institutions applying OBE and CBE co-exist in both urban and rural areas, using the graduates list provided by the MoH. Then, health facilities where those two types of graduates were working were identified with the help of each city’s education institutions and provincial and district health offices. We identified the clinical supervisors who oversaw both CBE- and OBE- nurses in those health facilities.

Study participants had to be accessible at the time of the study, be able to travel to the interview site, and provide their consent to participate in the study. Most clinical supervisors were trained in OBE when they were nursing students. Sampling was discontinued when theoretical saturation was reached.

Data collection

Open-ended questionnaires were administered. Individual interviews were conducted for supervisors, while focus group discussions (FGDs) were conducted with CBE- and OBE-nurses separately. The research team (six authors) who had strong local contextual knowledge and experience in research in low- and middle-income countries including the DRC developed interview guides for the individual interviews and FGDs in French. The interview guides comprised questions regarding respondents’ demographics, their perceptions of the competence of secondary nurses in general, the differences between the competence of CBE- and OBE-nurses, and their views on improving nursing care. The questionnaires and guides were pilot-tested and finalised. Prior to data collection, the chief officer of the Department of Health Science Education in the MoH trained 10 MoH officers and two provincial health officers per province on the interview guide to conduct quality interviews in the provinces. Between January and September 2021, 10 interview teams (eight of which were gender-mixed), each comprising one MoH officer from Kinshasa and two officers from the target provinces, collected data. All interviews and FGDs were conducted face-to-face in a private setting at nursing education institutions or district health offices to ensure a favourable and private interview environment. Each interview and FGD lasted between 30–60 min and were recorded using an audio recorder. Participants were informed of their right to refuse study participation and assured of the confidentiality of the information they provided. They were paid travel allowances from their workplace to the interview venue. Twenty supervisors were interviewed (11 males, 9 females, 10 working at public health facilities, 2 in private health facilities, 5 in religious health facilities and 3 in others), and 22 FGDs with CBE-nurses and 21 FGDs with OBE-nurses (6–8 participants per each FGD) were conducted.

Ethical consideration

The authors obtained ethical approval from the Ethics Committees of the MoH of the DRC (No. 137/CNES/BN/PMMF/2019 du 21/09/2019) and the National Center for Global Health and Medicine in Japan (NCGM-G-004023-00). All participants provided written informed consent.

Data analysis

The authors transcribed the audio-recorded interviews into Microsoft Word in French, then manually analysed the transcripts and read and reread them to familiarise themselves with the data. In accordance with the qualitative descriptive methodology, perceptions of the differences between CBE and OBE nurses and challenges in health facilities were identified, extracted and coded. A total of 26 codes were further analysed to identify similarities and differences, then categorised into nine themes and matched with the five competencies required for clinical practice, as well as influential factors or barriers to competency in the clinical setting.

Trustworthiness

Credibility of the findings was enhanced through data source, methodological and investigator triangulations [ 26 ]. Data were collected from three sources, namely CBE-nurses, OBE-nurses, and their supervisors. Both individual interviews and FGDs were used to collect data. An individual interview allows the interviewee to speak freely and frankly and allows the interviewer to probe topics in certain depth without interruption [ 27 ]. FGDs are useful for assessment purposes because researchers can obtain wider opinions and perceptions from participants who build on each other’s ideas through ‘piggybacking’ [ 28 ]. During the interviews and FGDs, interviewers noted key points and restated them to participants to confirm accuracy or credibility. Furthermore, credibility was supported through the analysis and interpretation by all authors. The primary coding, categorisation of key phrases, and interpretation of the qualitative data were initially undertaken by the second author who had lived in the DRC for a significant period of time and had strong local contextual knowledge. The analysis was separately conducted by the first author with a qualitative research background of more than a decade, and the last author with the same background as the second author. These three authors presented initial analyses to the remaining authors to discuss interpretations and seek clarification and alternate explanations, which led to the enhancement of confirmability [ 26 ]. Transferability and dependability were boosted through description of the research context, and study procedures including data collection and analysis [ 26 ].

Strength of CBE-nurses

Most of the supervisors recognised the CBE-nurses to be better, particularly at three competencies required for nurses in the DRC (i.e., establishing professional communication, making decisions about health problems, and engaging in professional development) which aligns with the findings of the quantitative study using the self-evaluation scale.

CBE allows nurses, in addition to the theory learned in school, to be confronted with realities on the ground... They try to solve problems in relation to the needs of the patients. (Supervisor 9 in Kasaï-Oriental Province)

Supervisors recognised that CBE-nurses communicate with patients and the community better than OBE-nurses, especially respecting patients and community habits, using understandable language, informing patients and communities about health services, and checking that given information was understood.

CBE-nurses communicate with patients before providing nursing care. They introduce themselves to the patient and start a conversation like ‘Where are you from?’ But OBE-nurses struggle to communicate with patients. (Supervisor 8 in Sud-Kivu Province) OBE-nurses prescribe medicine and say, ‘Take it at home’. That’s it. CBE-nurses explain how to take the medicine, what the results will be, and observe whether the patient understood that information, then say ‘Come back to the health centre if you don’t feel better, I am happy to see how you are doing’. (Supervisor 8 in Kasaï-Central Province, Supervisor 8 in Sud-Kivu Province) CBE-nurses go into the community, see how the community is suffering, and encourage them to visit the health centre. (Supervisor 8 in Kasaï-Central Province)

Supervisors also identified CBE-nurses’ superiority in data gathering from different sources to identify health problems, analysing them to plan nursing interventions, and assessing the results to improve the nursing plan. These are components to making decisions about health problems.

OBE-nurses are not interested in the root cause. CBE-nurses go out to understand the community and use that knowledge when they see patients at a health facility. (Supervisor 3 in Kwilu Province) I found that CBE-nurses are very focused, can identify issues and priority needs of patients, and plan nursing care more effectively than OBE-nurses. (Supervisor 1 in Sud-Kivu Province)

However, some supervisors who did not know about the introduction of a competency-based programme criticised CBE-nurses as they try to share and discuss patients’ health issues with colleagues and supervisors, which is in fact one of the components of the competency to make decisions about health problems.

