Broadening conceptions of learning in medical education: the message from teamworking

Let's talk about integration: a study of students' understandings of integration

Today, the knowledge concerning clinical reasoning is advanced enough to translate into curriculum interventions such as an integrated curriculum, in which science theory and clinical practice can be interwoven effectively. However, the interpretations of what integration means differ and the purpose of this study was to elicit how students understand integration. This study was carried out using an interpretative perspective. Medical students, in their 2nd year of study, were asked to apply basic science knowledge from all previous courses to clinical cases in an examination. Subsequent to the examination, focus group interviews were conducted. The interviews were audio recorded, transcribed and analysed by the use of qualitative content analysis. The analysis revealed how students comprehended integration: as the creation of wholeness, as relating new knowledge to core concepts, as reasoning, as application and as collaboration between teachers. The five categories were linked to three dimensions: intra-personal, inter-personal and organizational, each of which resonates with different theories of how expertise is developed. The outcome of this study adds to our understanding of how students conceptualize integration. The categories of 'integration' drawn out by the study are helpful in promoting further discussion of how eliciting students' own reports of cognition and may help the ongoing design of curricula by putting students at the center of the curriculum design process.

Five teacher profiles in student-centred curricula based on their conceptions of learning and teaching

BACKGROUND

Teachers' conceptions of learning and teaching are partly unconscious. However, they are critical for the delivery of education and affect students' learning outcomes. Lasting changes in teaching behaviour can only be realized if conceptions of teachers have been changed accordingly. Previously we constructed a questionnaire named COLT to measure conceptions. In the present study, we investigated if different teacher profiles could be assessed which are based on the teachers' conceptions. These teacher profiles might have implications for individual teachers, for faculty development activities and for institutes. Our research questions were: (1) Can we identify teacher profiles based on the COLT? (2) If so, how are these teacher profiles associated with other teacher characteristics?

METHODS

The COLT questionnaire was sent electronically to all teachers in the first three years of the undergraduate curriculum of Medicine in two medical schools in the Netherlands with student-centred education. The COLT (18 items, 5 point Likert scales) comprises three scales: 'teacher centredness', 'appreciation of active learning' and 'orientation to professional practice'. We also collected personal information about the participants and their occupational characteristics. Teacher profiles were studied using a K-means cluster analysis and calculating Chi squares.

RESULTS

The response rate was 49.4% (N = 319/646). A five-cluster solution fitted the data best, resulting in five teacher profiles based on their conceptions as measured by the COLT. We named the teacher profiles: Transmitters (most traditional), Organizers, Intermediates, Facilitators and Conceptual Change Agents (most modern). The teacher profiles differed from each other in personal and occupational characteristics.

CONCLUSIONS

Based on teachers' conceptions of learning and teaching, five teacher profiles were found in student-centred education. We offered suggestions how insight into these teacher profiles might be useful for individual teachers, for faculty development activities and for institutes and departments, especially if involved in a curriculum reform towards student-centred education.

Fostering professionalism among doctors: the role of workplace discussion groups

BACKGROUND

The professionalism of doctors has come in for increasing scrutiny and discussion, within the profession and in society. Professionalism has also become of central interest in undergraduate and postgraduate medical education. There is a great deal of debate about the nature of medical professionalism, how to promote it and what approaches to learning are most effective.

OBJECTIVE

This study aims to identify the role of workplace-based discussion groups in encouraging and supporting the development of professionalism among doctors.

METHODS

Workplace-based discussion groups including doctors from all non-consultant grades and specialties were established in five hospitals over a 6 month period in 2010-2011. A mixed-methods approach was used to identify the perceived impact of these groups on participants, which included interviewing the group facilitators and education leaders at participating hospitals.

RESULTS

Understanding of professionalism at an individual level was improved along with an increased awareness of the collective nature of professionalism in everyday clinical practice. Key to the success of the groups was the creation of a legitimate space to explore professionalism and professional challenges and the use of experienced facilitators who could build trust in the groups.

CONCLUSIONS

A purely individualistic approach to professionalism does not resonate with contemporary, team-based healthcare. Work-based groups can provide a focus for an approach to professionalism that is mindful of self, the team, the culture and the organisation. This evaluation provides guidance to a range of stakeholders on how to develop educational interventions that foster professionalism, personal and collective, and offers some pointers towards the range of factors that may impact on the outcomes of such activities.

Medical students' emotional development in early clinical experience: a model

Dealing with emotions is a critical feature of professional behaviour. There are no comprehensive theoretical models, however, explaining how medical students learn about emotions. We aimed to explore factors affecting their emotions and how they learn to deal with emotions in themselves and others. During a first-year nursing attachment in hospitals and nursing homes, students wrote daily about their most impressive experiences, explicitly reporting what they felt, thought, and did. In a subsequent interview, they discussed those experiences in greater detail. Following a grounded theory approach, we conducted a constant comparative analysis, collecting and then interpreting data, and allowing the interpretation to inform subsequent data collection. Impressive experiences set up tensions, which gave rise to strong emotions. We identified four 'axes' along which tensions were experienced: 'idealism versus reality', 'critical distance versus adaptation', 'involvement versus detachment' and 'feeling versus displaying'. We found many factors, which influenced how respondents relieved those tensions. Their personal attributes and social relationships both inside and outside the medical community were important ones. Respondents' positions along the different dimensions, as determined by the balance between attributes and tensions, shaped their learning outcomes. Medical students' emotional development occurs through active participation in medical practice and having impressive experiences within relationships with patients and others on wards. Tensions along four dimensions give rise to strong emotions. Gaining insight into the many conditions that influence students' learning about emotions might support educators and supervisors in fostering medical students' emotional and professional development.

Time to unravel the conceptual confusion of authenticity and fidelity and their contribution to learning within simulation-based nurse education. A discussion paper

High-fidelity patient simulation is a method of education increasingly utilised by educators of nursing to provide authentic learning experiences. Fidelity and authenticity, however, are not conceptually equivalent. Whilst fidelity is important when striving to replicate a life experience such as clinical practice, authenticity can be produced with low fidelity. A challenge for educators of undergraduate nursing is to ensure authentic representation of the clinical situation which is a core component for potential success. What is less clear is the relationship between fidelity and authenticity in the context of simulation based learning. Authenticity does not automatically follow fidelity and as a result, educators of nursing cannot assume that embracing the latest technology-based educational tools will in isolation provide a learning environment perceived authentic by the learner. As nursing education programmes increasingly adopt simulators that offer the possibility of representing authentic real world situations, there is an urgency to better articulate and understand the terms fidelity and authenticity. Without such understanding there is a real danger that simulation as a teaching and learning resource in nurse education will never reach its potential and be misunderstood, creating a potential barrier to learning. This paper examines current literature to promote discussion within nurse education, concluding that authenticity in the context of simulation-based learning is complex, relying on far more than engineered fidelity.

