Clinical supervision supports learners and paves the way for effective and efficient learning in clinical settings. This study aimed to explain the responsibilities of clinical supervisors in clinical education wards to improve the professional skills of medical students.In this qualitative study, we used the conventional content analysis approach. The sample consisted of 16 faculty members of medical sciences and medical graduates of Iranian universities. Purposeful sampling and semi-structured interviews were used to collect data. The Graneheim and Lundman method (2004) analyzed the data.From the analysis of interviews, 2 themes, 8 categories, and 18 subcategories were obtained. “Clinical supervisor responsibilities” as a theme includes the categories: “Creating motivation in learner”, “Learner’s need recognition”, “Performance evaluation”, “Creating learning opportunities”, and “Professional ethics education”. And, the sub-categories were: “Creating a supportive atmosphere”, “Task assignment”,“Understanding training needs”, “Understanding individual needs”, “Periodic evaluation”, “Proper feedback’, “Reduce work stress”, “Learner engagement’ , “Learning Facilitation”, “Attention to the patient’s treatment”, and “Ethical observance in relation to patients”.As the second theme “Clinical supervisor characteristics” included the categories of: “Scientific competence”, “Leading role”, and “Ethical model”. Their sub-categories are clustered as: “Knowledge of educational concepts”, “Mastery of professional concepts”, “Effective communication skills”, “Understanding managerial concepts”, “High resilience”, “Career commitment “, and “social commitment” .The clinical supervisor will improve the professional skills of medical students, which will improve the quality of services provided, train efficient graduates, and provide a safe and relaxing environment that leads to patient satisfaction. Medicine is perceived as one of the sacred and praiseworthy professions in every society. In all countries, comprehensive and appropriate in-service education for the empowerment and efficiency of healthcare workers has been on the top agenda of educational planners .One of the characteristics of medical education is the need to learn practical and communication skills along with cognitive and theoretical domains . ClinicaProviding the highest quality of clinical education to medical students is crucial for the delivery and care of public health . The inaGold Hummer conducted the first investigations into clinical supervision in the 1960s . In 1973Ensuring inclusive patient safety during clinical practices is essential for clinical supervision . AdequatDespite the benefits of a clinical supervision program; however, this position is not yet well designed in Iranian teaching hospitals. Students would be confronted with new environments that they do not have enough familiarity and experience with, and countless questions would arise in their minds. Since the medical students will be present in the clinical environment following the completion of basic sciences and preclinical courses and will gain insights on how to interact with the patient and family and various professional skills, the clinical supervisor position will significantly impact knowledge transfer students.Therefore, this study has tended to explain the duties and characteristics of clinical supervisors in clinical settings to strengthen the professional skills of medical students in Iranian universities of medical sciences.A qualitative approach and a conventional content analysis were used to describe a phenomenon in this research. Qualitative research was incorporated to achieve participants’ inner world and discover the meanings formed in a cultural context . ContentThe initial samples consisted of medical university faculty members who had teaching responsibilities in the clinical environment and had experience as the director of medical education in the teaching hospital. Also, the criteria for selecting students were those who graduated and have a certificate in medical education courses. Exclusion criteria were the participants’ unwillingness to continue cooperation.Semi-structured interviews were used to collect information. The research objectives were explained before the interview. A written informed consent form was given to the interviewees. The interviewees explicitly agreed to record the interview. The interviews were conducted on an individual basis. During the interview, a general question was asked first, and then, as the interview progressed, the questions were controlled in the direction of the research goal. Questions asked in the interview were: the interview started with general open-ended question “Please express your understanding of educational supervision in a clinical setting?”, Moreover, and to have deeper insight into the concept under study, according to the participants’ responses more detailed and follow-up questions were raised as follows: “What qualities do you think a clinical supervisor should have?”, “How can you be a good clinical supervisor?”, “ what are the roles and responsibilities of a clinical supervisor in a clinical setting with students’ attendance?”. Also, a series of in-depth questions were asked: “Can you explain more?” Talk about “,” “you mentioned ...., what do you mean?”. Also, the students were asked questions like: “Please describe your experience from the clinical course you went through”, “Describe your experience with the activities and roles of a clinical supervisor in hospital wards?”, “Based on your experience with the clinical environment, what characteristics can the clinical supervisor have to improve the quality of learning?” Each interview lasted 35 to 45 minutes and was conducted by the first author. Participants were selected by the purposive sampling method from among the informants who provided the most data about the study subject. The interview site was either hospital or university environment decided upon by close interaction of the researcher and participants. Sixteen people participated in the interviews Table .Table 1DGraneheim and Lundman (2004)  approachThe meaning units were then identified and coded. The codes were merged based on similarity and were clustered into several sub-categories. Next, the sub-categories formed main categories based on similarities and differences. Attempts were made to have the greatest homogeneity within the categories. Incorporating the categories, the themes or abstract ideas emerged. Attempts were made not to involve the researcher’s assumptions in the analysis process. An example of analysis process is shown in Table We employed the four critical criteria developed by Lincoln and Guba, including credibility, transferability, dependability, and confirmability .Regarding credibility, the researcher’s continuous presence in the field provided the researcher with a better understanding of the phenomenon. Allocating enough time to collect and analyze data helped the authors gain deep insight into the data. For transferability, interviews, coding, and analysis were recorded and reported in detail in all the research processes. The dependability was established using some techniques. The opinions of the research team and double-checking of the codes were an agreement between the extracted categories and sub-categories. Regarding confirmability, several interviews, extracted codes and categories were reviewed by two faculty members familiar with data analysis of qualitative research.In coordination with the relevant authorities and obtaining the consent and approval of the participants, the interview was conducted. Confidentiality was also observed.Out of 16 participants, 11 were faculty members, and the remaining were graduating medical students and residents. From the analysis of interviews, two themes, eight categories, and 18 subcategories were obtained after coding and comparing the codes based on similarities and differences Table .Table 3TThe theme clinical supervisor’s responsibilities refers to the of participants’ perception of the clinical supervisor’s responsibilities and activities that support students and patients. This theme include five main categories “creating motivation in the learner”, “ learner’s need recognition”, “performance evaluation”, “Creating learning opportunities,” and “professional ethics education”.It refers to the reinforcing factor and the desire of learners to learn and provide more service in the clinical setting. Its subcategories are “creating a supportive atmosphere “ and “task assignment”.“The treatment environment is stressful and anxious for both the patient and the therapist. This is where a supporter, an encourager and a word of hope can keep your engine running, or either,”… “If a cold word or a certain behavior stops your engine, this is where the presence of a supporter is felt in this situation,” (P 7).It refers to creating psychological and even legal support in the clinical environment, part of which is the supervisor’s responsibility. “If I know what I have to do in a clinical setting, I feel good, unlike the situation where I am unaware about what I am expected to do, from history-taking and physical examination to filling a medical history form and many other confusing things,” (P15).In the clinical setting, students’ duties and roles should be clearly defined; doing so they perform their duties properly like other medical staff. The clinical supervisor has to recognize the educational needs of the learners. Its sub-categories are “Understanding educational needs”, “Understanding individual needs”I was an intern, some of the cases we visited were very complicated and incomprehensible to our level of medical knowledge, I had a bad feeling there. We did not know if we had difficulty in learning or not, they are certain “fellow and residents cases, and this boundary was not clear to us and there was no one available to answer the questions.” (P16).The clinical supervisor should be aware of the needs of the various levels of students present in the clinical setting, including stagers, interns, and residents. “When Although I had a lot of energy and ideas, I swallowed my idea for fear of being humiliated…. nobody seemed to understand us. Everyone was used to the usual routine, “(P 14). Some professors only had a good relationship with a certain gender group and did not pay attention to us, they did not even understand our situation” (P 16).The clinical supervisor should be aware of the different characteristics of learners and their age and gender requirements. “It includes comprehensive monitoring and evaluation during the training course in the clinical environment to ensure students’ attainment of educational goals . Its subcategories are “periodic evaluation” and “ proper feedback”.“We have now designed software to record the attendance and activities daily. The issue of student evaluation is significant. And not that at the end of the semester, the instructor, who does not even remember the students’ names, gives a grade carelessly and on no basis” (P5).It refers to conducting assessments during the study and in each clinical ward and educational environment. I have been receiving feedback from students every three weeks since I became in charge of supervising the students in the ward. I ask them, what were the good wards and the bad ones? Write the positive and negative points. When 10 out of 60 students write that this ward does not have good training, there is something wrong with that particular ward. I get the feedback, talk to the Head and the faculty of that ward, and retry again two weeks later.”