I find that the OBE-nurses can decide and work alone, but CBE-nurses always consult and involve other staff to make decisions. (Supervisor 7 in Sud-Kivu Province)

One supervisor identified the strength of CBE-nurses with their habit of active learning to update their knowledge, which is the competency to engage in professional development.

I think the education reform has done something. The CBE-nurses adapt better to the context and perform better in their duties. They are motivated and active. The CBE- nurses ask me questions to develop themselves, while OBE-nurses who graduated in the same year pretend they know everything, and don’t try to learn. (Supervisor 13 in Kongo Central Province)

Weakness of CBE-nurses

Supervisors identified that CBE-nurses’ relative weakness is their clinical skills.

I don't know if it's because of the teacher or school curriculum, but I see that there is a problem with the CBE-nurses in terms of practical clinical skills. (Supervisor 2 in Lualaba Province) I find that the CBE-nurses have some insufficiency, for example, they don't have the capacity of reading flowcharts or using partogrammes. I suspect that the school teacher or the supervisor of clinical practice did not teach enough about how to use those tools. (Supervisor 7 in Sud-Kivu Province)

FGDs separately organised with OBE- and CBE-nurses supported this supervisor’s observation about the novice of CBE nurses’ clinical skills.

CBE-nurses have shortcomings in practice. It seems they have not received enough practical training before graduation. For example, they are not good at attending delivery or calculating the doses of medicines and infusions for children. (FGD with OBE-nurses in Kinshasa) Sometimes there are techniques that we still need to learn in-depth. Our knowledge and experience are limited. There are practices we didn’t confront during clinical training when we were students. (FGD with CBE-nurses in Bukavu province)

Challenges in health facilities

Some supervisors recognise the difficulty of having OBE-nurses and CBE-nurses work together in the same health facility and the importance of the supervisor's role.

[With my mediation,] CBE- and OBE-nurses in my health facility share information to understand their differences and complement each other. (Supervisor 3 in Kwilu Province) I ask CBE-nurses to mentor OBE-nurses so that the OBE-nurses can work like the CBE nurses. (Supervisor 8 in Kasaï-Central Province) We, the supervisors, need to understand the new education, to be able to put ourselves in the shoes of those who give the current care [CBE-nurses] so that, between the two [OBE- and CBE-nurses], things can smoothly move forward. (Supervisor 3 in Haut-Katanga Province)

FGDs with the CBE-nurses supported the supervisor's statement that CBE-nurses were committed to improving care in healthcare facilities.

When I first came to work, OBE-nurses thought that I was going to fight with them. It was like a war. But by integrating them into everything I already knew, they are now able to provide care with the competency-based approach, too. I showed them that I am trained in five competencies in my school, and how to solve a problem by integrating several resources. (FGD with CBE-nurses in Bukavu province)

However, not all CBE-nurses have such positive experiences in their workplace. Rather, they struggle to get support and understanding from colleagues.

There are not a lot of CBE-nurses in my health facility. So, it's difficult... There are some people who accept my way of working, but others don't. They don’t know the new competency-based approach, so they criticise me. (FGD with CBE nurses in Kinshasa) OBE-nurses criticised us saying that we are too proud because we studied with a competency base. They say we're going to replace them. We need to say, no, we didn’t come to replace you. (FGD with CBE nurses in Bukavu province) Our way of working with the new approaches creates a conflict in the workplace. (FGD with CBE nurses in Kinshasa)

In such a work environment, CBE-nurses experience difficulties in utilising their competencies.

OBE-nurses tell me to follow their way. I’m the only CBE-nurse in my workplace. It's a difficult situation. ...Their work experience is greater than mine, so they say they know better than me. (FGD with CBE nurses in Kinshasa) Where I work, the majority of the staff received OBE. They don’t know what I learned. Sometimes they treat me like a servant, and that causes conflicts between us. (FGD with CBE nurses in Kinshasa)

Based on such problematic situations in health facilities, both supervisors and CBE-nurses expressed the need for competency-based in-service training as recurrent programmes for experienced OBE-nurses/supervisors.

Most supervisors received OBE, so, they don’t know well about the competency-based approach. Training should be conducted for such supervisors so that all of us can have the same commitment. (Supervisor 1 in Sud-Kivu Province) There is something we don't know about new education. When the education reform is applied at the school, we, who are in the health facilities, must also be briefed on this, to speak the same language with newly graduated nurses. (Supervisor 6 in Kasaï- Central Province) I hope OBE-nurses get an opportunity to receive competency-based training. Then OBE- and CBE-nurses can work better together. (FGD with CBE nurses in Kinshasa)

Some supervisors noted that for CBE-nurses to demonstrate their competency, comprehensive health system strengthening is needed, including tackling the workforce shortage in health facilities.

Because of the shortage of staff, one nurse needs to cover several positions in my health facility and continuously work without the rest. We try to prioritise providing more or less satisfactory care for the patients. In this situation, when we find any issue in a nurse, it is difficult to judge if the nurse doesn’t have the competency, or is overwhelmed by the heavy workload. When the working conditions don't meet the standards, the judgement can be biased. Once the working condition meets the standards, then we can really reap the benefits of this new education approach in health facilities. (Supervisor 9 in Kasaï-Oriental Province)

Increasing the availability and quality of the health workforce and strengthening PHC are essential for achieving UHC in the DRC [ 7 ], and nurses are expected to play a particularly important role [ 9 ]. This is the first qualitative study to explore the effectiveness of CBE in secondary nurses who are working in lower level health facilities where there is no doctor, playing a critical role in providing PHC in the DRC [ 29 ]. The results show that supervisors in health facilities recognised that CBE-nurses have stronger competencies than OBE-nurses, especially in the areas of establishing professional communication, making decisions about health problems , and engaging in professional development. These results are aligned with the findings of the quantitative study in which the CBE- and OBE-nurses evaluated their own competencies using a DRC-specific self-assessment nurse competence scale [ 23 ]. The better performance by CBE-nurses in comparison with OBE-nurses has been proven in high- and upper-middle-income countries [ 30 , 31 , 32 ]. A review from China found that CBE-nurses performed better than OBE-nurses in terms of critical thinking, interpersonal communication, and professional development [ 33 ]. Our study showed that even in low-income countries such as the DRC, CBE can improve nursing care at health facilities.