Students improve patient care and prepare for professional practice: an interprofessional community-based study

BACKGROUND

We report on an education model that enables students to contribute to practice while experiencing the realities of complex team-working in the community.

AIMS

The study considers how interprofessional learning impacts on patient care and service delivery.

METHOD

A qualitative study using a realist approach. The views of practice-staff, patients and facilitators on how student team learning impacted on practice was obtained through focus groups, interviews and an e-questionnaire and compared to student analysis as feedback forms.

RESULTS

Staff from six Primary Health Care Teams (n = 23) stated that the student teams had offered solutions to improve the quality of patient care and on organisational systems. The positive value of the student work was confirmed by the course facilitators (n = 8). In addition, practitioners were propelled to maintain high professional standards. Patients (n = 23) recalled benefits directly attributable to the student work confirmed by the 434 student feedback forms.

CONCLUSION

Undergraduate interprofessional student teams in mid-training can support and help practice teams, and this subsequently benefits patient care. This practice-based interprofessional learning model offers learning, which is theory-based, and supports positive student contributions. This learning fits today's requirements for positive outcomes from education when mapped against the Kirkpatrick or the NHS (UK) education outcomes framework.

Optimisation of simulated team training through the application of learning theories: a debate for a conceptual framework

BACKGROUND

As a conceptual review, this paper will debate relevant learning theories to inform the development, design and delivery of an effective educational programme for simulated team training relevant to health professionals.

DISCUSSION

Kolb's experiential learning theory is used as the main conceptual framework to define the sequence of activities. Dewey's theory of reflective thought and action, Jarvis modification of Kolb's learning cycle and Schön's reflection-on-action serve as a model to design scenarios for optimal concrete experience and debriefing for challenging participants' beliefs and habits. Bandura's theory of self-efficacy and newer socio-cultural learning models outline that for efficient team training, it is mandatory to introduce the social-cultural context of a team.

SUMMARY

The ideal simulated team training programme needs a scenario for concrete experience, followed by a debriefing with a critical reflexive observation and abstract conceptualisation phase, and ending with a second scenario for active experimentation. Let them re-experiment to optimise the effect of a simulated training session. Challenge them to the edge: The scenario needs to challenge participants to generate failures and feelings of inadequacy to drive and motivate team members to critical reflect and learn. Not experience itself but the inadequacy and contradictions of habitual experience serve as basis for reflection. Facilitate critical reflection: Facilitators and group members must guide and motivate individual participants through the debriefing session, inciting and empowering learners to challenge their own beliefs and habits. To do this, learners need to feel psychological safe. Let the group talk and critical explore. Motivate with reality and context: Training with multidisciplinary team members, with different levels of expertise, acting in their usual environment (in-situ simulation) on physiological variables is mandatory to introduce cultural context and social conditions to the learning experience. Embedding in situ team training sessions into a teaching programme to enable repeated training and to assess regularly team performance is mandatory for a cultural change of sustained improvement of team performance and patient safety.

The learner's perspective in GP teaching practices with multi-level learners: a qualitative study

BACKGROUND

Medical students, junior hospital doctors on rotation and general practice (GP) registrars are undertaking their training in clinical general practices in increasing numbers in Australia. Some practices have four levels of learner. This study aimed to explore how multi-level teaching (also called vertical integration of GP education and training) is occurring in clinical general practice and the impact of such teaching on the learner.

METHODS

A qualitative research methodology was used with face-to-face, semi-structured interviews of medical students, junior hospital doctors, GP registrars and GP teachers in eight training practices in the region that taught all levels of learners. Interviews were audio-recorded and transcribed. Qualitative analysis was conducted using thematic analysis techniques aided by the use of the software package N-Vivo 9. Primary themes were identified and categorised by the co-investigators.

RESULTS

52 interviews were completed and analysed. Themes were identified relating to both the practice learning environment and teaching methods used.A practice environment where there is a strong teaching culture, enjoyment of learning, and flexible learning methods, as well as learning spaces and organised teaching arrangements, all contribute to positive learning from a learners' perspective.Learners identified a number of innovative teaching methods and viewed them as positive. These included multi-level learner group tutorials in the practice, being taught by a team of teachers, including GP registrars and other health professionals, and access to a supernumerary GP supervisor (also termed "GP consultant teacher"). Other teaching methods that were viewed positively were parallel consulting, informal learning and rural hospital context integrated learning.

CONCLUSIONS

Vertical integration of GP education and training generally impacted positively on all levels of learner. This research has provided further evidence about the learning culture, structures and teaching processes that have a positive impact on learners in the clinical general practice setting where there are multiple levels of learners. It has also identified some innovative teaching methods that will need further examination. The findings reinforce the importance of the environment for learning and learner centred approaches and will be important for training organisations developing vertically integrated practices and in their training of GP teachers.

The nursing home as a learning environment: dealing with less is learning more

PURPOSE

Despite the imperative to develop adequate competence in caring for the growing demographic of elderly patients with complex health care problems, nursing homes are underused as learning environments for the education of future doctors; thus, the authors aimed to gain more insight into the characteristics of the nursing home as a learning environment.

METHOD

Approaching the nursing home as a learning environment from a predominantly sociocultural perspective, the authors carried out five focus group interviews (December 2011 through February 2012) with 36 family medicine and elderly care medicine residents during their nursing home placements. Data analysis was an iterative process following a grounded theory approach. The software ATLAS.ti supported data analysis.

RESULTS

The authors identified 23 themes in five categories regarding the nursing home as a learning environment: organization, medical opportunities, communication, teamwork, and supervision. Working and learning in a nursing home was characterized by "dealing with less" (i.e., fewer resources), yet the residents reported that dealing with less resulted in "learning more." Family medicine and elderly care residents from different backgrounds differed in their perceptions and specific learning needs.

CONCLUSIONS

To the authors' knowledge, this study is one of the first to identify characteristics of the nursing home as a learning environment. The main challenge in the nursing home is dealing with less, which, according to the residents in the present study, often leads to learning more. To ensure that learning really happens, the authors call for high-quality supervision to support learners in the nursing home environment.

Engaging pediatric intensive care unit (PICU) clinical staff to lead practice improvement: the PICU participatory action research project (PICU-PAR)

Background

Despite considerable efforts, engaging staff to lead quality improvement activities in practice settings is a persistent challenge. At British Columbia Children’s Hospital (BCCH), the pediatric intensive care unit (PICU) undertook a new phase of quality improvement actions based on the Community of Practice (CoP) model with Participatory Action Research (PAR). This approach aims to mobilize the PICU ‘community’ as a whole with a focus on practice; namely, to create a ‘community of practice’ to support reflection, learning, and innovation in everyday work.

