On learning in the clinical environment

To teach is to learn twice, revisited: a qualitative study of how residents learn through teaching in clinical environments

BACKGROUND

Teaching helps the teacher's own learning as a professional-as the saying goes, 'to teach is to learn twice'. Near-peer teaching in clinical practice has been shown to contribute to the development of both teaching skills and necessary competencies for doctors. Research on how near-peer teachers learn through their teaching roles has mainly focused on classroom learning. However, understanding how the phenomenon of 'teaching is learning twice' occurs in clinical settings and its influencing factors is important for the development of a quality workplace learning environment. Therefore, this study investigated how residents learn through teaching in clinical practice and the factors influencing this process.

METHODS

This study's methodology is based on the constructivist grounded theory from a social constructivist perspective. Several teaching hospitals in Japan were included, and the study participants were post-graduate year 2 residents (PGY2s) from these hospitals. The interviews were recorded, transcribed into text, and analysed by the first author.

RESULTS

From January 2016 to July 2022, 13 interviews were conducted with 11 PGY2s from nine educational hospitals. The PGY2s played diverse educational roles in clinical settings and learned competencies as physicians in almost all areas through such roles. We found that knowledge transfer and serving as role models stimulated PGY2s' intrinsic motivation, encouraged reflection on their own experiences, and promoted self-regulated learning. Further, educating about procedural skills and clinical reasoning prompted reflection on their own procedural skills and thought processes. Supporting post-graduate year 1 residents' reflections led to the refinement of PGY2s' knowledge and thought processes through the verbal expression of their learning experiences. Such processes required the formation of a community of practice. Thus, education promoted learning through reflection and clarified the expert images of themselves that PGY2s envisaged.

CONCLUSIONS

The study found that residents acquire various physician competencies through multiple processes by teaching as near-peer teachers in clinical settings, that a community of practice must be formed for near-peer teaching to occur in a clinical setting, and that teaching brings learning to those who teach by promoting reflection and helping them envision the professionals they aim to be.

Exploring residents and supervisors' workplace learning needs during postgraduate medical education

Objectives

To identify the main enablers and challenges for workplace learning during postgraduate medical education among residents and their supervisors involved in training hospital specialists across different medical specialties and clinical teaching departments.

Methods

A qualitative explorative study using semi-structured focus group interviews was employed. A purposeful sampling method was utilized to invite participants who were involved in postgraduate medical education for hospital specialist medicine at two universities. Hospital physicians in training, also called residents (n=876) and supervisors (n=66), were invited by email to participate. Three focus groups were organized: two with residents and one with supervisors. Due to the COVID-19 pandemic rules prohibiting real group meetings, these focus groups were online and asynchronous. The data was analyzed following an inductive thematic analysis.

Results

The following overarching themes were identified: 1) the dual learning path, which balances working in the hospital and formal courses, 2) feedback, where quality, quantity, and frequency are discussed, and 3) learning support, including residents' self-directed learning, supervisors' guidance, and ePortfolio support.

Conclusions

Different enablers and challenges for postgraduate medical education were identified. These results can guide all stakeholders involved with workplace learning to develop a better understanding of how workplace learning can be optimized to improve the postgraduate medical education experience. Future studies could focus on confirming the results of this study in a broader, perhaps international setting and exploring strategies for aligning residencies to improve quality.

'Making room for student autonomy' - an ethnographic study of student participation in clinical work

Participation in clinical work is important for medical students' professional development. However, students often report that they experience a passive observer role, and further research on contextual factors that influence student participation is needed. The theory of practice architectures contributes a new perspective to this challenge by elucidating how cultural-discursive, material-economic, and social-political arrangements enable and constrain student participation in clinical work. The aim of this study was to explore how practice architectures in clinical learning environments enable and constrain medical students' participation. The study was designed as an ethnographic field study in three student clinics: 106 h of observation. Analysis comprised ethnographic analysis followed by application of the theory of practice architectures. The ethnographic analysis resulted in six themes: setting the scene, when to call for help, my room - my patient, getting in a routine, I know something you don't, and my work is needed. Applying the theory of practice architectures showed that material-economic arrangements, such as control of the consultation room and essential artefacts, were crucial to student participation and position in the clinical workplace. Furthermore, co-production of a student mandate to independently perform certain parts of a consultation enabled a co-productive student position in the hierarchy of care-producers. The findings offer a conceptually generalisable model for the study of material and social dimensions of clinical learning environments. Although not all clinical learning environments may wish to or have the resources to implement a student clinic, the findings offer insights into general issues about the arrangements of student participation relevant to most clinical teaching contexts.