Our study findings support the policy of the MoH in the DRC, which introduced CBE into the pre-service education system to achieve UHC through PHC. It also encourages other resource-limited countries to confidently promote CBE. However, the progress to shift from OBE to CBE has been slow. Fifteen years after the issuance of a ministerial decree, only 21% of the nursing education institutions have introduced CBE in the DRC. This study identified that the simultaneous implementation of the two approaches causes multiple challenges in health facilities, such as the feud between OBE- and CBE-nurses and the provision of unstandardised nursing care. The MoH continues preparing and conducting annual graduation examinations with different questions for CBE- and OBE-trained students, which places a heavy burden on the MoH in terms of finances, time, and human resources.

Some sub-Saharan African countries face the same challenges in implementing policies once they are enforced [ 34 ]. The successful transition from OBE to CBE in Rwanda highlights the importance of medium- and long-term reform plans [ 12 ]. In the DRC, the ministerial decree from the MoH to introduce CBE in 2005 was not legally binding, and the enforcement thereof was left to the provincial governments in a decentralised system, relying on each province’s leadership and capacity. A well-planned, legally binding CBE reform strategy will be helpful to speed up the transition to CBE. The MoH could consider abolishing the national standardised final examinations for OBE-trained students by a certain year. Strengthening the legally binding accreditation system for nursing education institutions could also be considered to close poor-quality ones, such as those having no capacity to introduce CBE curricula.

This study also revealed the importance of approaching the continuing professional development (CPD) system in CBE reform. Until all education institutions introduce CBE and all clinical nurses who graduated with OBE retire from their work, CBE- and OBE-nurses will continue to work together in health facilities across the country. This makes each health facility struggle to systematically provide standardised nursing care, as this study has identified. CBE-nurses expressed their challenges in demonstrating their competencies at their workplace where most supervisors and colleagues do not know about CBE. In fact, some supervisors who lack an understanding of CBE consider the performance of CBE-nurses, such as careful decision-making by consulting with other staff, as a shortfall and indicative of not being able to make decisions by themselves. This implies that supervisors lack a thorough understanding of the new education approach and cannot properly evaluate staff performance. To transfer the results of CBE to clinical practice, it is critical that all health facility staff, including supervisors and OBE-nurses, have a thorough knowledge of CBE through the CPD system so that CBE-nurses can effectively demonstrate their acquired competence in clinical settings [ 31 ].

The clinical skills of CBE-nurses were identified as relatively weak by supervisors. FGDs supported this observation and contradicts the curriculum of CBE in the fourth year which allocates longer hours in situational simulation and clinical training than the OBE curriculum (2498 h vs 2300 h) [ 23 ]. One of the reasons for this weakness could be the inadequate quality of clinical training provided for nurse students in health facilities, which is an issue in nursing education in many lower income countries [ 35 , 36 , 37 , 38 ]. In the DRC, provincial health departments have a role to monitor secondary nursing education institutions three times a year. However, no concrete monitoring tool for the provincial department exists to assess the quality of clinical training at health facilities. In the medium- and long-term plans for CBE reform, a concrete strategy to monitor and improve clinical training should be included. The collaboration between nursing education institutions, healthcare facilities, and officers at health departments at provincial and district levels is key to ensure highly competent future nurses.

Strong MoH leadership is critical in the comprehensive medium- and long-term strategic plan for a smoother transition from OBE to CBE both in the pre-service and in-service education system. In the DRC, three separate departments in the MoH manage human resources. The Department of Human Resources for Health is responsible for the recruitment and placement of personnel, the Department of Health Science Education is responsible for the pre-service education of secondary nurses, and the Department of Continuing Education is responsible for CPD. Although CBE reform is one of the priorities in the MoH [ 7 ], the three departments have no concrete plan to proceed with the reform in synergy. It is imperative to strengthen the cooperation between the three departments to accomplish the MoH’s priority to provide quality PHC at lower-level health facilities through competent nurses.

This study has several limitations. Although a 360-degree evaluation approach with each nurse is a more comprehensive methodology [ 39 , 40 ], being a low-income country with a vast territory and limited resources, it has been difficult for the MoH to apply it. The results from our study, using interviews and FGDs to carefully sampled nurses, are still informative for policy implications in the DRC; thus, our methodology could be useful for other resource-limited countries. This study did not explore the broader challenges and constraints such as the working environment, and possible solutions in the wider health system. A more comprehensive health system analysis could be considered in future studies.

The supervisors recognised that CBE-nurses have stronger competencies in professional communication, making decisions about health problems, and engaging in professional development, which supports the MoH policy to expand CBE in nationwide pre-service education. However, challenges exist for supervisors to assure standardised care at health facilities with two types of nurses, and for CBE-nurses to fully demonstrate their competencies at health facilities where they are a minority. The development and implementation of a well-planned, legally binding, longer-term CBE reform strategy, including an approach to the CPD system with strong cooperation among the three departments of the MoH, would be the key to accelerating the provision of PHC by competent nurses.

Availability of data and materials

The datasets used and/or analysed during this study are available from the corresponding author on reasonable request.

Abbreviations

• Competency-based education

Continuing professional development

• Democratic Republic of the Congo

Focus group discussion

General hospital

Health centre

Ministry of Public Health

National Center for Global Health and Medicine

Object-based education

Primary healthcare

Universal health coverage

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Acknowledgements

The authors would like to express their profound gratitude to the fieldwork team especially for the following MoH officers: Adolphe Ilondo Ngamashi, Angèlique Mukomba Muzinga, Beatrice Bobo Musesu, Elisabeth Akatshi Lushima, Jacob Mputu Tshiondo, Léonie Lubuimi Benge, Marcel Baroani Bunzuki, Marie-Thérèse Tshabu Bukasa, and Séverin Bushiri Mutupeke and to the health professionals who participated in the study.

