Development and Validation of a Measure of Medical Student Leadership in Team-Based Simulations.

Purpose: This study developed and collected evidence of validity for a new instrument for measuring medical student leadership skills in team-based simulations. There has been increased interest in developing leadership skills in medical schools and residency programs nationally. The American Medical Association (AMA) asserts that physician leadership in team-based care assures patient safety and quality of care.1 Although physicians are expected to hold designated leadership roles, traditional medical school curricula need to include formal leadership workshops or training sufficiently.2,3 Method: This study adapted existing frameworks in leadership by identifying the common qualities discussed throughout the current literature in medicine and synthesizing them into discrete, measurable leadership skills that could be observed in simulation settings. Fourteen leadership behaviors were identified and grouped into three broad domains of leadership: (a) clinical reasoning (3 behaviors), (b) patient communication (3 behaviors), and (c) team communication (7 behaviors). After expert review to establish construct validity, the instrument was piloted with 46 medical students. To improve reliability and sensitivity, one item was removed from patient communication: After approval by the Curriculum Oversight Committee, the instrument was implemented to assess the performance of 262 medical students. Maximum Likelihood Confirmatory Factor Analysis was used to verify a hypothesized factor model of the instrument that describes the relationships of observed variables with latent variables. The measurement model followed a two-step approach based on the model fit cutoff indices: χ2/df ratio ≤ 3, RMSEA ≤ .06 (90% confidence interval [CI] ≤ .06), SRMR ≤ .08, CFI ≥ .90, TLI ≥ .90.4,5 Results: The measurement model was modified to find a theoretically and statistically acceptable model. After considering the factor loading, item analysis, and expert review, it was determined that one item would be eliminated from the domain of “team communication.” Additionally, “team communication” was divided into 2 distinct domains, namely “team communication” and “inclusion.” The modified model showed a better fit to the data with four constructs: (a) clinical reasoning (3 items), (b) patient-centered care (3 items), (c) team communication (3 items), and (d) inclusion (3 items). The Cronbach’s alpha of the refined instrument was estimated to be 0.97, demonstrating appropriate internal consistency. The RMSEA estimate in the refined model was 0.06, and its associated 90% CI was 0.05, 0.07, indicating a good model fit. The SRMR estimate obtained 0.078, which also indicated a good model fit. The comparative indices of CFI and TLI were 0.917 and 0.885, respectively, showing a good and acceptable model fit. The chi-square (χ2 = 335, df = 48) was statistically significant (P < .001). Although the results of the chi-square test were not sufficient, the rest of the indices indicated that the fit of the model deems adequate and validated the hypotheses of the model. Discussion: The study found that the measurement model of medical student leadership achieved the requirements for construct reliability and validity. This study supports that the final assessment instrument can be used to measure the leadership development of medical students in a team-based simulation setting. With the implementation of this assessment instrument, simulations can be further expanded to foster medical students’ leadership skills. Significance: Medical leadership is one of the essential components of a team-based approach. In medical curricula, students will practice their roles in team-based simulations and translate leadership skills later in their careers when working with a team in a clinical setting. This instrument can be used to assess leadership with specific actionable traits in various team-based settings. Future physicians can develop their teamwork skills by practicing and evaluating leadership in a low-risk environment. Additionally, peers’ and preceptors’ feedback on leadership performance will support the development of skills that can be applied to high-risk environments. The wider implementation of this instrument may foster more productive and targeted leadership development in physicians, leading to better patient care outcomes in team-based environments. Acknowledgments: The authors wish to thank Dr. Matthew Tews for his contributions to this project.