Methodology

An iterative two-stage PAR process using mixed methods has been developed among the PICU CoP to describe the environment (stage 1) and implement specific interventions (stage 2). Stage 1 is ethnographic description of the unit’s care practice. Surveys, interviews, focus groups, and direct observations describe the clinical staff’s experiences and perspectives around bedside care and quality endeavors in the PICU. Contrasts and comparisons across participants, time and activities help understanding the PICU culture and experience. Stage 2 is a succession of PAR spirals, using results from phase 1 to set up specific interventions aimed at building the staff’s capability to conduct QI projects while acquiring appropriate technical skills and leadership capacity (primary outcome). Team communication, information, and interaction will be enhanced through a knowledge exchange (KE) and a wireless network of iPADs.

Relevance

Lack of leadership at the staff level in order to improve daily practice is a recognized challenge that faces many hospitals. We believe that the PAR approach within a highly motivated CoP is a sound method to create the social dynamic and cultural context within which clinical teams can grow, reflect, innovate and feel proud to better serve patients.

Clients' initiatives and caregivers' responses in the organizational dynamics of care delivery

Our aim with this article is to develop a typology for the analysis of client-caregiver encounters in health care. We first observed client-caregiver interactions in the homes of home care clients and during the care processes of surgical patients. We then conducted a data-driven analysis to identify the clients' initiatives and the degree of engagement in the responses they received. The clients shaped their care by commenting on, questioning, ensuring, and enriching their care. The responses from the caregivers consisted of neutral acceptance, disregard, and shared expansive development of the clients' initiatives. The typology developed from these will be a tool to widen our understanding of the complex interactions in care delivery and of the different conceptualizations of care that actors hold. In future studies this typology will help in the analysis of the organizational dynamics of health care delivery.

Thinking about thinking and emotion: the metacognitive approach to the medical humanities that integrates the humanities with the basic and clinical sciences

Medical knowledge in recent decades has grown prodigiously and has outstripped the capacity of the human brain to absorb and understand it all. This burgeoning of knowledge has created a dilemma for medical educators. We can no longer expect students to continue memorizing this large body of increasingly complex knowledge. Instead, our efforts should be redirected at developing in students a competency as flexible thinkers and agile learners so they can adeptly deal with new knowledge, complexity, and uncertainty in a rapidly changing world. Such a competency would entail not only cognitive but also emotional skills essential for the holistic development of their professional identity. This article will argue that metacognition--“thinking about thinking (and emotion)”--offers the most viable path toward developing this competency. The overwhelming volume of medical knowledge has driven some medical schools to reduce the time allocated in their curricula to the “soft-option” humanities as they tend to consider them an expendable “luxury.” Vanderbilt University School of Medicine, Nashville, TN, has moved away from the traditional conception of the medical humanities as “the arts,” composed of art, music, and literature, toward an approach that integrates the humanities with the basic and clinical sciences, based on metacognition. This metacognitive approach to the humanities, described in this article, has three goals: 1) to develop students as flexible thinkers and agile learners and to provide them with essential cognitive and emotional skills for navigating medical complexity and uncertainty; 2) to elicit in students empathy and tolerance by making them aware of the immense diversity in human cognition (and emotion); and 3) to integrate the humanities with the basic and clinical sciences. Through this metacognitive approach, students come to understand their patterns of cognition and emotions, and in the group setting, they learn to mindfully calibrate their thinking and emotions. They gain a humbling appreciation of the fallibility of the human mind/brain and how cognitive biases and misperception can lead to medical error. They come to appreciate the complex interplay between cognition and emotion, and the importance of cognitive monitoring and emotional regulation. In the group setting, students also gain a sense of perspective of their thinking patterns and emotions in relation to those of their peers. Perspective taking and mindfulness engender tolerance and empathy, which ultimately serves as a platform for working collaboratively in teams as medical professionals. Students become aware of the social context in which thinking and learning occur, and this further shapes their professional identity. Thinking, learning, and interacting in the group setting ultimately induces a shift from self-preoccupation and an individualistic approach to knowledge toward an appreciation of collective cognition and empathy towards others. In this article, I describe the metacognitive approach to the medical humanities at Vanderbilt University School of Medicine and how it is designed to develop students as agile learners and flexible thinkers with the mindful capacity for cognitive and emotional monitoring and regulation. Thinking and learning in the group setting of the colloquium ultimately also fosters the student’s professional identity.

Development and psychometric evaluation of the Undergraduate Clinical Education Environment Measure (UCEEM)

BACKGROUND

There is a paucity of instruments designed to evaluate the multiple dimensions of the workplace as an educational environment for undergraduate medical students.

AIM

The aim was to develop and psychometrically evaluate an instrument to measure how undergraduate medical students perceive the clinical workplace environment, based on workplace learning theories and empirical findings.

METHOD

Development of the instrument relied on established standards including theoretical and empirical grounding, systematic item development and expert review at various stages to ensure content validity. Qualitative and quantitative methods were employed using a series of steps from conceptualization through psychometric analysis of scores in a Swedish medical student population.

RESULTS

The final result was a 25-item instrument with two overarching dimensions, experiential learning and social participation, and four subscales that coincided well with theory and empirical findings: Opportunities to learn in and through work & quality of supervision; Preparedness for student entry; Workplace interaction patterns & student inclusion; and Equal treatment. Evidence from various sources supported content validity, construct validity and reliability of the instrument.

CONCLUSION

The Undergraduate Clinical Education Environment Measure represents a valid, reliable and feasible multidimensional instrument for evaluation of the clinical workplace as a learning environment for undergraduate medical students. Further validation in different populations using various psychometric methods is needed.

Validity in work-based assessment: expanding our horizons

CONTEXT

Although work-based assessments (WBA) may come closest to assessing habitual performance, their use for summative purposes is not undisputed. Most criticism of WBA stems from approaches to validity consistent with the quantitative psychometric framework. However, there is increasing research evidence that indicates that the assumptions underlying the predictive, deterministic framework of psychometrics may no longer hold. In this discussion paper we argue that meaningfulness and appropriateness of current validity evidence can be called into question and that we need alternative strategies to assessment and validity inquiry that build on current theories of learning and performance in complex and dynamic workplace settings.

METHODS

Drawing from research in various professional fields we outline key issues within the mechanisms of learning, competence and performance in the context of complex social environments and illustrate their relevance to WBA. In reviewing recent socio-cultural learning theory and research on performance and performance interpretations in work settings, we demonstrate that learning, competence (as inferred from performance) as well as performance interpretations are to be seen as inherently contextualised, and can only be under-stood 'in situ'. Assessment in the context of work settings may, therefore, be more usefully viewed as a socially situated interpretive act.

DISCUSSION

We propose constructivist-interpretivist approaches towards WBA in order to capture and understand contextualised learning and performance in work settings. Theoretical assumptions underlying interpretivist assessment approaches call for a validity theory that provides the theoretical framework and conceptual tools to guide the validation process in the qualitative assessment inquiry. Basic principles of rigour specific to qualitative research have been established, and they can and should be used to determine validity in interpretivist assessment approaches. If used properly, these strategies generate trustworthy evidence that is needed to develop the validity argument in WBA, allowing for in-depth and meaningful information about professional competence.