(P 8).Providing feedback to address deficiencies and shortcomings is valuable. However, this feedback should be provided thoughtfully and appropriately to the learner. “The educational supervisor can promote educational activities by using measures such as providing educational equipment, creating a healthy and fear-free learning atmosphere. Its subcategories are “reduce work stress “, “learner engagement” and “learning facilitation”.During this time, I saw many restless students, especially during the busy period, due to the heavy workload, stressful work environment, insomnia and many other things. Sometimes, I talk to them about my old experiences and big problems I had before and that they are all over now…. they cheer up and feel energetic”, (P 2).Creating a calm atmosphere is the basis for effective learning and teaching. ““Some instructors do not put students in a position of scientific evaluation at all. The round is one-sided. They do not ask the student for any clinical judgment,” (P 14).Giving responsibility and involving participants in group learning activities  is part of engaging students. “Many of the hospitals we worked there had poor teaching facilities; they didn’t have a good library to study or to find the references we needed. There were old computers, we had to bring our own. However, in the hospital environment, and the educational supervisor can provide the students with facilities like an amphitheater, a conference room to hold a journal club” (P 5).It refers to providing educational materials and equipment to facilitate educational activities. “Professional ethics education” deals with another responsibility of the clinical supervisor related to the patient. In addition to the student, the clinical supervisor must pay sufficient attention to the patient. Its sub-categories are “Attention to patient treatment “,“Ethical observance about the patient”.The patient who comes to the hospital with a thousand hopes is terrified and emotionally involved. The educational supervisor should also pay attention to this issue. On the other hand, care should be taken not to sacrifice education for treatment.” (P 9).It refers to the clinical supervisor’s sense of responsibility and attention to the patient’s treatment process. ““Rarely, however, there were professors with a weak perception of ethics. They shouted at the patients. They insulted them. They did not follow the charter of the patient’s rights. The patient did not dare to squawk either because they were unaware of their rights” (P 12).It refers to the rules and regulations regarding the observance of ethical issues and the patient’s human dignity in the clinical environment. The second theme refers to a clinical supervisor’s wide range of scientific, ethical, professional, and communication characteristics. These characteristics are effective in effectiveness of professional activities in the clinical setting. This theme has three main categories: “Scientific competence”, “Leading role” and “Ethical model”.“Scientific competence” refers to a clinical supervisor’s competence and knowledge of professional and specialized issues. The clinical supervisor should have high clinical knowledge and skills to be able to supervise the care, health and medical performance of students. Its subcategories are “knowledge of educational concepts” and “mastery of professional concepts”.As a clinical professor, I have to be a teacher other than a specialized instructor. I should love education and have a concern about my field of education. I have to take a medical education course and increase my training knowledge, needs assessment, evaluation and teaching methods “(P 3).It refers to the clinical observer’s familiarity with related concepts in teaching and learning. “The person who claims to teach the student must have even more knowledge in that field than other instructors ... The student must feel that the teacher is capable, has mastery, this way he/she can trust the teacher because he believes the instructor has sufficient expertise in the field” (P1).It refers to the knowledge and skills of the clinical supervisor in the specialized and professional field of medicine and clinical wards. ““ leading role is one of the traits of the clinical supervisor who guides learners in the process of teaching in a clinical environment. It guides the talents and energies of students toward achieving educational aims. This role guarantees the quality of care and patient safety in the hospital. Its subcategories are “effective communication skills”, “understanding managerial concepts”, “high resilience”.There are many times when I wish I had more time to talk to the teacher, but the connection between us is cut off and that connection is not established between the teacher and the student, especially during the internship.” (P 14).This sub-category is related to appropriate communication skills between the supervisor and the learner. “Everywhere in the world, it has been proven that you have to know something about management science when you take a job despite your expertise. A clinical supervisor must know about management factors and must have experienced how to interact and do conflict management” (P 8).Awareness of the basic concepts of management, including planning, organizing and monitoring, is an integral part of working in organizational environments. ““During this time, I witnessed a professor clashing with a student. In many places, complaints were lodged inside the university or even in the judiciary. I did not expect that student, but I expected more sobriety and better patience from the professor” (P 6).This sub-category addresses the resilience of the clinical supervisor in the face of shortcomings, deficiencies and criticisms in the educational environment. The clinical supervisor in the clinical setting should be a role model for other students. The clinical supervisor can influence the attitudes, values and behaviors of students. She/he can inspire students. Its sub-categories are “career commitment “, “social commitment “.“The first day we entered the ward, the teacher came earlier than everyone else. All the students gathered around him. He was a stylish professor. After a short introduction, the teacher said… listen …. This is a holy place, the patient’s body is holy. He/she allows us to examine his/her body and learn something, he/she has been very kind to us. Don’t say it smells bad! …. doric. I did not expect the teacher to say such things” (P 5).It refers to being a moral role model and a good reputation. Our teacher used to bring us together every week and said that God had allowed us to serve human beings. Seize this opportunity. Do not miss a moment of serving the people” (P 12).It refers to the clinical supervisor’s sense of responsibility to the organization, the community, the patient, and the students.” This study aimed to explain the responsibilities of a clinical supervisor in different hospital wards. There was a significant attitude toward the position of the clinical supervisor by participants of the study. The role of the clinical supervisor in the medical and educational environment has been neglected. Participants also noted both the responsibilities and individual characteristics of the clinical supervisor and its role in improving the quality of education and patient and medical students’ satisfaction.In this study, creating motivation in learners included two subcategories: creating a supportive atmosphere and assigning tasks to learners. Determining duties and responsibilities in students makes them more motivated to perform their responsibilities. In her research, Åsa Alsiö et al. found that supervising medical students in clinical activities and being clear about the expectations for each role was effective in enhancing learners’ motivation .Students in the clinical environment need the support and guidance of the instructors to strengthen their confidence in work, their sense of hope for the future, and to perform their professional duties properly. The main task of the clinical instructor is to provide opportunities for practical experience and to assess the status of patients. The clinical instructor should be available to answer questions, provide advice and guidance to students, and friendly support the clinical supervision of students in various situations , 23. ZahAnother category attained in the present research is to offer proper feedback to medical students. Providing feedback makes students become better aware of their performance and its improvement and promotion and try to eliminate shortcomings. Fassihi Harandi et al. in their study considered providing feedback to students during the clinical course as one of the highest acclaimed categories obtained in the quality assessment of clinical education .Another category highlighted in the present research is the creation of learning opportunities among learners. The presence of an educational supervisor paves the way for the transfer of teacher experiences to the learner. The learner can easily ask the instructor about the questions and issues that he will face in the future. In a study, medical students learned skills related to dealing with the patient, clinical examinations, and general procedures in the hospital. They consider the amount of learning to depend on motivation, patient access, and quality of teaching .The survey of Zamanzad et al. on satisfaction and evaluation of medical students, clerks, and externs regarding the quality of clinical education in central wards showed their low satisfaction. Lack of time management by instructors, roaming in the wards and wasting time were repeatedly pinpointed as causes of dissatisfaction .A calm and stress-free environment in students’ learning was extracted from the attained categories. Stressful environments lead to academic problems and reduced learning. In a study, stressors during medical education on medical students have been studied. The results showed that high stress and anxiety levels during medical education might negatively affect students’ learning and clinical success , 30.In this study, observance of professional ethics and attention to patient rights were gleaned as the responsibilities of the clinical supervisor. Participants believed that an educational supervisor’s responsibilities are not limited to learners but also include the patient and patients’ rights. Through direct instruction, the clinical supervisor must instruct the student about patients’ rights, although the positive and negative messages of medical ethics in implicitly conveyed to the learner through the hidden curricula.Batahi and Asayesh showed that more than half of medical students had moderate or poor knowledge of patient rights . HoweverRegarding the theme of Personal characteristics of clinical observers, the categories of scientific competence, leading role, and ethical model were obtained. Scientific competence included mastery of the professional career and expertise in education concepts. In this study, many instructors had much information about the concepts of teaching and learning, and their demographic information revealed that all of them had a master’s degree in medical education or had taken courses related to education.Darvishpour and Javadi-Pashak, in a study entitled “Good Clinical instructors from the perspective of nursing students extracted six main categories, including academic ability, clinical skills, communication skills, evaluation skills, personality, and educational management in the clinical setting .In our study, two categories of “career commitment “and” social commitment “were obtained following the professional ethics model. Students observe, analyze, and evaluate professional ethics through instructors’ practical behavior and attitudes in the clinical setting and wards.Undoubtedly, students gain knowledge through learning, directly or indirectly, by observing the behavior of professors and how to deal with the patient. To put it in another way, students repeat what the instructors do, not what they say . HoweverIn this study, the category of “leading role” was introduced as another characteristic of the clinical supervisor. This category includes “effective communication skills”, “high resilience” and “understanding managerial concepts”. The clinical supervisor will need good communication with instructors, students at different levels, and patients and their companions. A prerequisite for this relationship can improve communication effectively. Rahimi et al. reported communication ability and individual personality as essential characteristics of a good instructor from students’ perspective .In their review study entitled, “What makes a good clinical teacher in medicine?, Sutkin et al. reported the instructors’ knowledge, technical and clinical skills of clinical reasoning, positive communication with students in a supportive environment, communication skills and passion enthusiasm as the most common themes .This study had some limitations. Small sample sizes for the student was the first limitation. We had to select the student who knew the concern of education and were familiar with the concept of education. Moreover, it was more time-consuming research. The final limitation was the lack of research in clinical supervision in Iran. However, the duties and position of clinical supervisor are already seen in nursing schools, and suitable information and research have been done in this area. It is suggested to design quantitative and qualitative works in this regard.In Iran, the clinical supervisor is the missing link in clinical wards and environments. Although some experienced professors in clinical departments offer this role based on intrinsic motivations and love of education, no special trustee has been designed for the clinical supervisor in the educational system. This has caused medical students to feel confused about their duties, responsibilities, and expectations, and they have a sense of wasting time and lack of support from instructors.Improving the education of medical students in the clinical environment will enhance the quality of services and lead to the training of efficient and literate graduates and a safe and relaxing environment. In addition, it results in a sense of safety for patients and recipients of services in the clinical environment.


