Abstract
<sec> <title>BACKGROUND</title> <p>Bedside teaching (BST) has a rich history and remains an essential pedagogical approach within medical education (1-3). This active learning process, which takes place in the presence of patients, has been enhanced by the implementation of the structured approaches that enable students to develop problem solving and decision-making skills while modeling professional behavior and humanism (4, 5-8). The complexity of BST has been recognized and is often considered a stepwise process that starts with preparation and ends with delivery (9). BST comprises of both implicit and explicit aspects such as demonstration, teaching and assessment of trainee clinical skills.It also involves the on-the-fly role modeling of humanism, empathy and respect for patients (10). It is a time-honored practice of clinical learning approach that bridges theoretical knowledge with practical applications improving learning retention while nurturing professionalism required in workplace environment, Consequently BST foster more engagements and effective instructions where its value has been supported by extensive evidences in literature (1,5,11). Various BST approaches have been described in literature including the three- domain model (12), role modeling, patient centered approaches, report back model, direct observation, videoconferencing and case conferencing (13), the five step micro skill model (14) and trilogoue approach (interaction between patient student and teacher)(15). Over recent decades a growing number of challenges impacting the efficacy of bedside teaching has been identified in literature, these impediments include diminished instructional time for faculty (16), often compounded by inadequate preparation for teaching roles and increase patients load (17). Furthermore a decline in students examination skills (18), poorly prepared students and the unpredictable nature of hospital routine have exacerbated the complexities associated with delivering effective BST (19), the contemporary emphasis on patient centered care has also introduced complexities with patients occasionally expressing reluctance towards students involvement in their care or exhibiting uncooperative behavior (20). Moreover the integration of new technologies have been associated with a reduction in the time spent at patients bedsides consequently impacting opportunities for direct teaching (21) the studies further indicate inconvenience in teaching quality and a perceived deficit in innovative pedagogical approach within BST (22)(23). BST serves as a valuable instructions for active learning and cultivating professional behavior with authentic contexts thereby facilitating skills acquisitions from experienced clinicians (24)(25). A crucial aspect of BST involves carefully considering patients perspectivesnecessitating the avoidance of overly technical language (26)(27), one of the crucial aspects of effective BST is communications skills which promotes questioning, constructive feedback (28). Consequently educational institutes globally are increasingly integrating novel technologies and methodologies to modernize BST pedagogical framework and attain defined learning outcomes (29). The development of innovative practices demands creative approaches and a re-evolution of traditional teaching styles and methods. Through adoption of new concepts and technologies it is possible to stimulate new insights, enhances motivation, foster creativity and thought process that will enhance student’s engagements and motivations (30). The identified complexities and instructional values of iBST underscore the critical necessity of understanding its comprehensive frameworks, encompassing contemporary challenges to effectively transform pedagogical approaches. This transformation is pivotal for enhancing learning outcomes, elevating educational quality and fostering trainer’s self-sufficiency (22). The primary aim of this FGD is to search current BST approaches and practices by collecting visions, recognized experiences and perception of clinical teachers and postgraduate students involved in clinical education.</p> </sec> <sec> <title>OBJECTIVE</title> <p>The primary aim of this FGD is to search current BST approaches and practices by collecting visions, recognized experiences and perception of clinical teachers and postgraduate students involved in clinical education.</p> </sec> <sec> <title>METHODS</title> <p>Study Design A focus group discussion will be carried out to explore the current approaches and practices of BST through a phenomenological lens (31). This qualitative methodology is particularly suited to understanding the lived experiences and subjective meanings participants attribute to BST, allowing for rich, in-depth data collection that transcends mere descriptive accounts. Unlike other group techniques, the focus group discussion is not intended to achieve consensus, but rather serves as a valuable tool for preliminary instrument development (32) and for eliciting nuanced judgments to inform decision-making (33). It facilitates the gathering of participants' diverse ideas, perceptions, and opinions concerning BST by fostering dynamic interaction and probing underlying perspectives. Study site The study will be held at the Services Institute of Medical Sciences Lahore, which is affiliated with a 1500-bed hospital and hosts over 500 residents, the four years postgraduate program consisting of 1,2,3 and 4th year, in this institute both innovative and conventional bedside teaching are being conducted. Sampling Method The sampling method will be purposive sampling. This approach is specifically chosen to align with the study's phenomenological lens and qualitative nature, ensuring the selection of participants who possess direct, rich, and relevant experiences in BST. By intentionally selecting clinical teachers and postgraduate residents who are actively engaged in clinical education, this method facilitates in-depth exploration of their lived experiences and subjective meanings attributed to BST. Inclusion criteria for the FGD will comprise postgraduate residents of years 1, 2, 3, and 4, alongside experienced clinical teachers. Conversely, undergraduate students/medical officers and new clinical teachers will be excluded. Participants retain the right to withdraw from any part of the discussion without penalty, fear of termination, or any effects on