Knowing and acting in the clinical workplace: trainees' perspectives on modelling and feedback

In this article we discuss clinical workplace learning using a dual approach: a theoretical one and an empirical one. Drawing on the philosophical work of Aristotle, Polanyi and Schön we posit that the 'knowing and acting' underpinning day-to-day medical practice is personal and embraces by nature a tacit dimension. Consequently, imparting and acquiring this knowledge type necessitates personal interaction between trainer and trainee. The tacit dimension particularly influences modelling and feedback. In our empirical exploration we explore these educational routes in two disparate disciplines: surgery and paediatrics. We use a longitudinal design with in-depth interviewing. Our conclusion on modelling is: modelling is a dynamic and fragmented process reflecting discipline bound characteristics and working styles. On feedback it is: 'feedback' serves as vehicle for three distinctive forms of commenting on performance, each holding a specific power of expression for learning. We propose to view clinical workplace learning as: an interactive master-apprenticeship model encompassing modelling and feedback as natural educational routes. We conceptualise modelling and feedback as 'function' of interaction (developing grounded theory). Modelling function and feedback function may serve to study these routes as didactical components of ongoing interaction between trainer and trainee rather than an educator-driven series of unrelated events.

Reframing clinical workplace learning using the theory of distributed cognition

In medicine, knowledge is embodied and socially, temporally, spatially, and culturally distributed between actors and their environment. In addition, clinicians increasingly are using technology in their daily work to gain and share knowledge. Despite these characteristics, surprisingly few studies have incorporated the theory of distributed cognition (DCog), which emphasizes how cognition is distributed in a wider system in the form of multimodal representations (e.g., clinical images, speech, gazes, and gestures) between social actors (e.g., doctors and patients) in the physical environment (e.g., with technological instruments and computers). In this article, the authors provide an example of an interaction between medical actors. Using that example, they then introduce the important concepts of the DCog theory, identifying five characteristics of clinical representations-that they are interwoven, co-constructed, redundantly accessed, intersubjectively shared, and substantiated-and discuss their value for learning. By contrasting these DCog perspectives with studies from the field of medical education, the authors argue that researchers should focus future medical education scholarship on the ways in which medical actors use and connect speech, bodily movements (e.g., gestures), and the visual and haptic structures of their own bodies and of artifacts, such as technological instruments and computers, to construct complex, multimodal representations. They also argue that future scholarship should "zoom in" on detailed, moment-by-moment analysis and, at the same time, "zoom out" following the distribution of cognition through an overall system to develop a more integrated view of clinical workplace learning.

Beyond individualism: professional culture and its influence on feedback

CONTEXT

Although feedback is widely considered essential to learning, its actual influence on learners is variable. Research on responsivity to feedback has tended to focus on individual rather than social or cultural influences on learning. In this study, we explored how feedback is handled within different professional cultures, and how the characteristics and values of a profession shape learners' responses to feedback.

METHODS

Using a constructivist grounded theory approach, we conducted 12 focus groups and nine individual interviews (with a total of 50 participants) across three cultures of professional training in, respectively, music, teacher training and medicine. Constant comparative analysis for recurring themes was conducted iteratively.

RESULTS

Each of the three professional cultures created a distinct context for learning that influenced how feedback was handled. Despite these contextual differences, credibility and constructiveness emerged as critical constants, identified by learners across cultures as essential for feedback to be perceived as meaningful. However, the definitions of credibility and constructiveness were distinct to each professional culture and the cultures varied considerably in how effectively they supported the occurrence of feedback with these critical characteristics.

CONCLUSIONS

Professions define credibility and constructiveness in culturally specific ways and create contexts for learning that may either facilitate or constrain the provision of meaningful feedback. Comparison with other professional cultures may offer strategies for creating a productive feedback culture within medical education.

Relational leadership, decision-making and the messiness of context in healthcare

Decision-making is a neglected area in the leadership literature and in healthcare in particular. This paper draws on the Cynefin framework, which is a practice-based approach to decision-making, to theorize about leadership in healthcare. The framework uses a multi-ontology cognitive-based sense-making perspective to identify five domains of decision-making that are linked to individual leadership styles and given contexts. It is markedly different from other complexity approaches by the inclusion of the central domain of Disorder. While this inclusion is vitally important, the leadership implications of the approach are under-theorized. Focusing on the idea of Disorder, we argue alternatively that a relational leadership approach is needed to understand decision-making as a multi-ontology sensemaking approach and this also necessitates accounting for professional sensemaking in healthcare settings. The relational approach adopted here is based on Dian Hosking's work and views decision-making as a task that is undertaken through organizing processes that are cognitive but also social/cultural, political and emotional, and in which the social construction of leadership and context are inseparable individual and collective undertakings. When skilful relating is a part of leadership practice then multi-ontology sensemaking is a possibility in decision-making tasks. We support our arguments with illustrative examples to put forward a relational approach to leadership in healthcare.

Contextual dynamics in clinical workplaces: learning from doctor-doctor consultations

CONTEXT

Some studies have explored the role of learning context in clerkships and in clinical teams. Very little is known, however, about the relationship between context and competence development in more loosely framed, day-to-day practices such as doctor-doctor consultations, although such interactions are frequent and typical in clinical work.

METHODS

To address this gap in the literature, a study was conducted using semi-structured interviews in four different hospitals and participant observation at one site. Inductive content analysis was used to develop a framework. Special reference was made to the principles of situated cognition.

RESULTS

The framework illustrates how different situational, personal and organisational factors interact in every learning situation. The interplay manifests in three different roles that doctors assume in highly dynamic ways: doctors learn as 'actors' (being responsible), as 'participants' (being involved) and as 'students' (being taught); contextual influences also impact on the quality of learning within these roles.

CONCLUSIONS

The findings add to the current literature on clinical workplace learning and to the conceptualisation of context in the field of education. The practical contribution of the research lies in disentangling the complex dynamics of learning in clinical environments and in helping doctors and medical educators to increase their responsiveness to contextual factors.

Medical students' reactions to an experience-based learning model of clinical education

An experience-based learning (ExBL) model proposes: Medical students learn in workplaces by 'supported participation'; affects are an important dimension of support; many learning outcomes are affective; supported participation influences students' professional identity development. The purpose of the study was to check how the model, which is the product of a series of earlier research studies, aligned with students' experiences, akin to the 'member checking' stage of a qualitative research project. In three group discussions, a researcher explained ExBL to 19 junior clinical students, who discussed how it corresponded with their experiences of clinical learning and were given a written précis of it to take away. One to 3 weeks later, they wrote 500-word reflective pieces relating to their subsequent experiences with ExBL. Four researchers conducted a qualitative analysis. Having found many instances of responses 'resonating' to the model, the authors systematically identified and coded respondents' 'resonances' to define how they aligned with their experiences. 120 resonances were identified. Seventy (58 %) were positive experiences and 50 (42 %) negative ones. Salient experiences were triggered by the learning environment in 115 instances (96 %) and by learners themselves in 5 instances (4 %), consistent with a strong effect of environment on learning processes. Affective support was apparent in 129 of 203 statements (64 %) of resonances and 118 learning outcomes (58 %) were also affective. ExBL aligns with medical students' experiences of clinical learning. Subject to further research, these findings suggest ExBL could be used to support the preparation of faculty and students for workplace learning.