Implementing Kolb´s Experiential Learning Cycle by Linking Real Experience, Case-Based Discussion and Simulation

BACKGROUND

Background: To prepare medical students for their future, they must become acquainted with clinical practice, for example by means of simulations, clerkships and discussing patient cases. By connecting these different approaches, according to Kolb´s experiential learning cycle, the learning effect can be strengthened.

METHODOLOGY

In the development of a didactical program for students who are being prepared for their role as general practitioners, we have adopted a new didactic approach, in which educational formats are interlinked, according to Kolb´s experiential learning cycle. The content of these courses is determined by the Entrustable Professional Activities (EPAs) for the clerkship in family medicine, combined with the most common chief complaints of patients in the GP's practice. In 2019, the first course was implemented at the Technical University of Munich, Germany, with 6 medical students. A first seminar discusses patients who the students have seen for themselves during their clerkship in family medicine. In addition, matching theory is discussed and skills are practiced. In the next seminar, students apply the acquired knowledge and skills in scenarios with standardized patients. Students evaluated the courses as positive. The evaluations show they find discussing personally experienced patient cases and the opportunity to practice very valuable.

CONCLUSIONS

A course design according to Kolb's Experiential learning cycle, which integrates experience, theory and simulation, is a valuable addition to existing forms of teaching in medical education. Students appreciated both discussing personally experienced patient cases and the opportunity to re-practice similar cases in a simulated environment. To gain more insight into the learning effects, it is recommended to further explore this approach in a different context.

Exploring patient experiences in the student outpatient clinic - A contribution to learning

OBJECTIVE

To understand how patients experience participation in student encounters.

METHODS

Qualitative semi-structured telephone interviews with ten cardiac surgery patients who had attended voluntary postoperative consultations in a student outpatient clinic. The interview guide included questions about reasons for and experiences of being part of a teaching situation. Interviews were analysed through inductive thematic analysis where pieces of text in each interview were assigned different codes and condensed into themes.

RESULTS

The patients expressed a duality in their reasons for participating in student consultations: (1) a personal need for assurance (safety) and (2) a wish to help students (altruism). Students were perceived as professional and sometimes insecure. Being part of an educational situation was meaningful to the patients because they did not feel objectified. Knowing that there was a backup supervisor made the patients feel safe even though the supervisor was not present during all parts of the consultation.

CONCLUSIONS

Patients experienced safety, understood their role in all parts of the consultation, and shared a wish to help students learn.

PRACTICE IMPLICATIONS

A sequential consultation model alternating between student- and supervisor-driven supervision can balance student autonomy and patient safety. This knowledge could guide future patient-centred medical education in student clinics.

A systematic review of patient interactions with student pharmacists in educational settings

BACKGROUND

Patients may contribute to various aspects of student pharmacists' education within clinical, experiential and educational settings. There is an emerging body of literature describing and evaluating the contribution of patients to health care education; however, little is known about patients' contribution to pharmacy education specifically within educational settings.

OBJECTIVE

To explore the evidence relating to the involvement of patients in the education of student pharmacists, in terms of the nature, extent, and outcomes of their contribution.

METHODS

A systematic literature search was undertaken within Embase, MEDLINE, Education Resources Information Center, International Pharmaceutical Abstracts, PubMed, PsycINFO, CINAHL, and Scopus databases from inception to April 10, 2020. Inclusion criteria included primary research studies reporting on the active involvement of patients in pharmacy education, within an educational setting. Quality assessment appraisal for the included studies was conducted using the Mixed Methods Appraisal Tool.