The torrent of research during the coronavirus (COVID-19) pandemic has exposed the persistent challenges with reporting trials, open science practices, and scholarship in academia. These real-world examples provide unique learning opportunities for research methodologists and clinical epidemiologists-in-training. Dr. David Moher, a recognized expert on the science of research reporting and one of the founders of the Consolidated Standards of Reporting Trials (CONSORT) statement, was a guest speaker for the 2021 Hooker Distinguished Visiting Professor Lecture series at McMaster University and shared his insights about these issues.This paper covers a discussion on the influence of reporting guidelines on trials and issues with the use of CONSORT as a measure of quality. Dr. Moher also addresses how the overwhelming body of COVID-19 research reflects the “publish or perish” paradigm in academia and why improvement in the reporting of trials requires policy initiatives from research institutions and funding agencies. We also discuss the rise of publication bias and other questionable reporting practices. To combat this, Dr. Moher believes open science and training initiatives led by institutions can foster research integrity, including the trustworthiness of researchers, institutions, and journals, as well as counter threats posed by predatory journals. He highlights how metrics like journal impact factor and quantity of publications also harm research integrity. Dr. Moher also discussed the importance of meta-science, the study of how research is carried out, which can help to evaluate audit and feedback systems and their effect on open science practices.Dr. Moher advocates for policy to further improve the reporting of trials and health research. The COVID-19 pandemic has exposed how a lack of open science practices and flawed systems incentivizing researchers to publish can harm research integrity. There is a need for a culture shift in assessing careers and “productivity” in academia, and this requires collaborative top-down and bottom-up approaches.The online version contains supplementary material available at 10.1186/s13063-022-06624-y. The coronavirus disease 2019 (COVID-19) pandemic has introduced unique challenges and learning opportunities for research methodologists and clinical epidemiologists-in-training. As part of a McMaster University graduate course, experts are invited to share their insights about the current challenges, recent innovations, and future directions in trial methodology. The 2021 Hooker Distinguished Visiting Professor Lecture series featured Dr. David Moher , selective reporting , incomplete reporting , spin and misleading interpretations, and inconsistencies between sources . The publication of the first version of the CONSORT statement in 1996 had major downstream impacts for trial reporting practices. On a broader scale, it has influenced the development and implementation of evidence-based reporting guidelines , 5. OwinHowever, despite the many advances spurred by the development of CONSORT, challenges in communicating trials persist. Dr. Moher discusses how the application and misuse of reporting guidelines has remained problematic and that CONSORT has been used as a “quality control measure” . He says that this was never its intention, and the developers have explicitly stated that CONSORT should not be used as a scoring system. When asked about how we can better support the ultimate goal of improving the design and reporting of trials (which are often assumed to coincide), Dr. Moher reflects on his discussions with friend and colleague Prof Douglas Altman, “We spoke about this incessantly, the history of CONSORT really is primarily about trying to get people to improve the quality of reporting. It’s possible that if we were able to achieve that, that we might move to work on trying to improve the design of studies. It seems to me that the design of trials is not necessarily a low hanging fruit” as there is rarely one singular or agreed upon approach to the design of trials. He uses the example of randomization methods in COVID vaccine trials as an example, “Interestingly enough, with all the vaccine trials they only used a 1:1 [randomization] ratio, why didn’t they use 2:1? Did they have clinical equipoise, or did they think that the vaccine would be better?” In contrast, “there is only one way to report something, and that is clearly and transparently” irrespective of the study design. He discusses the “excitement” surrounding CONSORT and other similar initiatives as tools that improved the quality of reporting, “These interventions have helped a little ... the evidence is that there are still about 50% of reports of randomized trials that tell you nothing about the randomization process,” a less exciting reality, “I think we still have a way to go.”As part of the overwhelming volume of COVID-related research , many smResearch integrity is defined as encompassing honest and verifiable methods, reporting in adherence with rules, regulations, and guidelines, and following commonly accepted professional codes or norms , which aIn terms of practicing transparency, Dr. Moher believes that when it comes to addressing the issues with reporting , “we don’t seem to have a research ecosystem that promotes and values audit-and-feedback.” Audit and feedback (A&F) is a practice that motivates behavior change by generating an awareness of current practices and has been observed to perform best when compliance is low in healthcare settings . Dr. MohEven more resounding is the overwhelming support by patients who want their data shared , 24. RecWhat will it take to advance the state of the clinical research landscape? “I had sort of an epiphany, of spending much of my career looking at risk of bias and looking at the same result the whole time, either ‘unclear’ or ‘bad’... the epiphany is thinking more about policy and open science.” Dr. Moher suggests that this can be accomplished with a “digital dashboard for researchers, institutions and funders” at a departmental or institutional level, by different clinical fields within an academic hospital, and so on. The dashboard would track the number and quality of trials an investigator has published. As another idea, metrics such as the number of randomized controlled trials for which CONSORT or the Standard Protocol Items: Recommendations for Interventional Trials (SPIRIT)  were useOn the topic of concerns with transparency, Dr. Moher points out that publication bias is on the rise and that institutions contribute to this issue. Similarly, the prevalence of spin  and selective outcome reporting bias is very high. To address these biases, Dr. Moher says that we can encourage the use of existing tools such as preprints , which is an open science practice. This ensures that the original trial results are available and enhances transparency. Preprint use has been more common in some research fields, such as physics, and he believes that institutions should make this practice mandatory for all researchers “in recognition that peer review might change the manuscript by the time it is accepted.” These types of early research reports have had a big impact on human health and risk communication during the pandemic, but to those without professional knowledge, may be considered the same as final, peer-reviewed reports. Preprint results need cautious interpretation until there is sufficient evidence to make more definitive judgments. Most preprint servers indicate on the cover page and every subsequent page that the paper has not been peer reviewed. However, emerging evidence comparing preprints to published (and peer reviewed) reports suggests little difference in terms of results and linguistics.For researchers concerned with misuse of shared data, he emphasizes that there is currently very little evidence that this leads to any “scoops of intellectual content”. However, there are currently insufficient resources to help academics with data sharing, and he says that this must come from funders and institutions. For example, “data champions” in universities in the UK  and the Netherlands  help researchers share their data. Additionally, public funders are needed to support open science research—without which it is difficult to evaluate specific interventions and their impact—and journals and academic institutions need to participate more actively. He recommends the Transparency and Openness Promotion guidelines developed by the Center for Open Science . This haThe responsibility for fostering openness and improvement in the reporting of trials and health research also lies with publishers, journals, and their editors. “COVID has highlighted the very tenuous practice of peer review and editorial practice” says Dr. Moher, “in general, we do not train peer reviewers, a tremendous flaw, nor do we train editors, another flaw”. He provides a clinical analogy, “Do you think you would let me into the OR [operating room] to do surgery without training? Probably not... But why should people review manuscripts without training, why is there a different standard here?” In line with this, Crawley states in a commentary that journal editors have evaded accountability in addressing poor research and publishing misconduct based on the ICMJE recommendations, where “authors are assigned ‘responsibilities’; journal editors are assigned ‘freedoms’” .We discuss some of the challenges with investigating editorial and peer review practices. Publons , an organization and online platform that helps researchers document their peer review