The role of radiology in preclinical anatomy: a critical review of the past, present, and future

RATIONALE AND OBJECTIVES

Radiology has been an increasingly important component of preclinical anatomy instruction since the 1960s. The global status of medical imaging pedagogies and radiologists' roles in medical anatomy education is not well established but is important in determining the specialty's contribution to undergraduate medical education.

MATERIALS AND METHODS

PubMed was searched with various combinations of MeSH terms including "radiology," "undergraduate medical education," and "anatomy." Articles were reviewed for relevance, and referenced articles of possible relevance were hand-traced to ensure a wide capture of articles.

RESULTS

Although more medical schools around the world are using medical imaging to teach anatomy, some regions, such as the United States, show a decline in the proportion of imaging taught by radiologists. Lectures, small group discussions, and self-instruction remain the mainstay of current pedagogies and have witnessed dramatic changes over the past few decades with respect to the types of imaging used. Newer pedagogies use contextual and hands-on experiences to improve spatial and application principles. Qualitative and quantitative studies report somewhat mixed results of pedagogical efficacies but demonstrate generally high acceptance by students and instructors and often significant exam score improvement. Radiology as a specialty must overcome several challenges for it to become more involved in anatomy education, including teaching incentives and protected academic time.

CONCLUSIONS

As anatomy instruction and clinical medicine grow increasingly digital, it is ever more important that radiologists continue to develop new anatomy pedagogies and contribute to anatomy education in greater roles.

Peer influence on students' estimates of performance: social comparison in clinical rotations

CONTEXT

During clinical rotations, students move from one clinical situation to another. Questions exist about students' strategies for coping with these transitions. These strategies may include a process of social comparison because in this context it offers the student an opportunity to estimate his or her abilities to master a novel rotation. These estimates are relevant for learning and performance because they are related to self-efficacy. We investigated whether student estimates of their own future performance are influenced by the performance level and gender of the peer with whom the student compares him- or herself.

METHODS

We designed an experimental study in which participating students (n = 321) were divided into groups assigned to 12 different conditions. Each condition entailed a written comparison situation in which a peer student had completed the rotation the participant was required to undertake next. Differences between conditions were determined by the performance level (worse, similar or better) and gender of the comparison peer. The overall grade achieved by the comparison peer remained the same in all conditions. We asked participants to estimate their own future performance in that novel rotation. Differences between their estimates were analysed using analysis of variance (ANOVA).

RESULTS

Students' estimates of their future performance were highest when the comparison peer was presented as performing less well and lowest when the comparison peer was presented as performing better (p < 0.001). Estimates of male and female students in same-gender comparison conditions did not differ. In two of three opposite-gender conditions, male students' estimates were higher than those of females (p < 0.001 and p < 0.05, respectively).

CONCLUSIONS

Social comparison influences students' estimates of their future performance in a novel rotation. The effect depends on the performance level and gender of the comparison peer. This indicates that comparisons against particular peers may strengthen or diminish a student's self-efficacy, which, in turn, may ease or hamper the student's learning during clinical rotations. The study is limited by its experimental design. Future research should focus on students' comparison behaviour in real transitions.

Key elements in assessing the educational environment: where is the theory?

The educational environment has been increasingly acknowledged as vital for high-quality medical education. As a result, several instruments have been developed to measure medical educational environment quality. However, there appears to be no consensus about which concepts should be measured. The absence of a theoretical framework may explain this lack of consensus. Therefore, we aimed to (1) find a comprehensive theoretical framework defining the essential concepts, and (2) test its applicability. An initial review of the medical educational environment literature indicated that such frameworks are lacking. Therefore, we chose an alternative approach to lead us to relevant frameworks from outside the medical educational field; that is, we applied a snowballing technique to find educational environment instruments used to build the contents of the medical ones and investigated their theoretical underpinnings (Study 1). We found two frameworks, one of which was described as incomplete and one of which defines three domains as the key elements of human environments (personal development/goal direction, relationships, and system maintenance and system change) and has been validated in different contexts. To test its applicability, we investigated whether the items of nine medical educational environment instruments could be mapped unto the framework (Study 2). Of 374 items, 94% could: 256 (68%) pertained to a single domain, 94 (25%) to more than one domain. In our context, these domains were found to concern goal orientation, relationships and organization/regulation. We conclude that this framework is applicable and comprehensive, and recommend using it as theoretical underpinning for medical educational environment measures.

Learning through inter- and intradisciplinary problem solving: using cognitive apprenticeship to analyse doctor-to-doctor consultation

Today's healthcare can be characterised by the increasing importance of specialisation that requires cooperation across disciplines and specialities. In view of the number of educational programmes for interdisciplinary cooperation, surprisingly little is known on how learning arises from interdisciplinary work. In order to analyse the learning and teaching practices of interdisciplinary cooperation, a multiple case study research focused on how consults, i.e., doctor-to-doctor consultations between medical doctors from different disciplines were carried out: semi-structured interviews with doctors of all levels of seniority from two hospital sites in Switzerland were conducted. Starting with a priori constructs based on the 'methods' underpinning cognitive apprenticeship (CA), the transcribed interviews were analysed according to the principles of qualitative content analysis. The research contributes to three debates: (1) socio-cognitive and situated learning, (2) intra- and interdisciplinary learning in clinical settings, and (3), more generally, to cooperation and problem solving. Patient cases, which necessitate the cooperation of doctors in consults across boundaries of clinical specialisms, trigger intra- as well as interdisciplinary learning and offer numerous and varied opportunities for learning by requesting doctors as well as for on-call doctors, in particular those in residence. The relevance of consults for learning can also be verified from the perspective of CA which is commonly used by experts, albeit in varying forms, degrees of frequency and quality, and valued by learners. Through data analysis a model for collaborative problem-solving and help-seeking was developed which shows the interplay of pedagogical 'methods' of CA in informal clinical learning contexts.

Phenomenological analysis of patient experiences of medical student teaching encounters

CONTEXT

It is important to know how patients are affected by becoming opportunistically involved in medical student education. In previous studies, researchers rather than patients set the research agenda and expert patients or people well known to teachers were more often involved than ordinary people.

OBJECTIVES

This study aimed to explore how ordinary patients experience undergraduate medical teaching when they become involved in it opportunistically and to derive practical insights from the lived experiences of these patients.

METHODS

The research was conducted in line with a conceptual orientation towards communities of practice theory and used phenomenology as a way of exploring patients' lived experiences in depth. Minimally structured interviews were carried out with 10 patients following ordinary out-patient or general practice appointments in which students were being taught. Template analysis was used to generate provisional themes and a process of phenomenological reduction was used to distil individual respondents' lived experiences to their essence.