grades during assessments. Participants & Recruitments Participants will be recruited via personal contact and email invitation. Participation will be voluntary and anonymous, with participants retaining the right to withdraw at any stage without penalty. Following agreement, participants will receive an email to set the FGD schedule based on the mutual availability of participants. Each FGD session will comprise six participants, including two clinical teachers and four postgraduate residents, yielding a total sample size of 18 participants. To capture a range of both positive and negative experiences, residents from the first to fourth years of postgraduate training will be included alongside clinical teachers. This mixed-group composition is strategically chosen to foster a comprehensive understanding of BST from diverse perspectives. While acknowledging potential concerns regarding power dynamics and hesitancy in expressing critical opinions due to superior-subordinate relationships, such risks will be mitigated through the implementation of moderation techniques and explicit guidelines. A trained moderator will ensure a non-judgmental, inclusive environment, emphasizing anonymity and confidentiality, and encouraging all participants to freely express their views without fear of repercussions. Research Instrument Each FGD session is scheduled for 120 minutes, consisting of three 40-minute segments separated by a 20-minute break. Logistical preparations will encompass securing a location, arranging the room with named seating and a flip board, and ensuring recording equipment such as microphones and tape recorders are properly set up. A designated note taker will be present, and participants will be offered incentives including travel fees, free parking, and token of appreciation. The first author will serve as the moderator for each FGD, responsible for stimulating discussion, ensuring all participants have an opportunity to express their views, and maintaining a non-judgmental atmosphere that respects dignity and confidentiality. Two investigators will be present solely for observation, refraining from participation or interference. Another person appointed by the research team will act as the note taker, handling participant consents, detailed record-keeping, and summarizing the discussion. General guidelines for participants include respecting diverse opinions, speaking one at a time, ensuring anonymity, and understanding their right to voluntarily participate or withdraw without penalty. Voice recordings will be made after obtaining explicit permission. The interview protocol, which will undergo pilot testing and revision prior to data collection, commences with participant introductions, inquiring about their name, age, and year of residency. An opening question will then be posed to elicit their definition of BST, framed as "Based on your experience BST is...". This will lead into a series of main and probing questions designed to explore current and innovative approaches in BST, including the role of technology in enhancing and making innovative BST (iBST) design more inclusive, participants' experiences with iBST, and the identification of enablers or barriers to its effective implementation. The probing questions include: 1. Could you describe your experience about the current approaches & practices being used in BST? 2. Could you recognize innovative approaches of BST out of the current approaches? 3. Could you explain the features of technology embedded in current BST to enhance teaching/learning? 4. From your experience, how could technology is used to make iBST design more inclusive? 5. Could you share what are enablers or barriers to implement effective iBST? The moderator will actively probe when necessary to gather in-depth perspectives without leading the respondents. The session will conclude with closing questions inviting additional input and a summary of the discussions. The FGD will conclude with specific closing questions, including "Is there anything else you want to add?" and "How would you conclude what we have talked today?". Subsequently, the note-taker will record minutes, furnish a summary, collect field notes and referential adequacy materials for credibility, and maintain a detailed track record of the data collection process, thanking participants and arranging future correspondence as needed.</p> </sec> <sec> <title>RESULTS</title> <p>Thematic analysis, a commonly used method for organizing data according to ideas and concepts and exploring complex issues in medical education, will be employed. This approach will follow a systematic six-step framework (34); 1. Familiarizing with data: All recordings, note-taking, field notes, and debriefings will be reviewed. Transcripts will be made of each recording. Researchers will familiarize themselves with the data by reading the transcripts. 2. Generating initial codes: Qualitative data will be collected and transcribed. The transcripts will then be systematically reviewed, and initial codes will be generated through a process of labeling key aspects. Decisions will be made to preserve the original opinion to control coding accuracy, and inter-coder reliability will be ensured among the researcher team through inter-coder agreement (35). 3. Searching for themes: Following initial coding, the researchers will search for largerdesigns and possible themes through the dataset, collating related codes and labeled categories. 4. The identified themes will be revised against the coded extracts and whole dataset should ensure data accurately.. This process will help in the addition of new themes, establishing timeframes for each theme, and determining when data saturation has been achieved. Peer debriefing will be ensured regularly with local key members throughout the study to share their views and refine the themes. 5. Define each theme accurately and expressive name is givenand outlining its essence and what aspects of the data it captures. 