activities, offers free training in peer review (now Web of Science Academy). Dr. Moher discusses his hopes to evaluate the training as an intervention, which was met with great interest from publishing houses but little fiscal commitment, describing it as “a sad story.” This experience emphasizes the challenges faced by the research community, particularly in Canada, to obtain funding from entities such as the Canadian Institutes for Health Research (CIHR) for this type of research. Unfortunately, research on research and publishing practices is “low on the totem pole and it’s very sad because it has tremendous impact and consequence.” Elaborating on the lack of evidence on editor and reviewer core competencies , “we havDespite these limitations, Dr. Moher stresses that peer review is very important and encourages young researchers to participate as a way of “paying it back and paying it forward”. In discussing his approach, “I try to make my peer review evidence-based; it is not the opinion of David Moher...here is the facts and here is the evidence.” He mentions the CONSORT-Based Peer-Review Tool (COBPeer) as another good outcome of CONSORT and that it was effective in helping peer reviewers to identify inadequate reporting . But traPredatory publishers and journals also have a significant impact on the outputs of health research. Based on an international consensus definition, predatory journals are entities that prioritize self-interest at the expense of scholarship and are characterized by false or misleading information, deviation from best editorial and publication practices, a lack of transparency, and/or the use of aggressive and indiscriminate solicitation practices . Many reTrainees and young researchers are often more susceptible to calls from predatory journals due to less experience with publishing. But Dr. Moher clarifies that all researchers, including senior researchers, can get entangled, and directs us to guidance  to help To better evaluate research integrity and gaps in publishing practices, we discuss the study of research itself. Meta-science—also called research-on-research, meta-research, and many other names—has been described as the scientific discipline that seeks to evaluate the practice of research . This fiIn addition to meta-science, Dr. Moher believes that the use of technology will have a big impact on advancing meta-science and reporting guidelines. He gives an example of an artificial intelligence-based CONSORT compliance tool (which is currently being tested by some publishing houses) to evaluate compliance at the manuscript submission stage . “IndustNext, we discussed research collaborations, an area in which Dr. Moher has demonstrated incredible talent, having led numerous successful initiatives. Any advice for working with diverse groups of researchers and stakeholders? “Make it about the team, not about the individual,” he attributes any success of initiatives like CONSORT and the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) as a result of the team, “It is a team effort, it’s not an effort of David Moher.” Elaborating on international collaborations and cross-cultural differences, “How the message is delivered is critical” and paying attention to clarity in communication is essential. He points out the importance of working collaboratively, especially in spaces where big personalities can impede these processes, “Never stop listening to collaborators, including the difficult ones, and in academia, there can be an over-representation of difficult ones.” However, he cautions, “Try to avoid including people who find it difficult to play in the sandbox, or compromise,” admitting that he has had to terminate collaborations with disruptive individuals. He encourages us to stay humble and lead by example in what we do, as that is often much more enduring than what we say. “I think it’s really important to empower everybody” on his approach to promoting diverse and collaborative science, “You will definitely hear from the extroverts, but you need to give time to the introverts,” a statement that will likely resonate with many scientists, particularly as many have been thrust into the spotlight during the COVID-19 pandemic. Since the pandemic, the shift in the approach to science communication requires us to also communicate outside of our collegial circles and with multiple audiences. He emphasizes the need to stand by one's principles when pressured to report non-evidence-based information. To help researchers, journals should institute requiring a lay summary as part of any published article. Similarly, we need to augment patient and public involvement and engagement in research which will facilitate scientific communication. For this reason, we should also consider adding patient/public membership to journal editorial boards. Traditional publishing practices, as it relates to academic career advancement, are a major culprit in the persistent challenges with reporting of health research. Dr. Moher reflects on merit evaluations by academic institutions which reinforce these practices. Specifically, the “publish or perish” paradigm requiring researchers to report their annual number of publications and the proportion published in journals with a journal impact factor (JIF) greater than x. To what degree do metrics such as JIF matter? “Impact factors tell us nothing about the quality of the research, it’s an erroneous measure to use” he says, it indicates nothing about the authors yet it remains “ubiquitous in assessing researchers.” He believes this is a major flaw and describes his recent work evaluating the criteria for promotion and tenure in faculties of medicine within the U15, a collective of Canada’s self-appointed research-intensive universities. Progressive criteria  included aspects such as data sharing, and it was found that universities based their assessments on traditional criteria without considering open science practices .Dr. Moher elaborates on the competing forces between researchers and institutions, “I think our energies need to be based on changing policies at academic institutions about how researchers are rewarded.” The wide adoption of JIF by leadership is likely related to its ease of collection, “doesn’t matter whether it makes sense or not, it’s easy to collect.” He notes that JIF is associated with university ranking schemes, which are partly based on “productivity” as measured by numbers of publications, “ranking schemes, systems that are equally as problematic as journal impact factor.” This system also impacts students who are required to publish papers to complete their PhD. He directs us to the Declaration on Research Assessment (DORA) which is largely based on the belief, backed by evidence, that universities should not use JIF to assess researchers . He encoWe finish the discussion by asking Dr. Moher about his career mistakes and challenges. Have any of these experiences turned out to be the most rewarding? Reflecting on career successes and his “many failures,” he offers insights including personal struggles with dyslexia, “Everybody told me I would never succeed, and the people who really emphasized that I would never succeed were schoolteachers and university professors”. On many “no’s” and negativity, “don’t take it personally even if it’s meant personally,” something that is very prevalent in academia he says, and urges trainees to surround themselves with mentors who will help them, and to stay focused. “In the end of the day it’s about the methodology of what one is trying to do.” This advice aligns closely with that of his late colleague, Prof Doug Altman, who also spoke about the need for getting “good research practices out there into early career training before people develop bad ideas.”  There shHe also discusses the importance of capacity-building and mentoring the next generation, “I definitely want to empower mentees.” He pays close attention to including younger researchers, minorities, and women researchers, in particular, in his work. Dr. Moher discusses the challenges for this group, citing work by Professor Witteman and colleagues that found policies such as those at CIHR inherently discriminate against female research applicants . “Women Trust in trials and more broadly, scientific research, has been negatively impacted during the COVID-19 pandemic, partly due to the miscommunication of science. Several approaches by researchers can help to improve scientific integrity and regain public trust in science, including transparent reporting and open science practices such as data sharing. In contrast to the more traditional approaches for incentivizing career progression , Dr. Moher’s outlook and messages concerned with open science, if adopted more broadly, suggest the possibility for a research career that may be more sustainable for students considering a future in academia. Open science practices would positively impact the enterprise of research itself with the focus on more qualitative metrics such as registration of research and use of reporting guidelines. How quickly institutions align with and get up to speed with valuing these practices is uncertain, but there are examples that demonstrate this is possible, with various institutions in Europe leading the way. As students, through a more grassroots approach, we can help to educate and advocate for the importance of these practices, and challenge institutions to look critically at research and individual academic output, beyond the simpler assessment of quantity of one’s publications.Additional file 1. Dr. David Moher curriculum vitae.


