1Department of Child and family Nursing, Bouyeh Faculty of Nursing and Midwifery, Golestan University of Medical Sciences, Gorgan, Iran
2Department of Pediatrics, Pediatric Taleghani Teaching Hospital, Golestan University of Medical Sciences, Gorgan, Iran
3Education Development Center, Golestan University of Medical Sciences, Gorgan, Iran.
4Department of Community Health Nursing, Bouyeh Faculty of Nursing and Midwifery, Golestan University of Medical Sciences, Gorgan, Iran
Background: Morning reports are one the most popular clinical education in hospital setting. The first step to improve quality of this educational method is to know about current situation. The aim of this study was to study the effect of educational workshop on quality of morning report in Golestan University of Medical Sciences. Methods: In this interventional study, using census sampling 147 medical students participated. One day educational workshop held for the faculty members who were involved in morning reports. The quality of morning reports assessed by a questionnaire before and after running the workshop from the students perspectives. The data analyzed using Student's t-test. Results: The quality of morning report before workshop rated as 61.8% excellent and 38.2% good. The quality of morning reports after workshop rated 70.4% excellent and 29.6% good. Neither before nor after group rated the quality of morning reports as weak. There was no statistical significant difference between the students' perception of quality of morning report before and after running workshop. Conclusions: The quality of morning reports in the teaching hospitals were good. There was no significant statistical difference between the results before and after the workshop. Since the morning report is very important part of clinical education, any attempts to improve it would be highly valuable. Keywords: Morning Report, Educational Workshop, Medical Student, Faculty Members
Medical faculties as the founders of medical education must be very sensitive toward medical students and residents, as these learners play a crucial role in proving health services in society (1). Although physician clinical training occurs in real situations and with patients, it has basic differences with training in other fields. Among various methodologies of clinical training, morning report is almost the most practical all around the world (2). However, a pervasive plan accepted by all experts has not been presented in its usage(3). Normally the on-call group of the previous night is responsible for the next morning report and this team includes a professor, standby resident, standby resident of higher terms, and standby interns. First a short report of the previous night adopted cases is given in a few minutes or for saving the time it is written on the board previously. Then by choosing the leader of the discussion one or more patients are chosen and their status is discussed in details. It is recommended that a radiologist, pathologist, and even a medical librarian participate in the discussion regarding the patient and the topic of the discussion (4). The main advantages of morning reports include getting a general viewpoint of the performed activates in ward, analyzing different diagnostic treatment aspects of the patients, evaluating resident function, evaluating the service provided to the patients, identifying unpleasant events and their reasons and interaction among the medical staff (5). Wartman (1995) presented a new model of the morning report. This model included some new factors such as the review of patients who were released recently (4). Parino and Wilanova in their study showed that in 115 wards out 117 training wards, morning reports were given in order and more than 85% of the responders, found morning report atmosphere appropriate for social interactions (5). In a study the viewpoints of professors and students were studied about morning reports. 91% of the faculties, 68% of the residents, and 52% of the interns believed morning reports were good and others said they were about average. Also 77.8% of faculties, 41.9% of residents, and 66% of interns described the learning level in morning reports as good and very good and these results show those faculties’ and students, opinions of different degrees in the case of morning report don’t match (6). Studies show that medical education needs to change clinical training (7). Regarding the given explanations and importance and status of morning reports in medical students’ education, the first step to improve the quality of this methodology is to identify the current status. This study aimed to examine the way of performing this clinical education methodology and the effect of holding workshops as an educational intervention for improving the morning report condition.
In this educational intervention study the quality and quantity of the style of holding morning report sessions in treatment educational centers of Golestan University of Medical Sciences in 2008 before and after holding a one-day workshop about the way of training morning report for clinical faculties, was studied. For evaluating the effectiveness of these workshop students of the target group
who were participants of the morning report training were invited to participate in the study. 147 medical students entered the study for evaluating the effect of this educational workshop. Two groups of different students; 76 people in control group and 71 were put in intervention group. In the group of pre-workshop out of 76 medical students 46 people (60.5%) were stagers and 30 people (39.5%) were interns. In the group of post-workshop out of 71 students 55.9% were stagers and 42.6% were interns. The sampling method was census. All the medical students, stagers and interns in pediatrics, gynecology, internal, and surgery wards (before the intervention and after the educational workshop) were required to fill in evaluation surveys. Data collection tool was a made questionnaire which was derived to a great extent from the existing and used questionnaires in universities such as Mazandaran University and reliable related literature and included closed and one open-ended question. The control group included 76 students who filled a questionnaire about the quality and quantity of the training methodology of the morning reports, before the intervention (holding a workshop for clinical faculties). A one-day workshop of standard training of morning report was held for clinical faculties by Education and Development Center of Golestan University. Two months after holding the workshop, the intervention group students filled a questionnaire about the quality and quantity of the morning report for evaluation of the effectiveness of the educational workshop. Descriptive and T-student tests were used to analyze the data. All the ethical values such as unnamed questionnaires were taken in to consideration.