This study was supported by a Research Grant for International Health (19A10 and 20A04) from Japan's Ministry of Health, Labour and Welfare. The funder had no role in study design, data collection and analysis, decision to publish, or preparation of the manuscript.

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MN, MO, TK, GUK, SM, YM and TT developed the study design and data collection tools in consultation with DBJB, YE and MH. MO, DBJB, GUK, and YM supervised the field data collection discussion with MN, SM, TK and TT. MN, MO, SM, and TT undertook the data analysis. All authors contributed to the preparation of the paper. All authors read and approved the final manuscript.

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Nagai, M., Oikawa, M., Komagata, T. et al. Clinical competency of nurses trained in competency-based versus objective-based education in the Democratic Republic of the Congo: a qualitative study. Hum Resour Health 22 , 38 (2024). https://doi.org/10.1186/s12960-024-00921-0

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Little Hans – Freudian Case Study

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Case Study Summary

• Little Hans was a 5-year-old boy with a phobia of horses. Like all clinical case studies, the primary aim was to treat the phobia.
• However, Freud’s therapeutic input in this case was minimal, and a secondary aim was to explore what factors might have led to the phobia in the first place, and what factors led to its remission.
• From around three years of age, little Hans showed an interest in ‘widdlers’, both his own penis and those of other males, including animals. His mother threatens to cut off his widdler unless he stops playing with it.
• Hans’s fear of horses worsened, and he was reluctant to go out in case he met a horse. Freud linked this fear to the horse’s large penis. The phobia improved, relating only to horses with black harnesses over their noses. Hans’s father suggested this symbolized his moustache.
• Freud’s interpretation linked Hans’s fear to the Oedipus complex , the horses (with black harnesses and big penises) unconsciously representing his fear of his father.
• Freud suggested Hans resolved this conflict as he fantasized about himself with a big penis and married his mother. This allowed Hans to overcome his castration anxiety and identify with his father.

Freud was interested in the role of infant sexuality in child development. He recognised that this approach may have appeared strange to people unfamiliar with his ideas but observed that it was inevitable for a psychoanalyst to see this as important. The case therefore focused on little Hans’s psychosexual development and it played a key role in the formulation of Freud’s ideas within the Oedipus Conflict , such as the castration complex.

‘Little Hans’ was nearly five when has was seen by Freud (on 30th March 1908) but letters from his father to Freud provide the bulk of the evidence for the case study. These refer retrospectively to when Hans was less than three years old and were supplied to Freud through the period January to May 1908 (by which time little Hans was five years old).

The first reports of Hans were when he was 3 years old when he developed an active interest in his ‘widdler’ (penis), and also those of other people. For example, on one occasion, he asked, ‘Mummy, have you got a widdler too?

Throughout this time, the main theme of his fantasies and dreams was widdlers and widdling.  When he was about three and a half years old his mother told him not to touch his widdler or else she would call the doctor to come and cut it off.

When Hans was almost 5, Hans’ father wrote to Freud explaining his concerns about Hans. He described the main problem as follows:

He is afraid a horse will bite him in the street, and this fear seems somehow connected with his having been frightened by a large penis’.

The father went on to provide Freud with extensive details of conversations with Hans. Together, Freud and the father tried to understand what the boy was experiencing and undertook to resolve his phobia of horses.

Freud wrote a summary of his treatment of Little Hans, in 1909, in a paper entitled “ Analysis of a Phobia in a Five-year-old Boy. “

Case History: Little Hans’ Phobia

Since the family lived opposite a busy coaching inn, that meant that Hans was unhappy about leaving the house because he saw many horses as soon as he went out of the door.

When he was first asked about his fear Hans said that he was frightened that the horses would fall down and make a noise with their feet.  He was most frightened of horses which were drawing heavily laden carts, and, in fact, had seen a horse collapse and die in the street one time when he was out with his nurse.

It was pulling a horse-drawn bus carrying many passengers and when the horse collapsed Hans had been frightened by the sound of its hooves clattering against the cobbles of the road.  He also suffered attacks of more generalized anxiety . Hans’ anxieties and phobia continued and he was afraid to go out of the house because of his phobia of horses.

When Hans was taken to see Freud (on 30th March 1908), he was asked about the horses he had a phobia of. Hans noted that he didn’t like horses with black bits around the mouth.

Freud believed that the horse was a symbol of his father, and the black bits were a mustache.  After the interview, the father recorded an exchange with Hans where the boy said ‘Daddy don’t trot away from me!

Over the next few weeks Hans” phobia gradually began to improve.  Hans said that he was especially afraid of white horses with black around the mouth who were wearing blinkers.  Hans” father interpreted this as a reference to his mustache and spectacles.

• In the first, Hans had several imaginary children. When asked who their mother was, Hans replied “Why, mummy, and you”re their Granddaddy”.
• In the second fantasy, which occurred the next day, Hans imagined that a plumber had come and first removed his bottom and widdler and then gave him another one of each, but larger.

Freud’s Interpretation of Hans’ Phobia

After many letters were exchanged, Freud concluded that the boy was afraid that his father would castrate him for desiring his mother. Freud interpreted that the horses in the phobia were symbolic of the father, and that Hans feared that the horse (father) would bite (castrate) him as punishment for the incestuous desires towards his mother.

Freud saw Hans” phobia as an expression of the Oedipus complex . Horses, particularly horses with black harnesses, symbolized his father. Horses were particularly suitable father symbols because of their large penises.

The fear began as an Oedipal conflict was developing regarding Hans being allowed in his parents” bed (his father objected to Hans getting into bed with them).

Hans told his father of a dream/fantasy which his father summarized as follows:

‘In the night there was a big giraffe in the room and a crumpled one: and the big one called out because I took the crumpled one away from it.  Then it stopped calling out: and I sat down on top of the crumpled one’.