Research fellowship programs help medical graduates acquire research skills for an academic career. While our institution employed a large number of research fellows, it did not offer them a formal training program. This study aimed to assess the views of fellows and their mentors regarding the current research fellowship program, and to seek their suggestions for a formal training program at our medical center. We conducted a qualitative descriptive study using both focus group discussions and individual interviews with research fellows, and individual interviews with their mentors. We recruited all eligible participants by email. We collected data in person and analyzed it thematically. We followed the consolidated criteria for reporting of qualitative research (COREQ) checklist. A total of 17 research fellows and 17 mentors participated in the study. Participants described the current non-formal program and proposed suggestions for a formal training program. The identification of available vacant positions and the recruitment process followed an unstructured approach, through networking with mentors and previous fellows. Although there is a formal contract, there is no job description, and no definition of roles, responsibilities and rights. Some fellows get the opportunity of being involved in all aspects of research and benefit from a favorable mentor-mentee relationship. Conversely, others struggle with authorship and with the projects allocated to them, some being “non-research” related. Not all fellows end up publishing their projects. Participants provided suggestions to shift into a formal training, including measures to improve on the recruitment process of fellows, defining roles and exposure to all aspects of research. Research fellows are eager to learn, but the currently available program is unstructured. They need a formal training program that meets their expectations, one that offers equitable learning opportunities and benefits to all. Research fellowship programs provide young medical graduates research training opportunities and prepare them to become independent scientists. In medical disciplines, a research fellow is “a graduate who holds a masters or a doctoral degree in a health science discipline, residency or equivalent clinical experience” . SeveralThe American University of Beirut-Medical Center (AUB-MC), in Lebanon, has invested in expanding its research programs over the last decade. Scientists from various academic departments recruit research fellows on a yearly basis to assist them in the conduct and the implementation of their research projects. A research fellow usually commits for a full-time one or two years of research with minimal interruptions for travels and interviews for residency positions .As a formal and structured training program for research fellows at our institution was not available, there was a need to design one, providing equitable and optimal learning opportunities to all of them. This study constitutes the first formative phase of a project aiming at establishing a “Research Fellowship Program” at AUB-MC. It encompasses the general and target needs assessment of the Six-step approach in developing, implementing and evaluating curricula for medical education, as described by D. Kerns . We aimeThis is a qualitative descriptive study, based on focus groups discussions (FGDs) and in-depth interviews with fellows and in-depth interviews with mentors at AUB-MC. Through considering the perspective of both fellows and mentors, this study illuminates our understanding of a comprehensive range of factors of the contextual and the individual factors influencing the fellowship experience.We received ethical approval from the Institutional Review Board (IRB) at AUB-MC to conduct the study, under the protocol number IM.MC.01. All study participants provided oral informed consent. Written consent was not required, as the risk associated with the current study was below the minimal risk. We audio-recorded the verbal consent of participants at the beginning of the FGD or interview. The Clinical Research Institute (CRI) at AUB-MC provided the logistical support for the study conduct. We followed the COnsolidated criteria for REporting Qualitative research (COREQ) Checklist, as suggested by Tong et al.   , while aThe principal investigator (MC) conducted the in-depth interviews with mentors at AUB-MC. Given her medical profession background and being a faculty at the same institution, she had a prior professional relationship with some mentors. Similar to FGD, the interviewer used the same interview guide that included a number of probing questions. All interviews were conducted in English. The duration of each interview was 30 minutes.We transcribed verbatim all FGDs and in-depth interviews. Simultaneously, we translated Arabic statements into English. One investigator conducted the initial coding (EK), with the input of the senior researcher (GHA) on the coding process. The research team met on several occasions to discuss the analysis.We followed the six phases of the thematic inductive analysis, suggested by Braun and Clarke , includiFirst, the coder familiarized herself with the content of each transcript. She read and re-read each transcript while taking notes on what the data mean. This was followed by a systematic line by line coding capturing the essence of the data. After coding one transcript, she met with the senior researcher (GHA) to ensure congruence in the interpretation of meanings. She then proceeded in coding the remaining transcripts independently. For phase 3, GHA and EK met to discuss the relationship between the codes and to create a log of candidate themes and sub-themes. In phase 4, MC, GHA and EK reviewed those candidate themes and refined them based on a consensus. At this stage, they were mainly concerned to identify the relationship between the themes, both hierarchically and laterally. In phase 5, the research team met to finalize each theme and sub-themes and ensure that the results are congruent to the research question. In phase 6, the narrative of the results, including the research team interpretations of the findings, supported by quotes from interviewees was prepared.In addition, we triangulated the themes elicited from fellows and mentors to establish similarities and differences, as well as expansion of themes between those two actors. To ensure privacy, we assigned a code to each participant. In the quotes included in the results section, we refer to FGD participants as “FGxPx”, and to interview participants as “Mx” or “Px”, to refer for mentors and fellows, respectively.To increase credibility, we adopted two strategies. We audio recorded all conversations, transcribed them verbatim, and used them as the main data repository. We used triangulation between two different actors. As for confirmability (i.e. objectivity), we used three strategies. First, we described the study methods in explicit details. Second, two investigators (EK and GHA) met to reach agreement on the coding strategy, and thereafter, on the candidate themes. All team members were involved in the final data analysis, so as to avoid misinterpretation of the results. Third, given that one research team member (MC) had prior relationship with the participants, we used reflexivity, whereby team members were mindful of their personal biases when doing the analysis in order to avoid any subjective interpretation of findings. We used a semi-structured interview guide to increase the dependability of our research. For authenticity, we reported disconfirming results.We conducted 5 FGDs and 3 interviews with a total of 17 research fellows ; see flow diagram -The inductive thematic analysis led to the following two main findings:Description of the current non-formal training programProposed suggestions for a formal training programa better residency program (FG2.P2)” in the United States as “research experience is a must (FG1.P4)”. For those preparing for their United States Medical Licensing Examination (USMLE) exams, the fellowship provided them with time flexibility to prepare for their tests, and later on, for their residency interviews. The fellowship also provided a needed financial support. For a few, research fellowship filled a gap when all the other options failed. Many others pointed to academic motives, including interest verging towards being “passionate about research (FG1.P5)”, acquiring in-depth knowledge on a specific medical specialty or sub-specialty, and an opportunity to get more publications. For some, the research fellowship year helped them choose their career path, i.e. academic or clinical track, or even public health.Fellows reported that the research fellowship experience offered them better chances in getting accepted into “… a lot of … [was] word of mouth (M1), which was confirmed by fellows, who indicated that they depended on their network and direct communication with mentors or previous fellows to identify available opportunities.Both fellows and mentors indicated no repository for vacant positions and that the process of hiring was not standardized. Few mentors advertised their vacant research positions, but ““I noticed it after—after I took the SHARP course, a lot of emails started pouring in from attendings (FG1.P5)”.Fellows added that graduates from the same medical school (AUB) were at advantage for two reasons: first, they know most of the mentors; second, some AUB graduates had completed a research certificate, such as the Scholars in Health Research Program (SHARP) , which eI was working with the PI before—in Med school…so I sent out an e-mail saying “I wanna work with a person in neurology and such”, and so when I was finishing up my project and I knew I was going to graduate, I asked if there was a position open for me, and then she told me “yes, just apply” and I applied (P1)”.Some fellows indicated that the available positions were not always timely, hence they were engaged in positions not matching their interest. “Then, mentors interviewed the candidates and selected the best match. Some mentors targeted those who were interested in spending more than one year in research and those who were not sitting for the USMLE exams during their research year.I had talked during the handover about all the projects that were running which were like three at the time. I kind of knew what was expected. But I didn’t know exactly what my role would be… (FG2. P1)”.Both mentors and fellows indicated that research fellowship positions did not have a clear job description. The responsibilities and the roles assigned to the fellow were left utterly to the mentor’s decision and the available resources. Mentor and fellow met upon the fellow recruitment, to discuss mutual expectations. Typically, there was no orientation or training, but rather previous fellows handing over their projects to the newcomers. “Fellowship opportunities were not always funded by research grants. Therefore, some fellows were paid, while others worked as volunteers. Paid fellows usually signed a contract with the human resources department. However, this contract did not stipulate the working hours, vacations, rights nor duties. Most of the fellows indicated limited opportunities to negotiate their contract with the mentor. Interestingly, the unspecific contract allowed more time flexibility to sit for USMLE exams and leave intermittently for their residency interviews in the United States. In addition, it provided room to later negotiate their role with the mentor. Volunteer research fellows did not have to sign any contract, did not get any job-related benefits, and sometimes not even authorship on projects they worked on.Fellows’ perspective. Upon enrollment, fellows expected to be involved in all research aspects, and to enjoy some independence, while receiving the appropriate