One hundred and forty seven stagers and interns entered the study in two groups before and after the intervention. The longest time of clinical training of students was 42.9%, 90 days and the shortest time was 4.8%, 20 days. 55.3% (the highest percent) had participated more than 4 times in morning report and 27.6% reported once a week. 42.3% (the highest percent) of the students were in control group or internal ward before the holding of the workshop and 8.5% (the lowest percent) were in gynecology ward. The intervention group or the post-workshop participants included 38.6% in internal ward and 15.8% from gynecology. In the control group 61.8% reported the quality as excellent and 38.2% reported as good. The weak quality was not allocated any percents. After holding the workshop 70.4% reported the quality of morning report as high and 29.6% reported it as good the weak quality was not included. There was not a significant difference between the groups in the case of students viewpoint about the quality of morning report before and after holding the workshop (table number 1). The numerical data was analyzed by T-test for two independent groups.
The students participated in the study answered the question of “In that training course, which one of the following is the most effective in your clinical learning?” 42.9% mentioned morning report, 32.7% clinical round, and 18.4% clinical training in clinic, and the rest case study.
Table 1- The medical students' point of view toward the quality of morning report
Table 2- The quality of morning reports from the viewpoint of the medical students
Frequency of the answers
Questions about the quality of morning report
Before holding the workshop (%)
After holding the workshop(%)
Is the time duration of morning report suitable?
Is the number of students suitable?
Is the size of the salon in which the morning report is being held suitable?
Is face to face interaction of students and faculties possible?
Is the meeting quiet enough?
Is the number of faculties participating suitable?
Does the place include educational facilities such as Computer, Negatoscope, Video projector, and white board?
Are the sessions held in schedule order?
Are the professors on time?
Does the morning report have a special daily leader?
Are the educational equipment used effectively for case identification?
Is there a planned schedule for the participation of a radiologist, pathologist and pharmacologist?
Are the cases chosen by student-professor consultation?
Is the number of introduced cases suitable each sessions?
Has the identification of patients adopted in the morning or the previous night been recorded on the board before the start of the session?
Are the introduced cases among the previous night or yesterday morning?
Is the method of choosing a case for morning report based on learning musts?
Is there the possibility of question and answer for all the students?
In what percent of the sessions has there been enough focus on the introduced patient and performed discussions?
Is the learning environment relaxing?
Is the professor’s feedback to the student presenting the case efficient and useful?
At the end of patient introduction, does the professor wrap it up?
Is the session time effective and useful for training and learning?
Table no.2 shows the quality of the morning report with separate questions from the viewpoint of students before and after holding the workshop.
The quality of morning report session has been good in this study, the quality of the morning report before and after the workshop has not been significantly different but according to the importance of morning report in medical students’ education, the observed increase is of importance. Any kind of attempt for improving education must be supported and developed. In a study the method of case selection, leadership, participant's satisfaction and educational value of morning report in Imam Khomini Hospital studied. Most participants considered morning report sessions effective; but, suggested issues such as communication skill, emergency department management, critical thinking, ethics, professionalism and evidence-based medicine should be added to the sessions (8). In present study before holding the workshop 61.8% of the students mentioned that the quality has been excellent and 38.2% evaluated that as good. None of the groups reported the quality as weak. In a study in Yazd 48% of students in gynecology ward reported the quality of morning report as excellent (9). In the present study also, a large percent of students before and after the intervention reported the quality as excellent. This can be because of the development of education status in recent years and holding constant retraining courses by Education and Development Center.
In another study about the condition of morning reports in educational hospitals of Kerman University of Medical Sciences, in 27 reports there has been a delay of less than 5 minutes, in 7 reports the delay was between 5 to 15 minutes, and in two cases more than 15 minutes (2). In the present study in pre workshop group the highest percent (50.7%) announced that the session is held on schedule and only 13% said that the report might not have been scheduled in advance. In the study of Kerman University the average duration of the sessions was 62 minutes but this time duration varies among departments and changes from 35 minutes to 90 minutes. Also the rate of intra-group change was considerable. Holding time distribution of intra-group was 5 which mean that even in one group the duration of morning report varied considerably (2). In the present study in pre-workshop group the average time of the morning report was reported as 50%; more than an hour, 5.3% half an hour and in the other group the average was reported more than an hour by 43.7% and half an hour by 7%. In Kerman University study among 36 understudy morning reports only 20 had a definite leader and in the rest of the cases the meetings were not led constantly (2). In the present study in pre-workshop group 65.3% announced that they had a leader and 76.1% said that the leader could lead the discussion well. In post-workshop group 76.6% mentioned that they sometimes had an assigned leader and 14.1% said that the leader could lead the discussions appropriately. The study of the quality of morning report in different wards showed that gynecology ward got the score of 48% and its evaluation was excellent (9). Some of the proofs show that taking the educational standards of morning report increase satisfaction rate among professors
and students (10). Daily notes of medical students in pediatric wards revealed morning report as important way for learning more about diseases (10). In Zaman-zadeh's study in 2005, the students also were more satisfied with quality of clinical education than the others one (12) and finally in a survey, some of the faculty members stated that for achieving the educational aims of morning report, the medical recommendations must be based on medical evidences and fostering self-directive learning in students (13).