RESULTS

The presence of students in ambulatory consultations was normal. Nine respondents described transactional relationships in which they remained outside the community of practice of which the doctor and student were members. Only an intimate problem would engage them deeply enough for a student's presence to 'bother' them. One patient's personal and professional background led her to regard doctors' handling of consultation dynamics as factors contributing to whether teaching consultations were negative or positive experiences. When doctors' sensitive and inclusive behaviour drew her into a triadic relationship with the student and doctor, she experienced mutual benefits with students. When it did not, she felt objectified and alienated.

CONCLUSIONS

Provided they receive the clinical care for which they are attending a consultation and are treated respectfully, patients may sometimes willingly become 'objects' from which students learn. They may, however, become more deeply engaged in teaching consultations in which they participate actively in a triadic relationship of mutual benefit with a doctor and student. Teaching consultations call for doctors to be sensitive and adaptable.

Advances in clinical education: a model for infectious disease training for mid-level practitioners in Uganda

Advances in health professional education have been slow to materialize in many developing countries over the past half-century, contributing to a widening gap in quality of care compared to developed countries. Recent calls for reform in global health professional education have stressed, among other priorities, the need for approaches that strengthen clinical reasoning skills. While the development of these skills is critical to enhance health systems, little research has been carried out on the effectiveness of applying these strategies in the context of severe human resource shortages and complex disease presentations. Integrated Infectious Disease Capacity Building Evaluation (IDCAP) based at the Infectious Diseases Institute at Makerere University created a training program using current best practices in clinical education to support the development of complex reasoning skills among clinicians in rural Uganda. Over a period of 9 months, the program integrated classroom and clinic-based training approaches and measured indicators of success with particular reference to common infectious diseases. This article describes in detail the IDCAP approach to integrating advances in health professional education theory in the context of an overburdened, inadequately resourced primary health care system; results from the evaluation are expected in 2012.

The role of role: learning in longitudinal integrated and traditional block clerkships

CONTEXT

Traditional block clerkship (BC) structures may not optimally support medical student participation in the workplace, whereas longitudinal integrated clerkship (LIC) structures seem more conducive to students' active engagement in patient care over time. Understanding the ways in which these two clerkship models influence students' roles and responsibilities can inform clinical learning programme design.

METHODS

This was a multicentre qualitative study. We conducted semi-structured interviews with LIC and BC medical students at three institutions early and late in the core clinical year to explore their experiences with patients and the roles they served. Using the framework of 'workplace affordances', qualitative coding focused on students' roles and qualities of the learning environment that invited or inhibited student participation. We compared transcripts of early- and late-year interviews to assess students' changing roles and conducted discrepant case analysis to ensure that coding fit the data.

RESULTS

Fifty-four students participated in interviews. They described serving three major roles in clinical care that respectively involved: providing support to patients; sharing information about patients across health care settings, and functioning in a doctor-like role. Both LIC and BC students served in the providing support and transmitting information roles both early and late in the year. By contrast, LIC students commonly served in the doctor-like role in managing their patients' care, particularly late in the year, whereas BC students rarely served in this role. Continuity in settings and in supervisors, and preceptors' endorsement of students' legitimate role afforded opportunities for students to participate actively in patient care.

CONCLUSIONS

Although both LIC and BC students reported serving in important roles in supporting their patients and sharing information about their care, only LIC students consistently described opportunities to grow into a doctor role with patients. The high level of integration of LIC students into care systems and their deeper relationships with preceptors and patients enhanced their motivation and feelings of competence to provide patient-centred care.

Educational outcomes of the Harvard Medical School-Cambridge integrated clerkship: a way forward for medical education

PURPOSE

The authors report data from the Harvard Medical School-Cambridge Integrated Clerkship (CIC), a model of medical education in which students' entire third year consists of a longitudinal, integrated curriculum. The authors compare the knowledge, skills, and attitudes of students completing the CIC with those of students completing traditional third-year clerkships.

METHOD

The authors compared 27 students completing the first three years of the CIC (2004-2007) with 45 students completing clerkships at other Harvard teaching hospitals during the same period. At baseline, no significant between-group differences existed (Medical College Admission Test and Step 1 scores, second-year objective structured clinical examination [OSCE] performance, attitudes toward patient-centered care, and plans for future practice) in any year. The authors compared students' National Board of Medical Examiners Subject and Step 2 Clinical Knowledge scores, OSCE performance, perceptions of the learning environment, and attitudes toward patient-centeredness.

RESULTS

CIC students performed as well as or better than their traditionally trained peers on measures of content knowledge and clinical skills. CIC students expressed higher satisfaction with the learning environment, more confidence in dealing with numerous domains of patient care, and a stronger sense of patient-centeredness.

CONCLUSIONS

CIC students are at least as well as and in several ways better prepared than their peers. CIC students also demonstrate richer perspectives on the course of illness, more insight into social determinants of illness and recovery, and increased commitment to patients. These data suggest that longitudinal integrated clerkships offer students important intellectual, professional, and personal benefits.

The proof is in the pudding: putting Actor-Network-Theory to work in medical education

What constitutes valid evidence from medical education research is typically grounded in the scientific paradigm of proof through experiment. Here, explanation through single meaning is privileged over exploration of multiple presentations of phenomena--short, interpretation eclipses appreciation. This approach is challenged as reductive by naturalistic qualitative methods such as rich ethnographic field reports, presented as narratives. Contemporary ethnographic approaches have entered medical education by a back door--disguised as a stable of 'social learning theories'. Communities of Practice theory, Activity Theory and Actor-Network-Theory (ANT) all serve as research practices forming identifiable contemporary ethnographies. 'Evidence' is conceived as exploratory rather than explanatory, through baroque descriptions of innovations in learning organizations, including medicine. ANT is then both a theory of innovation in organizations and an ethnographic method, where practice and theory coincide. ANT is interested primarily not in epistemologies, but in how a phenomenon such as an 'illness' is conceived across differing practices as multiple ontologies (experienced meanings), each meaning generated and suspended within a particular network of effects. How such networks are initiated and developed has significance for rethinking the nature of 'evidence', restoring faith in the value of a good story.

Faculty development initiatives designed to promote leadership in medical education. A BEME systematic review: BEME Guide No. 19

BACKGROUND

Due to the increasing complexity of medical education and practice, the preparation of healthcare professionals for leadership roles and responsibilities has become increasingly important. To date, the literature on faculty development designed to promote leadership in medical education has not been reviewed in a systematic fashion.

AIM

The objective of this review is to synthesize the existing evidence that addresses the following question: 'What are the effects of faculty development interventions designed to improve leadership abilities on the knowledge, attitudes, and skills of faculty members in medicine and on the institutions in which they work?'