guidance from mentors. They were also aware that their work would be limited to research projects of their mentors, and thus unable to conduct their own projects.satisfied… [and had] “the experience [they] wanted” (FG2.P2). The friendly work environment and the teamwork allowed for a smooth transition and hand over of various project, from one fellow to another. Indeed, the availability of other research team members, such as a research assistant or a coordinator in some units, helped the fellow in both research and administrative tasks. For some, working on several projects was beneficial. Some fellows described their mentor-mentee relationship as “good”, the mentor being supportive and always generating ideas for new projects, and others learned teamwork and how to appropriately manage their time.Several fellows were ““We, unfortunately, are—they think our lives are dedicated to this research, throughout the day, twenty-four seven, it’s not how it works (FG1.P1)”.Conversely, some fellows expressed an overall disappointment “Preparing PowerPoints to a conference over the weekends, they send you an e-mail on Saturday night, and you end up working all day tomorrow (P1)”. They would accept those tasks in order to get a good recommendation letter, the only documentation that they have successfully completed their fellowship.Many reported unfair project allocation, leading to working on a large number of projects, sometimes unrelated, or doing someone else’s assignments. Consequently, they were not able to complete their projects. Some were even assigned tasks that are not related to research, such as administrative tasks, I feel that my PI is very busy. I barely have time to sit down and discuss the projects (FG1.P3)”.Fellows also complained that mentors were not available to provide guidance or career advice. “At the institutional level, fellows described delays in contracts leading to delays in payment, and in privileges . There was a lack of training on softwares (such as Oracle), crucial for their daily research related financial activities, resulting sometimes in delays in grants administration.Mentors’ perspectives. Mentors expected their fellows to be interested in academia, to know research ethics regulations and to be dedicated for their work. They expected them to at least to have the basic research skills . Mentors pointed to many unmet expectations from their fellows: primary motive not being research, not being available all the time (due to studying for exams and traveling for residency interviews), and lacking some skills . Mentors also complained that some fellows might have opted for research only because they did not have any other option. They also noted that the one-year commitment is very short considering the time needed to get oriented, and the time spent on residency interviews. Mentors also described their own failure in meeting fellows’ expectations. They indicated that their clinical workload gave them little time to closely oversee their fellow’s work. Others candidly admitted lacking experience and skills to lead research projects. Some admitted they were not passionate about research, and they only did it for promotion’s, with little coordination between the relevant departments . Also, the lack of funding strongly impacted the ability to recruit research fellows and other research staff, such as a research nurse or a research unit coordinator, to assist both mentors and fellows.Fellows’ perspectives. For most fellows, the research experience was fulfilling. They reported acquiring hands-on experiences on how to select a successful project, collect and analyze data, conduct a trial, build a database, and perform a literature search. They also said they learned how to establish a network of peers, exchange ideas, share challenges and seek advice on problematic situations. Yet, the ultimate outcome was publications, which was not met all times.Mentors’ perspectives. Mentors agreed that the research fellows’ productivity was “variable”, depending on their interest in research, their motivation and their dedication. Some were hard workers and were able to publish four or five papers in one year, while others did not publish any.real (FG1.P4)” contract, with a clear definition of the fellow’s roles, responsibilities, and expectations by both parties. Fellows and mentors asked for a database for matching fellows with mentors, based on their interest. “I wish that there was kind of like a platform where we know who are the attendings and what positions do they have (FG1.P5)”. They requested a structured time allocated to meet with their mentors on a weekly basis to discuss projects, progress, and challenges.Fellows suggested having a “How to deal with the sensitive data, for example, if you’re working with data that’s, I don’t know, the names are anonymous or whether you have access to it, something like that, you know (FG1.P3)”. Fellows and mentors suggested to make the research fellowship become “legitimate (FG1.P4)”, meaning that it should be a program with a certificate of completion at the end of the year. One of the mentors suggested to have a 2-year fellowship program and another proposed to have the SHARP summer course as the core curriculum for the research fellowship, to be coupled with mentoring by a faculty of a specific specialty.The fellows recognized that the availability of a research coordinator in the unit was extremely helpful in taking over the administrative work, and in coordinating various tasks between research team members. More institutional support was also recommended in terms of availability and training on software for statistics, referencing and others, in addition to resources/guides for application to the IRB, data transfer… “That fellow can work with the PI but at the same time can utilize resources through that fellowship program (M6)”. One mentor highlighted the importance of the program as a platform for fellows to establish networks with their peers, and to get the sense of belonging to a certain community “But it’s a sense of belonging, the group together, and people discussing and learning, this is what I think is the most important (M2)”. Another one suggested to incorporate research training with residency programs “I also was thinking about, in the States, they incorporate research into residency programs which would mix research and residency programs and I think this would be a new credible opportunity (FG1-P4)”.Regarding the formal training program, fellows suggested a pre-enrollment orientation to help understand what the field is all about. Both actors indicated the need for more intensive training to be held in the morning or at lunch break, on a weekly or biweekly basis, covering various topics. In addition, fellows suggested to have sessions with experienced mentors, who would help them delineate expectations and provide them with guidance on how to manage their projects. On the other hand, they suggested that some mentors’ skills and competencies need improvement. Few mentors proposed having yearlong sessions dedicated to journal clubs and presentations of the fellows’ project. The mentors noted that the program should not target only fellows in a paid position, but also those volunteering. Some mentors highlighted the importance of having technical resources, from the CRI, for instance, to support research fellows in areas where the mentor does not have the time to do so. “This study constitutes the formative phase of a large project aiming at establishing a formal research fellowship program at AUB-MC, and provides a baseline description to build upon. The current research fellowship opportunities have several challenges related to the availability of vacant positions, the unstructured recruitment process, and the ill-defined roles, responsibilities, and rights of fellows.Although our sample is limited to AUB-MC, we believe that the suggested formal program can be scaled to programs in Lebanon and other low to middle income countries. In a country/region where clinical research is still limited, establishing a strong research training program is meant to support career development of individual fellows and fostering a research environment to build a strong academic workforce. Indeed, a structured research training program enhances career development in clinical research, as it has been shown in various specialties including dentistry , surgeryAt our institution, undoubtedly, both fellows and mentors show motivation and interest in research. Several restraints, related to personal and organizational factors, weaken their engagement. However, they provided suggestions to address those restraints. We took these suggestions into consideration to design a structured research fellowship training program, similar to other programs described in the United States –10. The Challenges in the mentor-mentee relationship reported in this study included lack of time, limited mentorship skills , the relFellows identified challenges related to financial constraints and sometimes lack of unit coordinators and infrastructure to support capacity building and research fellows’ trainings; such challenges were described during the experience in capacity building in South Asia  and otheThe current process of position identification based on networking with peers and faculty, rather than a structured database is a main limitation. Both fellows and mentors recommended having a database with matching of fellows’ interest with available positions. This possibility needs exploration for feasibility, by the human’s resources department at the level of the institution.The fellows reported on challenges related to authorship, and this has been previously described in academia. For instance, in one study on medical students involved in research, 26% reported that expectations and criteria for authorship were not clarified . Thus, iThere is no “formal” contract or specific job description for research positions. Fellows recommended having a formal contract describing their roles, responsibilities and rights. While such a problem may seem to be related to the recruitment and the hiring process at AUB-MC, mentors and fellows are expected to meet and discuss mutual roles, responsibilities and rights.An important issue that was not highlighted by fellows nor mentors was the training on balancing personal factors and soft skills that is crucial for advancement of physician-scientist . Indeed,Several metrics to measure the benefits of clinical research training have been identified and included research productivity, the traditional tool for the evaluation of research training outcomes , educatiResearch training has a major impact on physicians’ academic career. This study identified the views and gaps in the training of medical graduates, specifically related to the identification of research positions, the job description, the expectations of fellows and mentors, and the outcomes of the training program. These findings serve to establish a formal research training program, a prototype to follow in Lebanon and in the region. Several challenges were highlighted; Some of them may be addressed by building a portal for available research fellowship positions, accessible by both fellows and mentors, and by designing a structured program, that ensures equitable learning opportunities and benefits to all fellows. Further investigations are needed to explore the long term impact of such a program in low to middle income countries on fellows’ academic achievement, including publications and successful grants submissions. Finally, additional research is needed to assess the impact of the online research training on fellows’ performance, as this opens the door for fellows from various countries to benefit remotely from research fellowship programs.S1 Table(DOCX)Click here for additional data file.