This study, has taken a look at the qualitative status of holding morning report sessions of Golestan University of Medical Sciences and it gave a simple and clear picture of the current status. Definitely caring about the type of holding morning reports as one of most effective methods of clinical education is of prime importance. One of the most important differences of clinical education with other kinds of training is its problem-based manner, in other words in clinical training the patient plays a key role as the problem and the learner has to analyze the problem and provide a way for diagnosis and treatment by planning a clear framework. With all these, morning repot is one of the best methods of clinical education which can be put in to proactive in most specialties.
A general look at the current condition of morning reports in this study showed that although there are some shortcomings but first, groups held it constantly and firmly and secondly, the principles have been taken in to consideration to a great extent. Although there was not a meaningful difference between the surveys of post and pre workshop groups, but this can be because of the two groups being different.
We would like to thank all the medical students who participated in this study.
Conflict of interest: This study does not include official codes of conflicts of interest.
Funding and support: This research has been done by the financial support of deputy of research and technology of Golestan University of Medical Sciences.
Research committee approval: This study was done after the approval of research in Education Committee of Medical Education Development Center of Golestan University of Medical Sciences.
1. Khosravi A, Derakhshan A. Assessment of quality and quantity of morning report. Medical journal of Mashhad University of Medical Sciences 2001; 43(70): 48-45. [In Persian].
2. Haghdoost AK, Jalili Z, Asadi Kara E. Morning reports in training hospitals affiliated to Kerman University of Medical Sciences in 2006 strides in development of medical education. Journal of Medical Education Development Center of Kerman University of Medical Sciences 2005; 2(2): 88-94. [In Persian].
3. Kadivar M, Morshedi M. The study of compatibility of medical diagnosis discussed in morning reports with discharge time in a teaching hospital center. Teb va Tazkiyeh 2003; 51: 58-63. [In Persian].
4. Wartman SA. Morning report revisited: a new model reflecting medical practice of the 1990s. J Gen Intern Med 1995; 10(5): 271-2.
5.Parrino TA, Villanueva AG. The principles and practice of morning report. JAMA 1986; 256(6): 730-3.
6. Afshari P, Sadeghi S. The comparison of faculties, medical residents and medical students regard quality of morning report in Ahwaz University of Medical Sciecnes. Proceeding of the 7th National Medical Education Conference. Iranian journal of medical education 2005; 14(Suppl): 21-2. [In Persian].
7.Sarrafi Nezhad A. The study of the stagers and medical interns of Kerman University of Medical Sciences' perspective about quality of education, students role and strategies for quality improvement of medical clinical education in a ten year period from 1994 to 2003. Procceding of the 1st International Conference on Reform and Change in Medical Education, 2005: 63-4. [In Persian].
8. Moharari RS, Soleymani HA, Nejati A, Rezaeefar A, Khashayar P, Meysamie AP. Evaluation of morning report in an emergency medicine department. Emerg Med J. 2010 Jan;27(1):32-6.
9. Zare S, Behnamfar Zahra, Behnamfar Zohreh, Mirjalili MR.Quality of Morning Report at Yazd Shahid Sadoughi Teaching wwwwwwww
Hospital in 1386. The journal of Medical Education and Development Center 2007; 2(2): 56-60. [In Persian].
10. Elliott SP, Ellis SC, Bitter Pill. Attempting change in a pediatric morning report. Pediatrics 2004; 113: 243-7.
11. Amouzegar H, Haghighat M, Kadivar MR, Qolami M. Evaluation of Medical Clerkship Training in Pediatric Department of Shiraz University of Medical Sciences Based on Students' Logbooks. Iranian Journal of Medical Education 2007;7(1): 7-14 [In Persian].
12.Zamanzad B, Moezzi M, Shirzad H. Rate of satisfaction and evaluation of medical students (interns and externs) from the quality of clinical education in Shahre-kord university of Medical Sciences in 2005. Koomesh, Journal of Semnan University of Medical Sciences 2007; 9(1): 13-20 [In Persian].
13.Rahnavardi M, Bikdeli B, Vahedi H, Alaei F, Pourmalek F, Amini A, et al. Morning report: A survey of Iranian senior faculty attitudes. Intern Emerg Med. 2008 Mar;3(1):17-24.