Freud and the father interpreted the dream/fantasy as being a reworking of the morning exchanges in the parental bed.  Hans enjoyed getting into his parent’s bed in the morning but his father often objected (the big giraffe calling out because he had taken the crumpled giraffe – mother – away).

Both Freud and the father believed that the long neck of the giraffe was a symbol for the large adult penis.  However Hans rejected this idea.

The Oedipus Complex

Freud was attempting to demonstrate that the boy’s (Little Hans) fear of horses was related to his Oedipus complex .  Freud thought that, during the phallic stage (approximately between 3 and 6 years old), a boy develops an intense sexual love for his mothers.

Because of this, he sees his father as a rival, and wants to get rid of him.  The father, however, is far bigger and more powerful than the young boy, and so the child develops a fear that, seeing him as a rival, his father will castrate him.

Because it is impossible to live with the continual castration-threat anxiety provided by this conflict, the young boy develops a mechanism for coping with it, using a defense mechanis m known as identification with the aggressor .

He stresses all the ways that he is similar to his father, adopting his father’s attitudes, mannerisms and actions, feeling that if his father sees him as similar, he will not feel hostile towards him.

Freud saw the Oedipus complex resolved as Hans fantasized himself with a big penis like his father’s and married to his mother with his father present in the role of grandfather.

Hans did recover from his phobia after his father (at Freud’s suggestion) assured him that he had no intention of cutting off his penis.

Critical Evaluation

Case studies have both strengths and weaknesses. They allow for detailed examinations of individuals and often are conducted in clinical settings so that the results are applied to helping that particular individual as is the case here.

However, Freud also tries to use this case to support his theories about child development generally and case studies should not be used to make generalizations about larger groups of people.

The problems with case studies are they lack population validity. Because they are often based on one person it is not possible to generalize the results to the wider population.

The case study of Little Hans does appear to provide support for Freud’s (1905) theory of the Oedipus complex.  However, there are difficulties with this type of evidence.

There are several other weaknesses with the way that the data was collected in this study. Freud only met Hans once and all of his information came from Hans father. We have already seen that Hans’ father was an admirer of Freud’s theories and tried to put them into practice with his son.

This means that he would have been biased in the way he interpreted and reported Hans’ behavior to Freud. There are also examples of leading questions in the way that Hans’ father questioned Hans about his feelings. It is therefore possible that he supplied Hans with clues that led to his fantasies of marriage to his mother and his new large widdler.

Of course, even if Hans did have a fully-fledged Oedipus complex, this shows that the Oedipus complex exists but not how common it is.  Remember that Freud believed it to be universal.

At age 19, the not-so Little Hans appeared at Freud’s consulting room having read his case history.  Hans confirmed that he had suffered no troubles during adolescence and that he was fit and well.

He could not remember the discussions with his father, and described how when he read his case history it ‘came to him as something unknown’

Finally, there are problems with the conclusions that Freud reaches. He claims that Hans recovered fully from his phobia when his father sat him down and reassured him that he was not going to castrate him and one can only wonder about the effects of this conversation on a small child!

More importantly, is Freud right in his conclusions that Hans’ phobia was the result of the Oedipus complex or might there be a more straightforward explanation?

Hans had seen a horse fall down in the street and thought it was dead. This happened very soon after Hans had attended a funeral and was beginning to question his parents about death. A behaviorist explanation would be simply that Hans was frightened by the horse falling over and developed a phobia as a result of this experience.

Gross cites an article by Slap (an American psychoanalyst) who argues that Hans’ phobia may have another explanation. Shortly after the beginning of the phobia (after Hans had seen the horse fall down) Hans had to have his tonsils out.

After this, the phobia worsened and it was then that he specifically identified white horses as the ones he was afraid of. Slap suggests that the masked and gowned surgeon (all in white) may have significantly contributed to Hans’ fears.

The Freud Archives

In 2004, the Freud Archives released a number of key documents which helped to complete the context of the case of little Hans (whose real name was Herbert Graf).

The released works included the transcript of an interview conducted by Kurt Eissler in 1952 with Max Graf (little Hans’s father) as well as notes from brief interviews with Herbert Graf and his wife  in 1959.

Such documents have provided some key details that may alter the way information from the original case is interpreted. For example, Hans’s mother had been a patient of Freud herself.

Another noteworthy detail was that Freud gave little Hans a rocking horse for his third birthday and was sufficiently well acquainted with the family to carry it up the stairs himself.

It is interesting to question why, in the light of Hans’s horse phobia, details of the presence of the gift were not mentioned in the case study (since it would have been possible to do so without breaking confidentiality for either the family or Freud himself).

Information from the archived documents reveal much conflict within the Graf family. Blum (2007, p. 749) concludes that:

“Trauma, child abuse [of Hans’s little sister], parental strife, and the preoedipal mother-child relationship emerge as important issues that intensified Hans’s pathogenic oedipal conflicts and trauma. With limited, yet remarkable help from his father and Freud, Little Hans nevertheless had the ego strength and resilience to resolve his phobia, resume progressive development, and forge a successful creative career.”

Support for Freud (Brown, 1965)

Brown (1965) examines the case in detail and provides the following support for Freud’s interpretation.

1 . In one instance, Hans said to his father –“ Daddy don”t trot away from me ” as he got up from the table. 2 . Hans particularly feared horses with black around the mouth.  Han’s father had a moustache. 3. Hans feared horses with blinkers on. Freud noted that the father wore spectacles which he took to resemble blinkers to the child. 4 . The father’s skin resembled white horses rather than dark ones.  In fact, Hans said, “Daddy, you are so lovely. You are so white”. 5 . The father and child had often played at “horses” together.  During the game the father would take the role of horse, the son that of the rider.

Ross (2007) reports that the interviews with Max and Herbert Graf provide evidence of the psychological problems experienced by Little Hans’s mother and her mistreatment of her husband and her daughter (who committed suicide as an adult).

