Page 85 - Journal of Special Operations Medicine - Winter 2014

medics and medic instructors. An educational environ- basic military requirements for and demographics of the
ment measurement tool used worldwide was selected majority of SOF medics in service. All participants self-
and given to these self-identified SOF medics to survey identified as SOF medics and all were or had been in
their learning environments and perceptions of curricu- the Army branch of service. To ensure anonymity, par-
lum. Participants’ responses were quantified, analyzed, ticipants’ voluntary disclosure of their rank, age, time
and reviewed to determine perceptions and attitudes frame of initial medic training, and career progression
toward their traditional curriculum and the reflection- since were disregarded and not reported to avoid poten-
centered curriculum. tially identifying information.

Intervention
Evidence Synthesis The intervention consisted of presenting 34 SOF medics
with the same case study extracted from a 2012 edi-
Study Design and Methods tion of the Journal of Special Operations Medicine. To
This study used a descriptive crossover design in which control for possible variations in experience and expo-
surveys were randomized; in addition to this author as sure to clinically atypical cases among participants, they
the PI, the surveys were also administered by proxies to received a recognizable scenario. The selected practice
reduce the possibility of bias. reflection was presented in writing before the survey
instrument was administered; in Survey version A, par-
Setting ticipants were asked to reflect on a traditional curricu-
The first setting was a military medical conference at lum by completing the survey instrument first, the case
which attendees were asked by the PI if they were or had study was presented second, and participants completed
been SOF medics during their military career. Several the same survey based on the modified curriculum. In
participants asked the PI if they could refer and/or give Survey version B, the opposite occurred: The case study
surveys to other SOF medics in attendance or not able to was presented before the traditional curriculum and the
attend, which enabled snowball sampling; approximately instrument was completed after each option was pre-
four surveys were returned to the PI after they were dis- sented. The surveys were compiled for distribution by
tributed. Of the 50 surveys distributed, 34 were returned an assistant, alternating between versions A and B one-
to the PI, and 10 surveys were collected from participants for-one, and then stacked in two piles with only the top
until the end of February 2013, well after the conference of the packets showing, to ensure thorough random-
had concluded. Ten of the 34 surveys were omitted from ization and investigator/proxy blindness during survey
analysis because the participants had not completed all distribution.
questions, which reduced the surveys analyzed to 24. Of
the returned surveys, 18 were version A, in which SOF Measurement
medics evaluated their traditional curriculum first, and The Dundee Ready Educational Environment Measure
16 surveys were version B, in which SOF medics evalu- (DREEM) survey instrument is used worldwide in medi-
ated the reflection-based curriculum first. cal, nursing, and clinical interdisciplinary education to
evaluate changes in curriculum; its psychometric prop-
Sampling erties and validity have been validated by nursing sci-
Based on the inclusion criteria, those who self-identified entists and medical researchers, and it is a reliable tool
as SOF medics were given a written example of a prac- for assessing curricular modifications. 66–68 The DREEM
tice reflection and the survey instrument, which was was developed using input from 80 international medi-
slightly modified to reflect SOF-specific clinical verbiage cal educators and has been used by clinical educators
(i.e., “clinical practice” was replaced with “care in com- on five continents. 69–71 Its construct validity is confirmed
bat”). Changing the verbiage within the instrument does through analyses and testing by experts in graduate clin-
not affect its psychometric validity. Civilians without ical education, and it has high internal consistency with
65
military medical experience and non-SOF/conventional average Cronbach’s alpha of 0.93. 65
military medics and providers were excluded; for in-
stance, a physician who had been a Special Forces of- Instrument scoring
ficer prior to entering medical school was excluded from Scoring was modified to match the survey administered:
participation, as he had not served as an enlisted SF or 5 for Strongly Agree, 4 for Agree, 3 for Neutral, 2 for
SOF medic. Disagree, and 1 for Strongly Disagree. All questions in
the DREEM are of equal weight. Within the DREEM
Participants provided full, written informed consent and there are five subscales: participants’ perceptions of
no specifically identifying information was requested or learning, perceptions of instructors/faculty, academic
retained. All SOF medics who consented to surveying self-perceptions, perceptions of learning atmosphere, and
were male and over the age of 21 years, consistent with social self-perception. The DREEM can also be used to

Call for Innovation: Practice Reflections and Clinical Curricula 75