Four factors were identified in this scale: physical fitness, approaches to learning, social interaction, and imagination. The results indicated good reliability and validity of OFPS-P, which can be used to evaluate preschool children’s performance on outdoor free play and to support teachers’ effective support in outdoor play activities in kindergartens.Children’s outdoor free play, which is characterized by intensive physical engagement and diverse social interactions, plays a unique role in early childhood development and education. However, existing scales cannot comprehensively measure children’s performance in outdoor free play. The research purpose of this study was to develop and validate an Outdoor Free Play Scale for Children-Preschool Version (OFPS-P) with good reliability and validity, in order to provide a practical tool for teachers to understand the level of children’s outdoor free play. Based on the review of existing scales of children’s play and the uniqueness of children’s outdoor free play, we developed a scale with 12 items and validated the scale with two samples of preschool children with exploratory (n Play is fundamental for children’s learning. Children fully develop their cognitive, social, physical, and motor abilities through experiences, inquiries, and social interactions in play. But current attention is usually paid to young children’s indoor free play, either in practice or in research. In fact, outdoor free play activities have distinct characteristics from indoor play, especially in the value of developing children’s physical fitness, social interaction, imagination, and approaches to learning ,2,3,4,5.Based on the unique value of children’s outdoor play activities on early childhood development, the statutory framework of 2021 UK Early Years Foundation Stage (EYFS) legislated that early education institutions in the UK must set up dedicated outdoor play areas for children aged 0–5, or plan and conduct outdoor activities every day, weather permitting . SimilarAccording to the Affordance Theory, outdoor play has three fields of consideration: (1) the field of interactive limitation, which refers to the space’s physical features affecting interactions, (2) the field of promoted interaction, which recognizes how participants perceive and predict the common activity in the space, and (3) the field of free interaction, which reflects the participants’ agency and decision-making . This moOutdoor play is beneficial to children’s overall learning and development. It provides children with a variety of outdoor experiences and opportunities for active learning. Children’s outdoor free play has unique characteristics. Firstly, different from static indoor play activities, children’s outdoor free play is dominated by dynamic activities, so children enjoy a high level of physical activity , so thatThe second unique characteristic is related to the value of outdoor play for children’s approaches to learning. In particular, outdoor free play has the potential to enhance children’s activity organization and planning, problem-solving, concentration, and initiative. Generally speaking, there are fewer restrictions on young children’s outdoor free play. Children are more likely to arrange and choose their own play content as much as possible under safe circumstances in outdoor free play compared with in other play activities . In thisOutdoor free play is also believed to be more conducive to promoting children’s social development. In this process, language communication, learning, imitation, and negotiation between children are particularly important .Last but not least, outdoor free play offers children more opportunities to show their imagination. Compared with the relatively closed and restrained indoor space, the outdoor play space is more open, free, and diverse, so that children have the conditions to make “bolder” attempts. Their imagination and creativity are more likely to be stimulated accordingly . StudiesThe flexible outdoor learning environment provides teachers with the opportunity to observe children’s behavior, and children’s spontaneous play provides teachers with rich information about children’s individual interests and learning styles . If teacChildren’s outdoor free play significantly develops as children age. For example, in terms of physical fitness, young children’s overall gross motor movement  and fineThere are also studies revealing early gender differences in children’s outdoor free play. Boys are found to prefer and are frequently engaged in outdoor play, whereas girls prefer indoor sedentary activities better . AlthougThe characteristics of age and gender development of children in outdoor free play activities provide a basis for the development of a scale for evaluating children’s outdoor free play. If the scale can sensitively reflect and express the specific performance of children of different ages and genders in various aspects of outdoor free play, a more developmentally appropriate outdoor free play setting can be prepared by teachers.There have long been studies on the development of children’s play and different scales are available to understand children’s play behaviors. However, the existing scales of children’s play are mostly developed based on children’s indoor play activities. Based on a systematic literature review, the following five children’s play scales are found to tap some of the features of outdoor free play activities.The Observational System for Recording Activity in Children-Preschool Version (OSRAC-P)  providesPeer Play Scale  is focusRevised Knox Preschool Play Scale (RKPPS)  is a claThe Symbolic Play Scale  sorts thThe Play Checklist  is an obBased on the review of the above-mentioned classic play scales for young children, we realized that none of them can systematically capture the characteristics of children’s outdoor free play and its unique value to children’s development. We believed that developing a specialized scale for children’s outdoor free play development would fill this gap. Therefore, the objective of this study was to develop and validate an Outdoor Free Play Scale in Children-Preschool Version (OFPS-P), so as to provide a practical, easy-to-understand, and easy-to-operate tool for teachers to better understand the development of children’s outdoor play.The word “play” in Chinese characters is composed of “游” and “戏”. “游” is a type of free and unrestrained physical activity, and “戏” mainly refers to playful activities. However, under the influence of Confucian culture, the play of ancient Chinese children tended to be “peaceful and harmonious”; children barely reached their limits in outdoor physical exercises and competitive games, therefore the intensity of physical exercises was reduced. Later, under the influence of the Imperial Examination System, children’s play become strongly learning-centered or focused on intelligence improvements, sometimes even showed signs of “not playing but only studying” . For a lMinistry of Education of the People’s Republic of China  demandedMore than half of the kindergartens in China carry out outdoor activities for more than two hours per day . Unlike In Chinese kindergartens, indoor free play is mainly carried out in specialized areas. Through arranging certain materials such as equipment, toys, props, tools and operating materials, teachers support and guide children’s operation, communication, exploration and expression and therefore promote children’s independent learning and development. However, due to the stereotypical beliefs and the behavioral-orientated education in Chinese kindergartens, which focused on learning, teachers often offer specific learning tasks and materials during the process of play. In practice, the common way is to radiate or infiltrate the theme and objectives of collective teaching into the play environment and activities ; puzzle Based on the review of the above-mentioned classic play scales for young children and the unique scenario in Chinese kindergartens for children’s outdoor free play, we believed that developing a specialized scale for children’s outdoor free play development would benefit teachers’ organization and scaffolding in children’s outdoor free play and fill the research gap of a lack of scales to systematically capture characteristics of children’s outdoor free play and its unique value to children’s development. Therefore, the objective of this study was to develop and validate an Outdoor Free Play Scale in the Children-Preschool Version (OFPS-P), so as to provide a practical, easy-to-understand, and easy-to-operate tool for teachers to better understand the development of children’s outdoor play.Two rounds of classroom observations were conducted to collect data for scale validation in the summer and fall of 2020.ageM = 59.54, SD = 9.278; boysn = 47.1%; 3-4yn = 40, 4-5yn = 53, 5-6yn = 47) from two public kindergartens, one of which was relatively small, providing kids with small-sized play equipment to have the outdoor play in the limited space in the community (n = 72).The other was bigger with spacious and specialized outdoor playground, offering abundant play materials and various equipment (n = 68). The classroom observation data generated from these participants were used for item analysis and exploratory factor analysis (EFA).A total number of 381 children from four kindergartens in Guangzhou, Guangdong Province, China, were selected to participate in this study. During the first round , we had 140 participants  from two kindergartens during the second round . One of them was a forest kindergarten (n = 117) with a large and rustic outdoor playground, and a large variety of play equipment and materials, with a tradition of outdoor activities. The other kindergarten owned a moderate-sized outdoor playground and only a few items of large-sized play equipment. Nevertheless, the variety of play equipment and materials was abundant. The data collected in this round were used for confirmatory factor analysis (CFA).There were 241 participants  for advice on the coverage and appropriateness of the selected items.We then randomly selected a class from each of the three grades  from four kindergartens and recorded a 6-min play video of each kid. Children’s behaviors in outdoor free play was evaluated based on the recorded information. The observer can easily review and discuss the behaviors to seek accurate coding with video-taped play episodes, which is not feasible for on-site observation. Among these play videos, we randomly chose 20 video clips  to train two assessors in using the scale for