RESULTS

Twelve studies were eligible for inclusion in this systematic review. Nine studies explored the use of patients as educators providing valuable insight about their lived experience. Six studies involved patients in question-and-answer sessions, providing students with opportunities to inquire about their lived experience in relation to medicines, health care, and medical conditions. Studies that reported on students' learning outcomes demonstrated improvements in communication skills, deeper understanding of patients' lived experience particularly relating to mental illness, and increased confidence in providing care for patients. Among patients, participation in the educational process led to greater satisfaction, empowerment, and knowledge from sharing personal experiences. There were no clinical outcomes measured among patients participating in the included studies. The 5 nonrandomized quantitative studies ranged from low to moderate levels of quality, the 4 mixed-methods studies were of low quality, and the 3 qualitative studies were of high quality.

CONCLUSION

The involvement of patients in the education of student pharmacists was found to benefit both patients and students. Student-specific outcomes included development of communication skills and new insights about patients' lived experience. Further research is needed to better understand the long-term impact of patient involvement in pharmacy education, in terms of students' learning outcomes and clinical outcomes among patients.

Cultural Historical Activity Theory for Studying Practice-Based Learning and Change in Medical Education

Cultural historical activity theory (CHAT) is a social theory which is useful as a methodological framework for the vital task of studying practice-based learning in complex learning environments. CHAT is an apparatus considering learning as occurring through practice, through collective activity, and mediated by culturally specific instruments. Because CHAT is increasingly drawn upon in medical education academia, it is necessary for medical educationalists to be familiar with this theory. This methodology article explains how CHAT theorizes learning in dynamic workplaces within an activity system comprising multiple practitioners engaged in activity, which is collaborative, multi-voiced, and bounded by a shared intended object. It provides an accessible overview of the central concepts within CHAT and a description of a methodological strategy (activity system analysis) to incorporate CHAT into one's own work. CHAT also theorizes where tensions lie within and between activity systems, causing difficulties in achieving the intended object, defining such tensions as contradictions. It is through the overcoming of past contradictions that activity has come to exist in its current form, abiding by social norms of the present time, and CHAT allows consideration of how practice within a system may be changed through resolution of contradictions. For example, the Change Laboratory is a contrived intervention where practitioners consciously contribute to developing and embedding new, improved ways of practicing using CHAT principles. This allows practitioners to have agency in improving their own areas of learning and practice. Throughout this article, examples are provided of how CHAT has been usefully applied to various aspects of medical education research, including undergraduate education, postgraduate education, and continuous professional development. By building on the introduction to CHAT provided in this article, the reader can start to use CHAT methodologically to describe complexity, identify practice-based contradictions, and develop improved forms of practice-based learning, in his/her own context.

Competency-based undergraduate curriculum implementation in anesthesiology-A survey-based comparison of two models of training

Background and Aim:

Imparting the knowledge and skills of Anesthesiology to undergraduates can be challenging. Competency Based Undergraduate (CBUG) Curriculum for the Undergraduate medical students introduced by the Medical Council of India (MCI) aims to improve the quality of the Indian Medical Graduate (IMG). The Department of Anesthesiology and Critical Care of our college redrafted the training program and brought it in-line with the CBUG Curriculum beginning February 2019. A questionnaire based survey was conducted to assess the efficacy, satisfaction levels and the perception of the students towards the new competency based curriculum. The aim was to assess the students perception of the competency based curriculum and to evaluate two slightly different approaches to the implementation of the curriculum.

Material and Methods:

Two groups of undergraduate medical students belonging to the 6^th and 8^th term, underwent two different models of teaching. The 8^th term students had already completed their theory classes based on the older curriculum a year ago when they were in 6^th term. However, their clinics and tutorials were modelled as per the new CBUG Curriculum. The current 6^th term students had their first exposure to Anesthesiology and their theory, tutorials and clinics were scheduled in the same term, simulation based training was added, the operation theatre rotation was held in the mornings at 0730hrs and the intensive care unit rounds were held in the evenings. There was no difference in the theory classes taken for the two batches, however the clinics were different. After both the batches finished their rotation, they were given the survey questionnaire to assess their perception of the model of CBUG Curriculum that they were exposed to.