6. Producing the report: Finally, all results, encompassing the defined themes, will be presented in a comprehensive report, typed and made fair for reporting. Trustworthiness and Rigor Trustworthiness in qualitative research is a fundamental concept, addressing the validity and credibility often questioned in qualitative studies (36, 37, and 38). This study will systematically apply the stringent criteria for trustworthiness developed by Lincoln and Guba (39,40), encompassing credibility, transferability, dependability, and conformability. These four dimensions criteria (FDC) (41, 42, 43), will be built into the study's design and execution to confirm the precision and consistency of its findings. Credibility Credibility, which ensures that the research findings are true, admirable, and believable, will be established throughout various stages of the focus group discussions. Before the FGDs, credibility will be fostered by engaging participants with comprehensive background information, obtaining informed consent, familiarizing the team with the protocol, conducting induction meetings, training, and interview piloting, and clearly defining roles. During the FGDs, credibility will be maintained through the continuous engagement of a local coordinator within the setting. After the FGDs, all additional relevant materials, documents, and field notes will be collected for analysis and storage to support credibility. Member checking will also be employed, involving all the participants to review transcripts and endorse findings and reports immediately after data collection, during data analysis, and after analysis. The entire findings are not shown to participants except specific parts from whole findings to involve their inputs correctly. Transferability Transferability is the applications of results in other settings or context with thick description;it will be done through purposive sampling technique which increase the reliability of results by getting different opinions and experiences. Adequate informations are gathered by ensuring operational and theoretical saturations which is in line with the Guba‘s recommendations thereby the results can be employed in highly detailed account of participants and environment. Dependability The research process will be ensured to be stable and consistent over time, a detailedtransparent audit trail of all methodological process and data analysis will be maintained, and there will be sequential data collection, processing and analysis. the researchers will review all recordings note taking, field notes and debriefings thus generating transcripts, the researchers will familiarize with the data to generate codes and inter-codal reliability will be ensured among research team members after inter-codal agreement to maintain original opinion and codal accuracy, whole data will be secured in institutional drive with well-definedspecific login credential during collection, processing and analysis. thus bringing research process auditable and under constant revisions. Conformability The conformability will confirm that findings are truly insightful of participants experiences not based on researchers biases, this will be further achieved by sharing results with others as systematic reflexivity, regular debriefing for sharing and refining themes, through their written or oral experiences. By using triangulation process which will assess the credibility of the results findings by means of methodological and theoretical triangulation. The process of conformability will be achieved through by sufficient resources, effective useful team, and strictly following proposal guidelines which will provide rigor standards in future research. Reporting and findings The findings will be structured applicably by qualitative data analysis techniques confirming rich descriptions and quotes to describe themes ensuring the principles of transferability and conformability of all findings during peer meetings and group reflexivity. The triangulation process, encompassing both methodological and theoretical approaches, will also be used to assess and strengthen the conformability and credibility of the research results. Finally, the research will be reported in line with established guidelines, such as the Consolidated Criteria for Reporting Qualitative Research (44). Limitation of study design This study will have limited generalizability due to its non-random sampling approach. Further limitations related to the qualitative components include potential recall bias or the lack of reliable information, as predicted by Weber and colleagues (45). In terms of recruitment, the study will not select potential participants from other professions or paramedical professionals; therefore, member checking will be critical to confirm data integrity. Triangulation and reflexivity strategies will be employed to minimize investigator biases, ensuring that findings are objective and accurately reflect participants' experiences and perspectives. Adhering to the interview protocol and conducting analysis with a team of investigators will further minimize the risk of interpretation bias. Recall bias is considered minimal as all residents and teachers are within similar age groups (46). Small-size selection bias will be addressed by including a heterogeneous group of four residents and two teachers across three sessions until saturation is reached. The free encouraging environment will be delivered to the participants for their beliefs and expressions in order to ensure to deal with response biases.</p> </sec> <sec> <title>CONCLUSIONS</title> <p>The qualitative experiences as a result of these FGDs sessions will be instrumental in developing and refining innovative bedside model which will discourse the needs of training, applicability and usefulness of key components of data saturation and inter-rater reliability which will be pragmatic during data collection confirming that research findings are rigorous and reliable as to complement quantitate data, this will also be strengthened by the addition of FDC (four dimension criteria) of trustworthiness - credibility, transferability, dependability, and conformability, each component will enhance and strengthen the findings like credibility through techniques like member checking, validating the resulted findings, transferability will warrant the provision of rich detailed findings to other researchers for applicability in their context, Dependability will ensure the audit trail of research process ,conformability will be accomplished by investigators reflexivity and methodological triangulations. By efficacious application of this FDC the data derived as a result of FGDs sessions will be dependable, ridiculous and dynamic in developing and validating innovative bedside teaching model.</p> </sec> <sec> <title>CLINICALTRIAL</title> <p>Nil</p> </sec>