evaluation. They could pause the video after every minute and take 30 s to score. The total score of children’s behaviors for each minute will be calculated. In case of hesitant or inconsistent scoring during this process, the two assessors watched the video again together and discussed with each other to determine the final score. The inter-rater reliability of the two raters was ranged from 76.5% to 96.3%. The two assessors discussed the disagreed items until agreements among all items of the scale were reached.The data collection of T1 and T2 followed a strict protocol, and observations were conducted with the same procedure in all four selected kindergartens. Before the observation, researchers explained the relevant information to teachers and parents, guaranteed to protect the privacy of participants and obtained informed consents. Each child’s outdoor free play process was filmed for 6 min after the warming-up stage (around 5 min), with a break interval of 1 min. Based on our observations, children were able to demonstrate a comprehensive variety of play behaviors for evaluation in 6 min as they had been warmed up.In the process of filming, if children showed signs of withdrawal, fear, resistance, etc., researchers stopped recording immediately. Two research team members were responsible for data collection, with one being responsible for filming and the other for writing field observation scripts to ensure that the observation procedures were compliance with the agreement. After that, the research team members adjusted the description of the scale items according to the video clips and the written field observation notes.Based on the initial scale, two assessors rated the scale in the video clips of children’s play collected in the first round , and modified item descriptions based on the play situation in the video and field observation. Later, the observation data were used in item analysis and EFA to construct a tentative scale. After that, the research team rated children’s play behaviors as shown in the video clips collected in the second round with the tentative scale . The resulting data were used in CFA to finalize the scale construct. The specific contents of the OFPS-P can be found in During the formulation of the scale structure, we consulted several classic play scales of relevant content. Four basic and unique characteristics of outdoor play, i.e., physical fitness, approaches to learning, socialization, and imagination, were generalized based on this review of scales. They therefore served as the basic dimensions to assess children’s outdoor free play in the scale. We also selected items from classic play scales for reference.Items reflecting participants’ approaches to learning were composed based on Preschool Learning Behaviors Scale (PLBS)  and ChilThe descriptive statistics of children’s performance in different dimensions were reported in p < 0.01), therefore a total of 12 items remained for exploratory factor analysis [Extreme value analysis and homogeneity test were conducted to examine the items of the scale. Results of the independent samples t-test showed that all items qualified psychometric standards  . We condα = 0.905 and CR value of all scale dimensions exceeded 0.6, indicating a good internal consistency of the scale [AVE) as the index of the convergence validity of the scale. The construct validity of the scale was tested by comparing the square root of AVE and the Pearson correlation between dimensions. Test results showed that the AVE was larger than 0.5 for all dimensions, and the correlations between the dimensions were less than the square root of the corresponding AVE, indicating that the scale had ideal construct validity [Data collected from the second sample were used for CFA. Results of the goodness-of-fit test indicated a good model fit, as shown in he scale ,59. The p < 0.05) and Socialization . Specifically speaking, girls showed a lower level of physical fitness but a higher level of social skills compared with boys.As shown in F = 96.512, p < 0.01), Physical Fitness F = 967.484, p < 0.01), Approaches to Learning F = 18.526, p < 0.01), Socialization F = 25.987, p < 0.01), and Imagination F = 11.928, p < 0.01). Follow-up post hoc comparisons revealed that no significant differences were found between the socialization of 4–5 year olds and 5–6 year olds (p > 0.05), neither in the imagination dimension between 3–4 year olds and 4–5 year olds (p > 0.05).To further understand the sensitivity of the scale to the performance of children of different ages in outdoor free play activities, we conducted a one-way ANOVA with age as the independent variable, and the overall and each dimension score as the dependent variables. In Four fundamental aspects were identified in OFPS-P to understand children’s outdoor free play, namely Physical Fitness, Approaches to Learning, Social Interaction, and Imagination. Physical Fitness highlights the most outstanding contribution of outdoor play to children, namely, movements , thus maCompared with educational play, free play cultivates children’s social communication ability in authentic situations . The dimα = 0.905), therefore 6 min should be a good amount of time when applying this scale. Children’s strengths and weaknesses in outdoor play can easily be detected, which is important for teachers to figure out the follow-up actions in supporting children’s development. To improve the accuracy of rating, we also encourage teachers to film children’s play and rate while watching the replay. Through the observation of one or several groups of children in the class, teachers can also reflect on their beliefs in outdoor free play, modify the outdoor play environment, and create opportunities for outdoor free play. Therefore, the scale is of great significance to improve the quality of outdoor free play in kindergartens.There are only 12 items in OFPS-P, which captures children’s specific behaviors in outdoor free play activities and is not affected by the types of outdoor play. Teachers need to make sure that children have been in the state of outdoor play (about 15 min after the start of play), then focus on each targeted child for about 6 min, and rating them individually before they achieve an overall picture of these targeted children’s play performance in outdoor free play in the aspects of Physical Fitness, Approaches to Learning, Social Interaction, and Imagination. In this study, the assessors of our research team evaluated each child’s performance based on 6 min of the child’s play, and the statistical results showed good reliability (Based on the results regarding the age and gender-related differences in the performance of children’s outdoor free play, we found that there was an overall improvement in the development of children’s play behaviors as they grew up. However, in certain dimensions, the age differences were not significant. For example, we found that there were no significant differences in social interactions between K2 and K3 children’s social interactions in outdoor play. We believe that this result is closely related to the composition of the outdoor areas of kindergartens in China. The outdoor areas of Chinese kindergartens are mostly composed of areas for sports equipment, sand and water play, construction play, and gardening. These areas are generally less structured and lack teachers’ special guidance on peer interaction and communication strategies . TherefoConsistent with the previous results on gender differences, we found that in outdoor free play, boys’ physical fitness was significantly better than girls’, whereas girls’ social development was significantly better than boys’. However, we found that both boys and girls performed well in outdoor play in Approaches to Learning and no significant gender differences were found. This is inconsistent with the existing studies on children’s play performance in classrooms . We consBased on this analysis of children’s age and gender differences in outdoor free play, it is suggested that teachers should better examine the possibility of developing children’s physical fitness, social interaction, approaches to learning, and imagination in outdoor free play, and offer specialized guidance to the weak developmental stages.This study is unique in the development and validation of OFPS-P, which is valuable in understanding children’s play performance in outdoor free play and to support teachers’ facilitation of children’s learning in outdoor free play activities. There are also limitations in this study. First of all, the participating kindergartens are all from urban areas, which might not be representative to reflect an overall scenario of outdoor free play in the country. However, the kindergartens selected were of different levels of facilities and support for children’s outdoor play; therefore the results still have great implications. We suggest that the follow-up studies include kindergartens from a more diverse background, including rural areas. Second, it is particularly important to note that the scale developed in this study is only applicable to children’s outdoor free play, but not children’s sedentary or non-play behaviors. Therefore, it is suggested that future studies investigate the various types of activities in outdoor play besides, so that children’s outdoor experiences can be better understood. Thirdly, although OFPS-P showed good reliability and validity from the item analyses and factor analyses, we have not conducted test-retest validation and this will be the next step of further validation. As this is one of the first scales particularly developed to understand children’s outdoor free play behaviors, teachers are encouraged to use OFPS-P in their daily teaching and to enhance their role in the outdoor free play activities. Future studies can further explore the role of teachers in children’s outdoor free play with the help OFPS-P and the way to integrate OFPS-P in teachers’ professional development.As an important component of kindergarten activities, outdoor free play plays a unique role in children’s development . HoweverThis study is one of the first to develop and validate a tool for evaluating preschool children’s outdoor free play. Item analysis, EFA, and CFA showed that OFPS-P had good reliability and validity. The sensitivity to the performance of children across different genders and ages in outdoor free play evidenced the discriminant validity of the scale. Therefore, we considered OFPS-P as a scale with good psychometric characteristics and it can be used to evaluate children’s outdoor free play in practice.