Ross suggests that “Reread in this context, the text of “A Phobia in a Five-year-old Boy” provides ample evidence of Frau Graf’s sexual seduction and emotional manipulation of her son, which exacerbated his age-expectable castration and separation anxiety, and her beating of her infant daughter.

The boy’s phobic symptoms can therefore be deconstructed not only as the expression of oedipal fantasy, but as a communication of the traumatic abuse occurring in the home.

Blum, H. P. (2007). Little Hans: A centennial review and reconsideration . Journal of the American Psychoanalytic Association, 55 (3), 749-765.

Brown, R. (1965). Social Psychology . Collier Macmillan.

Freud, S. (1905). Three essays on the theory of sexuality . Se, 7.

Freud, S. (1909). Analysis of a phobia of a five year old boy. In The Pelican Freud Library (1977), Vol 8, Case Histories 1, pages 169-306

Graf, H. (1959). Interview by Kurt Eissler. Box R1, Sigmund Freud Papers. Sigmund Freud Collection, Manuscript Division, Library of Congress, Washington, DC.

Graf, M. (1952). Interview by Kurt Eissler. Box 112, Sigmund Freud Papers. Sigmund Freud Collection, Manuscript Division, Library of Congress, Washington, DC.

Ross, J.M. (2007). Trauma and abuse in the case of Little Hans: A contemporary perspective . Journal of the American Psychoanalytic Association, 55 (3), 779-797.

Further Information

• Sigmund Freud Papers: Interviews and Recollections, -1998; Set A, -1998; Interviews and; Graf, Max, 1952.
• Sigmund Freud Papers: Interviews and Recollections, -1998; Set A, -1998; Interviews and; Graf, Herbert, 1959.
• Wakefield, J. C. (2007). Attachment and sibling rivalry in Little Hans: The fantasy of the two giraffes revisited. Journal of the American Psychoanalytic Association, 55(3), 821-848.
• Bierman J.S. (2007) The psychoanalytic process in the treatment of Little Hans. Psychoanalytic Study of the Child, 62: 92- 110
• Re-Reading “Little Hans”: Freud’s Case Study and the Question of Competing Paradigms in Psychoanalysis
• An” Invisible Man”?: Little Hans Updated

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Additionally, commercial academic offers of Copilot come with a Customer Copyright Commitment. This means, education customers can be confident in using our services without the concerns of copyright claims. 

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We have exciting updates to our Learning Accelerators as well in Teams for Education to help personalize learning at scale: 

• New features in Reading Progress and Microsoft Teams for Education are coming to all educators starting later this month at no additional cost. They leverage AI to draft content like rubrics, assignment instructions, personalized reading passages, and learning objectives, all while keeping the educator in control.  
• Reading Coach now comes with enhanced AI features so students can create their stories and pick their own path as the story progresses: increasing student agency and motivation. It’s going to be available on the web, as a dedicated Windows app, and as an LMS integration. Customers interested in signing up for the preview of the LMS integrations for Reading Coaches and other Learning Tool integrations can go to aka.ms/LMSIntegrations  
• Microsoft’s teacher tool, Math Progress is now entering private preview, and Math Coach, our student tool, will follow soon. These tools leverage AI to help students identify where they’re struggling and provide real-time step-by-step coaching on mathematical problem solving. 

How AI Navigators are leveraging technology for impact    

During the event, I also had the pleasure of introducing our AI Navigators. They highlight how state departments, ministries of education, universities, and K-12 schools are leveraging Microsoft AI tools and solutions to better prepare students for their future. The stories of these navigators demonstrate how AI technology can create even more impact in the hands of great educators to make a real difference in student learning. 

Wichita Public Schools in Kansas serves 47,000 students and 5,600 educators and administrators. Microsoft Copilot gives their teachers what they want the most—time—allowing them to focus more on each student and bring a greater diversity of tailored learning experiences into the classroom.   

The University of South Florida is using Copilot for Microsoft 365 to accelerate faculty workflows and create their own solutions, such as their Help Desk Bot. Before, people had to review every help desk ticket and it would take a few hours before the IT team could respond. Now, response time is a matter of seconds. Faculty can also do more work in less time—querying and summarizing documents in seconds—leaving them more time to spend building new projects and student relationships. 

California State University San Marcos is using Microsoft Dynamics 365 Customer Insights and testing Copilot to overcome data collection hurdles and support each student individually. They’re now able to centralize communications with students, staff, faculty, and external partners and use data meaningfully in personalized interactions with students.   

We also shared remarkable partner stories from PowerSchool and Anthology who are leveraging the Azure OpenAI Service. The University of Leeds uses the AI Design Assistant from Anthology to empower instructors to quickly and easily build course structure, rubrics, and more. And Colorado Springs School District 11 utilizes PowerSchool AI capabilities to free up time spent creating materials to focus on student needs and engagement.  

Engage in deeper learning experiences 

We also shared new resources to deepen engagement and increase AI literacy for leaders and educators: 

• The Microsoft Education AI Toolkit is a free resource that education leaders can use to develop AI plans for their institutions. It will help to lower the barrier of entry with examples, case studies, and getting started materials to help you evaluate and implement AI solutions.  
• Explore the AI in Education Report for the latest insights from Microsoft, partner organizations, and academia on new opportunities and challenges.  
• The Minecraft AI Prompt Lab is designed to empower educators with the skills and knowledge needed to creatively use Minecraft Education as a dynamic teaching tool, leveraging the strengths of Microsoft Copilot to enhance their teaching abilities. 

Paige Johnson discusses new Microsoft security offerings with Corey Lee, Security Chief and Technology Officer at Microsoft.

How Microsoft tools keep students and information safe

In terms of security, we are introducing the following:  

• A new Microsoft Defender for endpoint offering designed to protect student devices will be available soon to any Microsoft 365 A5 customer at a discounted price.   
• Microsoft Copilot for Security , the first and only generative AI solution that helps security and IT professionals amplify their skillsets, collaborate more, see more, and respond faster. Tune into Microsoft Secure event on March 13, 2024, to get the latest updates on Microsoft Copilot for Security.  
• Free security trainings so that school leaders, educators, students, and even families can learn how to make smart decisions when they are in an educational environment.   