SEARCH STRATEGY

The search, which covered the period 1980-2009, included six databases (Medline, EMBASE, CINAHL, Web of Science, ERIC, and ABI/Inform) and used the following keywords: faculty development; in-service training; doctor; medic; physician; faculty; leadership; management; administration; executive; and change agent. Hand searches were also conducted, and expert recommendations were solicited.

INCLUSION AND EXCLUSION CRITERIA

Articles with a focus on faculty development to improve leadership, targeting basic science and clinical faculty members, were reviewed. All study designs that included outcome data beyond participant satisfaction were examined. From an initial 687 unique records, 48 articles met the review criteria in three broad categories: (1) reports in which leadership was the primary focus of the intervention; (2) reports in which leadership was a component of a broader focus on educational development; and (3) reports in which leadership was a component of a broader focus on academic career development.

DATA EXTRACTION

Data were extracted by three coders using the standardized Best Evidence Medical Education coding sheet adapted for our use. One reviewer coded all of the articles, and two reviewers each coded half of the dataset. Coding differences were resolved through discussion.

DATA SYNTHESIS

Data were synthesized using Kirkpatrick's four levels of educational outcomes. Findings were grouped by intervention type and level of outcome.

RESULTS

Forty-eight articles described 41 studies of 35 different interventions. The majority of the interventions targeted clinical faculty members and included workshops, short courses, fellowships, and other longitudinal programs. The majority of studies were quantitative in nature, though five studies used a qualitative design, and 12 studies used mixed methods. All quantitative studies were quasi-experimental and most employed a single group design; only two studies had a comparison group. Qualitative study designs were typically not specified. The majority of evaluation data, primarily collected post-intervention, consisted of participants' responses to questionnaires and interviews. KEY POINTS AND SUMMARY OF OUTCOMES: Despite methodological limitations, the faculty development literature tends to support the following outcomes: ▪ High satisfaction with faculty development programs. Participants consistently found programs to be useful and of both personal and professional benefit. They also valued the practical relevance and applicability of the instructional methods used. ▪ A change in attitudes toward organizational contexts and leadership roles. Participants reported positive changes in attitudes toward their own organizations as well as their leadership capabilities. Some reported an increased awareness of--and commitment to--their institution's vision and challenges, whereas others reported greater self-awareness of personal strengths and limitations, increased motivation, and confidence in their leadership roles. A greater sense of community and appreciation of the benefits of networking were also identified. ▪ Gains in knowledge and skills. Participants reported increased knowledge of leadership concepts, principles, and strategies (e.g., leadership styles and strategic planning), gains in specific leadership skills (e.g., personal effectiveness and conflict resolution), and increased awareness of leadership roles in academic settings. ▪ Changes in leadership behavior. Self-perceived changes in leadership behavior were consistently reported and included a change in leadership styles, the application of new skills to the workplace (e.g., departmental reorganization and team building), the adoption of new leadership roles and responsibilities, and the creation of new collaborations and networks. Observed changes primarily suggested new leadership positions. ▪ Limited changes in organizational practice. Although not frequently examined, changes in organizational practice included the implementation of specific educational innovations, an increased emphasis on educational scholarship, and the establishment of collegial networks. ▪ Key features of faculty development. Features contributing to positive outcomes included the use of: multiple instructional methods within single interventions; experiential learning and reflective practice; individual and group projects; peer support and the development of communities of practice; mentorship; and institutional support. ▪ Avenues for future development: Moving forward, faculty development programs should: ground their work in a theoretical framework; articulate their definition of leadership; consider the role of context; explore the value of extended programs and follow-up sessions; and promote the use of alternative practices including narrative approaches, peer coaching, and team development. METHODOLOGICAL ISSUES: More rigorous and diverse research designs are needed to capture the complexity of interventions in this area. Varied methods of assessment, utilizing multiple data sources to tap changes at the interpersonal and organizational level should be explored, as should the maintenance of change over time. Process-oriented studies, comparing different faculty development strategies and clarifying the process of change through faculty development, should also become a priority.

CONCLUSION

Participants value leadership development activities and report changes in attitudes, knowledge, skills and behavior. Moreover, despite methodological limitations, certain program characteristics seem to be associated with positive outcomes. Further research is required to explore these associations and document changes at both the individual and organizational level.

Theory and practice in the design and conduct of graduate medical education

Medical education practice is more often the result of tradition, ritual, culture, and history than of any easily expressed theoretical or conceptual framework. The authors explain the importance and nature of the role of theory in the design and conduct of graduate medical education. They outline three groups of theories relevant to graduate medical education: bioscience theories, learning theories, and sociocultural theories. Bioscience theories are familiar to many medical educators but are often misperceived as truths rather than theories. Theories from such disciplines as neuroscience, kinesiology, and cognitive psychology offer insights into areas such as memory formation, motor skills acquisition, diagnostic decision making, and instructional design. Learning theories, primarily emerging from psychology and education, are also popular within medical education. Although widely employed, not all learning theories have robust evidence bases. Nonetheless, many important notions within medical education are derived from learning theories, including self-monitoring, legitimate peripheral participation, and simulation design enabling sustained deliberate practice. Sociocultural theories, which are common in the wider education literature but have been largely overlooked within medical education, are inherently concerned with contexts and systems and provide lenses that selectively highlight different aspects of medical education. They challenge educators to reconceptualize the goals of medical education, to illuminate maladaptive processes, and to untangle problems such as career choice, interprofessional communication, and the hidden curriculum.Theories make visible existing problems and enable educators to ask new and important questions. The authors encourage medical educators to gain greater understanding of theories that guide their educational practices.

Critically reflective work behavior of health care professionals

INTRODUCTION

Better understanding of critically reflective work behavior (CRWB), an approach for work-related informal learning, is important in order to gain more profound insight in the continuing development of health care professionals.

METHODS

A survey, developed to measure CRWB and its predictors, was distributed to veterinary professionals. The authors specified a model relating CRWB to a Perceived Need for Lifelong Learning, Perceived Workload, and Opportunities for Feedback. Furthermore, research utilization was added to the concept of CRWB. The model was tested against the data, using structural equation modeling (SEM).

RESULTS

The model was well represented by the data. Four factors that reflect aspects of CRWB were distinguished: (1) individual CRWB; (2) being critical in interactions with others; (3) cross-checking of information; and (4) openness to new findings. The latter 2 originated from the factor research utilization in CRWB. The Perceived Need for Lifelong Learning predicts CRWB. Neither Perceived Workload nor Opportunities for Feedback of other practitioners was related to CRWB.

DISCUSSION

The results suggest that research utilization, such as cross-checking information and openness to new findings, is essential for CRWB. Furthermore, perceptions of the need for lifelong learning are more relevant for CRWB of health care professionals than qualities of the workplace.

Becoming a practitioner: workplace learning during the junior doctor's first year

BACKGROUND

Newly qualified doctors (interns) report that they learn a great deal in the first year of practice, but exactly what is learnt is not well understood.

AIMS

To document the reflections and perceptions of first year junior doctors in order to reveal and chronicle their informal and often tacit learning in the workplace within a practice methodology framework.