These new security offerings are already being implemented in K-12 and higher education. For example, Microsoft Defender helped Fulton Country Schools to instill confidence in district leadership, staff, and students after a ransomware scare in December 2021. Similarly, Newington College has students across four campuses and protecting their data is a big issue. Microsoft 365 Education A5 gives them a holistic view of their security environment. If an account were to be compromised, tools such as Microsoft Defender and Microsoft Sentinel would help keep data, servers, and workstations safe, managed and patched. 

Paige Johnson, Vice President, Education at Microsoft with Chris Reykdal, Superintendent of Public Instruction in Washington State.

Microsoft and the changing world of work  

The latest findings from an IDC InfoBrief , sponsored by Microsoft, as well as Microsoft’s own New Future of Work report confirm that the need for an AI-ready workforce has already arrived. Today’s graduates are expected to be able to use Microsoft Copilot and other AI technologies as they progress from classroom to career.  

I had a fascinating conversation with the Superintendent of Public Instruction in Washington State, Chris Reykdal, about responsible AI implementation. After recognizing the need to prepare Washington State students for the world of work with AI, a group of education leaders was assembled to reimagine several pieces of their education system, including grade-level learning expectations about AI, teacher professional development, institutional policies and practices, and curated resources for AI adoption.  

Watch Reimagine Education on-demand to hear the latest and catch up on the top announcements in this quick one-minute recap! 

Why reimagine? 

There has never been a better time to collectively reimagine education. I hope you are excited about and ready to leverage the opportunities AI can bring to education. We are inspired by the passion, persistence, and ingenuity that you demonstrate every day. Thank you for all that you do to help prepare the next generation of leaders and innovators! 

AI in education brings opportunity to life

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OPTIMIZED BY THE LAB, PERFECTED BY DENTISTS

Free Your Practice From Overpriced Implants

If you are among the growing number of dentists seeking to expand the implant services you offer patients in your practice, the Glidewell HT™ Implant System can help you succeed with a simplified surgical procedure , expert lab support , and unrivaled cost savings . Manufactured in Irvine, California, from high-strength titanium alloy, Glidewell HT Implants are a proven, premium-quality solution that can help you grow your practice while making treatment available to more patients.

• Cut Your Costs – Priced at a fraction of comparable implant systems — and saves you 20% on your lab bill when you restore your implant case with Glidewell*
• Clinically Proven – 99.2% success rate and 0.2 mm mean bone loss¹
• Ease of Use – User-friendly, efficient surgical protocol with length-specific drills that make it easy to achieve the appropriate depth of the implant osteotomy
• Advanced Design – Developed in collaboration with Dr. Jack Hahn, the creator of the NobelReplace ® implant

Use our  ROI Calculator  to see how much Glidewell HT implants can reduce your surgical and restorative costs.

Powerful Solutions for Growing Your Practice

Formerly known as the Hahn™ Tapered Implant System, the Glidewell HT Implant System pairs a proven implant design enjoyed by thousands of dentists with support from the most technologically advanced dental lab in the U.S. With 50 years of restorative experience and an array of online and live CE resources, Glidewell offers the clinical support needed for dentists to take on an expanded range of surgical procedures in the general practice.

Wherever you are in you implant journey, we offer an array of live courses for expanding your skill set through Glidewell Clinical Education as well as our partnership with the prestigious Resnik Implant Institute  and support for the AAID MaxiCourse ® Newport Beach. In addition, we support you with an array of FREE online CE:

• Live and interactive webinars and study club, including exclusive content for Glidewell HT users
• Comprehensive library of on-demand online courses
• Professionally produced step-by-step technique guides and how-to videos

Make Treatment More Affordable for Your Patients and Profitable for Your Practice

The Glidewell HT Implant System is engineered to help dentists succeed in implant dentistry through ease of use, reduced costs and our unwavering commitment to support your practice — from implant placement to final restoration. While you can pay as much as $500 for other premium-quality implants, the Glidewell HT Implant is a proven, FDA-cleared solution that dramatically lowers to cost of placing and restoring implants. Together, we can make high-quality treatment available to more patients. –Jim Glidewell, CDT Founder and President of Glidewell Recipient of the 2023 AAID Isiah Lew Memorial Research Award

Jim Glidewell, CDT, has dedicated his life to expanding patient access to care by making treatment more efficient, predictable and affordable.

Lifetime Warranty — From Implant to Restoration

For the ultimate peace of mind

Prove, Time-tested Implant Design Features

SUCCESS RATE 1

Mean bone loss in 2-year study 1, designed with purpose.

• Color-coded platform
• Machined collar
• Conical prosthetic connection
• Coronal microthreads
• Sharp buttress thread
• Resorbable blast media

Tapered body

• Dual-led thread pattern

Tapered body for use in anatomically constricted areas

Machined Collar

Machined collar for flexible apicocoronal positioning and soft-tissue maintenance

Conical Prosthetic Connection

Conical prosthetic connection and platform switching for excellent seal, stability and strength

Coronal Microthreads

Coronal microthreads for crestal bone preservation

Sharp Buttress Thread

Deep, sharp threads for high primary stability in all bone types

Resorbable Blast Media

Proven resorbably blast media (RBM) surface with proprietary processing to promote osseointegration

Tapered Body

Dual-Led Thread Pattern

Pronounced, dual-lead thread pattern with self-tapping grooves for swift insertion

Simplify Implant Surgery — From Single Units To The Full Arch

Glidewell HT Implants are specially designed to perform in even the most demanding clinical cases. View case studies to learn how Glidewell HT Implants are used in the following situations: limited space, immediate provisionalization, edentulous ridges, extraction with immediate placement and single-unit posterior. 

Instructions for Use

The Glidewell HT Implant System consists of dental implants, prosthetic components, surgical instrumentation, and related accessories for use by qualified, licensed clinicians and laboratory technicians fully trained in their application. Learn how to place Glidewell HT Implants today. 

*Discount offered only at Glidewell and cannot be combined with any other special offers. Case must include an implant-level or multi-unit abutment-level impression with a Glidwell HT transfer coping or a digital scan with a Glidewell HT scan body. Impressions over cementable abutments are not eligible for discount.

The Glidewell HT Implant System is manufactured by Prismatik Dentalcraft, Inc., a wholly owned subsidiary of Glidewell Laboratories. NobelReplace is a registered trademark of Nobel Biocare. Glidewell HT and Hahn are trademarks of Prismatik Dentalcraft, Inc.

It has simplified the surgical and the prosthetic protocol immensely. With the Glidewell HT system, each implant has a specific … final drill, so you don’t need drill stops. You don’t have to look at the black lines. It makes implants so easy.

I’ve been placing implants since 1984, and they’ve all been designed by Dr. Jack Hahn — from Steri-Oss ® , to NobelReplace ® , to the Glidewell HT Implant. I’ve found that as his designs have changed and improved over the years, the predictability for both the bone and soft tissue has gotten even better.

This is so much farther ahead than anybody else. You’re going to go to this product and I haven’t had one person that’s switched over that didn’t say, ‘I’m glad I switched over.’

The Glidewell HT Implant simplifies the surgical protocol better than any system I’ve ever used, and restoring my cases with Glidewell's implant lab has completely solved issues with fit and occlusion.

I switched to Glidewell HT implants several years ago and have been so impressed with the clinical success of the implants. They have performed well in every clinical situation, from single-unit implants, to full-arch cases, to immediate placement at grafted sites. Hahn implants are the gold standard in my office and make every case a slam dunk!

• Slide 1 - resnik
• Slide 2 - hochberg
• Slide 3 - misch
• Slide 4 - yates
• Slide 5 - oakey

Not yet placing implants or looking to learn new procedures? Join the growing numbers of clinicians who are making treatment available to more patients and growing their practices with the help of hands-on courses offered by Glidewell Clinical Education and the Resnik Implant Institute. Glidewell also offers exclusive, complimentary webinars to help Hahn users enhance their implant skills.

Glidewell Clinical Education Training Center

Resnik Implant Institute

Online Study Club

Kerr M, Allen B, Park N. Clinical and radiographic evaluation of tapered implants with an aggressive reverse buttress thread and crestal microthreads: a retrospective study. For the full report, visit  glidewell.com/ht-2-year .

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Case Study: Taylor Swift

Life is just a classroom (taylor's version).

Explore the career and influence of Time Magazine’s 2023 Person of the Year, music artist Taylor Swift! Learn more about Swift’s music, corporate sponsorships, marketing, merchandising and concert and fan experiences. Participants will gain an appreciation for and become a part of the Swiftie community. 

Meet Your Instructor

Kate Blanton

Kate Blanton has been working in public education for over twenty years as a public school teacher, academic advisor, and adjunct instructor in higher education since 2008. An Ohio native, Blanton joined the Gamecock community in 2016 in the College of Hospitality, Retail and Sport Management. She currently serves as an academic advisor for the Sport and Entertainment Management program and teaches as an adjunct instructor in the department. Blanton became a Swiftie after being invited to attend Night 1 of the record-breaking Era’s Tour in June 2023. Blanton hopes to share her appreciation for the business enterprises of Swift’s unique career with community members.

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MCQ on Assessment and Evaluation | Questions with Answer

MCQ on Assessment and Evaluation : Evaluation is the criteria of success and failure of an activity. In education, evaluation is used in order to know whether the changes in the behavior of the students are as the pre determined objectives or not.

Evaluation and measurement is an important topic of pedagogy section. Every year in teaching related competitive exams, CTET or State TET (Teacher Eligibility Test) 4 to 5 Questions are asked. In this article, we have discussed most important multiple choice questions on assessment and evaluation. Make sure you check these questions please visit to know about Evaluation.

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Mcq on Evaluation and measurement in Education

1. Evaluation is a process of…?

a) Qualitative

b) Quantitative

c) Both qualitative and quantitative

d) None of the above

2 Error of Evaluation is..?

• Personal error
• Variable error
• Constant error
• All of the above

3 School based assessments…

• Encourage teaching to the test as they involve frequent testing.
• Focus on exam techniques rather than outcome.
• Offer less control to the students over what will be assessed.
• Improve learning by providing a constructive feedback.

4. Teacher can utilize both assessment for learning and assessment of learning to …

a) Know learning needs of child and select teaching strategy accordingly.

b) Assess child’s performance at periodic intervals and certify his/her performance.

c) Monitor children’s progress and set appropriate goals to fill their learning gaps.

d) Know children’s progress and achievement level.

 Answer: c

• Also read: Important MCQ on Pedagogy

mcq on assessment and evaluation in education

5. For evaluation teacher should use…

• Objective type question.
• Essay type question.
• Oral testing.
•  Focuses on child’s development in different learning areas.
• It is useful to label children as slow, poor or intelligent.
• Or it has been mandated by the right to education Act of India.

8. Assessment for learning.. .

• Foster motivation.
• Is done for the purpose of segregation and ranking.
• Emphasis the overall importance of grades.
• Is an exclusive and a peer assessment.

9. Which of the following highlights assessment for learning?

• Teacher assesses conceptual understanding of the students besides focusing on the processes of thinking.
• The teacher assesses the students by comparing their responses to ‘standard’ responses.
• Teacher assesses the students based on the information given in the textbooks.
• The teacher assesses a student based on his/her performance in comparison to other.

10. Assessment of learners’ achievement helps the teacher to

• Evaluate the effectiveness of pedagogy.
• Make ability grouping of learners in the classroom.
• Prepare activity log for teaching.
• Maintain the performance record of learners.
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Thus, We have discussed some important mcq on Assessment and Evaluation that will help you to clear the concept of measurement and evaluation. Visit to know objective questions on pedagogy.

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