METHODS

New Zealand interns, from three sites, participated in group interviews modelled on a conversation and joint enquiry style.

RESULTS

We found that learning in the first year after graduation falls into three broad themes: (1) concrete tasks, (2) project management and (3) identity formation. Identity formation appeared the most challenging and included getting used to being seen by others as a doctor.

CONCLUSION

All themes have implications for curriculum development and clinical supervision in both undergraduate programmes and during internship. The third theme (identify formation) is the most complex. We draw on a model from management literature, to describe intern education as a process of becoming: as an unfolding and as a transformation of the self over time. We argue that reconfiguring internship as a period of identity formation, and as a self-determined, active process of 'becoming a doctor' provides a wider perspective than enculturation or socialisation theories to understand this significant transition.

Experiential learning: AMEE Guide No. 63

This Guide provides an overview of educational theory relevant to learning from experience. It considers experience gained in clinical workplaces from early medical student days through qualification to continuing professional development. Three key assumptions underpin the Guide: learning is 'situated'; it can be viewed either as an individual or a collective process; and the learning relevant to this Guide is triggered by authentic practice-based experiences. We first provide an overview of the guiding principles of experiential learning and significant historical contributions to its development as a theoretical perspective. We then discuss socio-cultural perspectives on experiential learning, highlighting their key tenets and drawing together common threads between theories. The second part of the Guide provides examples of learning from experience in practice to show how theoretical stances apply to clinical workplaces. Early experience, student clerkships and residency training are discussed in turn. We end with a summary of the current state of understanding.

The curriculum is dead! Long live the curriculum! Designing an undergraduate medicine and surgery curriculum for the future

Where changing social circumstances demand reform of medicine, this in turn provokes new thinking in medical education. Curriculum changes, however, are often ill conceived, consisting of syllabus (content) modification, rather than careful consideration of fundamental principles and theory shaping a curriculum process initiative. The undergraduate medicine and surgery curriculum of the future must address some basic fault lines in current provision, such as medical culture's failure to democratise work practices ensuring patient safety. While acquiring a reputation as innovative and progressive, and after a decade of success with current provision, Peninsula Medical School (UK) has recognised the need to develop its curriculum for the future. Such a curriculum will be guided by best evidence from medical education to inform pedagogical practices and by sophisticated curriculum theory. Drawing on social learning pedagogies and curriculum reconceptualisation models for guidance, and incorporating evaluation of its current provision and published evaluations of other curricula (particularly Longitudinal Integrated models), fundamental principles were conceived to guide curriculum reform.

Simulation: an effective pedagogical approach for nursing?

Simulation features strongly within the undergraduate nursing curriculum for many Universities. It provides a variety of opportunities for students as they develop their clinical nursing skills. The nursing literature highlights the potential of this approach and the positive opportunities afforded to students in terms of developing competence and confidence. However, much of this literature focuses upon the more operational concerns of simulation. This paper reflects upon the evolution of simulation in nurse education. It considers the theoretical positioning and understanding of simulation as a teaching and learning approach for undergraduate nursing skills development. The work of Vygotsky (1978) and Lave and Wenger (1991) are highlighted in order to begin to explore the theoretical basis of simulation as an effective pedagogical approach for nurse education today, enabling students to learn to be nurses.

Putting the expert together again

CONTEXT

The study of expertise in medical education has a long history of success. Researchers have identified and elaborated on many dimensions of expert performance. In part, this success has derived from researchers' ability to effectively isolate the dimensions and explore each separately. Although this deconstruction of the expert has been successful, the need to recombine the dimensions of expertise as part of an integrated construct of expert practice has recently become an increasingly evident imperative in health professions education.

METHODS

The aims of this paper are first to explore dimensions of expert practice as they are expressed in the expertise literature; secondly, to describe more recent programmes of research that have tried to elaborate on how experts integrate these various dimensions during daily practice, and, finally, to examine the potential implications of research exploring how experts integrate their own knowledge and skills with the affordances of the environment in which they work.

RESULTS AND CONCLUSIONS

There are both challenges and opportunities in elaborating an integrated discourse on expertise. Exploring directions for research related to this integrated construction of the practising expert may add an important dimension to our educational repertoire.

Tensions in informed self-assessment: how the desire for feedback and reticence to collect and use it can conflict

PURPOSE

Informed self-assessment describes the set of processes through which individuals use external and internal data to generate an appraisal of their own abilities. The purpose of this project was to explore the tensions described by learners and professionals when informing their self-assessments of clinical performance.

METHOD

This 2008 qualitative study was guided by principles of grounded theory. Eight programs in five countries across undergraduate, postgraduate, and continuing medical education were purposively sampled. Seventeen focus groups were held (134 participants). Detailed analyses were conducted iteratively to understand themes and relationships.

RESULTS

Participants experienced multiple tensions in informed self-assessment. Three categories of tensions emerged: within people (e.g., wanting feedback, yet fearing disconfirming feedback), between people (e.g., providing genuine feedback yet wanting to preserve relationships), and in the learning/practice environment (e.g., engaging in authentic self-assessment activities versus "playing the evaluation game"). Tensions were ongoing, contextual, and dynamic; they prevailed across participant groups, infusing all components of informed self-assessment. They also were present in varied contexts and at all levels of learners and practicing physicians.

CONCLUSIONS

Multiple tensions, requiring ongoing negotiation and renegotiation, are inherent in informed self-assessment. Tensions are both intraindividual and interindividual and they are culturally situated, reflecting both professional and institutional influences. Social learning theories (social cognitive theory) and sociocultural theories of learning (situated learning and communities of practice) may inform our understanding and interpretation of the study findings. The findings suggest that educational interventions should be directed at individual, collective, and institutional cultural levels. Implications for practice are presented.

Workplace learning from a socio-cultural perspective: creating developmental space during the general practice clerkship

Workplace learning in undergraduate medical education has predominantly been studied from a cognitive perspective, despite its complex contextual characteristics, which influence medical students' learning experiences in such a way that explanation in terms of knowledge, skills, attitudes and single determinants of instructiveness is unlikely to suffice. There is also a paucity of research which, from a perspective other than the cognitive or descriptive one, investigates student learning in general practice settings, which are often characterised as powerful learning environments. In this study we took a socio-cultural perspective to clarify how students learn during a general practice clerkship and to construct a conceptual framework that captures this type of learning. Our analysis of group interviews with 44 fifth-year undergraduate medical students about their learning experiences in general practice showed that students needed developmental space to be able to learn and develop their professional identity. This space results from the intertwinement of workplace context, personal and professional interactions and emotions such as feeling respected and self-confident. These forces framed students' participation in patient consultations, conversations with supervisors about consultations and students' observation of supervisors, thereby determining the opportunities afforded to students to mind their learning. These findings resonate with other conceptual frameworks and learning theories. In order to refine our interpretation, we recommend that further research from a socio-cultural perspective should also explore other aspects of workplace learning in medical education.