Results:

The results of the survey revealed that about 80% of the students in both groups preferred that theory classes and practical training should be conducted in parallel in 6^th term. About 60% students in both groups felt that early morning clinics 0800hrs were better than mid-morning clinics at 1100hrs as they get to see and do more procedures. 66%-82% students in both groups felt that the practical training in the OT, ICU and skills lab were very helpful or extremely helpful. The most important aspect of Anesthesiology rotation was “learning basic life saving skills and simulation based learning“ according to 85% students in both groups. Nearly 80% students in both groups felt that the training in Anesthesiology should be allotted more time and more weightage in undergraduate training. 72% students in 6^th term and 63% students in 8^th term felt more confident of handling emergencies after their Anesthesiology rotation.

Conclusion:

The new curriculum was extremely well received by the students of both groups. The model used for 6^th term students comprising of teaching theory and practical in the same term and having early morning clinics, was found to be superior as compared to the model used to teach 8^th term students where there was a gap of one year between theory and practical teaching and the clinics were held midmorning.

Nursing Students' Perceptions of Menstrual Distress during Clinical Practice: A Q-Methodology Study

This study aimed to explore the cluster patterns of female nursing students’ perceptions of the effects of menstrual distress during clinical practice. This study adopted the Q-methodology study design. We recruited female nursing students from a college in northern Taiwan. Forty-seven Q-statements were constructed to explore participants’ experiences of the impact of menstrual distress on clinical learning. In total, 58 participants subjectively ranked Q-statements concerning menstrual distress experiences during clinical practice and were classified. After Q-sorting, the subjective ranking process PQ Method (version 2.35, Schmolck, Emmendingen, Germany) was employed for factor analysis. Four patterns of shared perspectives, accounting for 46.6% of the total variance, were identified: (a) influencing clinical learning and making good use of painkillers; (b) responsible attitudes and diversified relief of discomfort; (c) seeking peer support and effect on mood; (d) negative impact on learning ability and conservative self-care. Clinical practice is a major component of nursing education; menstrual distress affects female nursing students’ clinical learning and performance. The exploration of clustering different nursing students’ perceptions may facilitate customized strategies to enable more appropriate assistance.

Perceived barriers to medical leadership training and methods to mitigate them in the undergraduate medical curriculum: A mixed-methods study of final-year medical students at two medical schools

INTRODUCTION

Effective leadership is vital for high-quality healthcare. Despite progress in leadership development for junior doctors, studies reflect perceptions that junior doctors feel underprepared for leadership. This study aims to understand medical students' perceptions about barriers to effective leadership training and how to mitigate these.

METHODS

This was a mixed-methods study utilising focus group interviews structured using four trigger questions. Qualitative narrative responses underwent quantitative inductive coding applied by two independent coders. Commonly occurring codes underwent thematic analysis to understand underpinning themes.

RESULTS

Thirty-one students were interviewed from King's College London (n=24) and St George's, University of London (n=7). Cohen's kappa statistic of inter-rater reliability was 0.73. The priority areas were the equity of teaching, implemented approaches and methods of assessing competency. The study presents a driver diagram summarising findings.

CONCLUSION

This study presents medical students' perceptions about barriers to effective leadership training in current undergraduate curriculum and interventions to mitigate these.

[Overview on research in the field of medical education]

Medical education is a relatively young field of research that has been characterized by many innovations over the last 20 years. The main topics were the preparation of students for their medical work and imparting of profound knowledge about scientific contexts in medicine. For a long time, the main focus was on learning the necessary knowledge and skills; however, this is no longer considered sufficient. In order to carry out the work as a physician well, other qualities are also necessary, such as communication, collaboration, professionalism, science and reflectivity. Worldwide these aspects are being increasingly integrated into the learning objectives of medical schools and residency programs. The structure of medical studies at many universities has also changed. So-called vertical integration strengthens the integration of theoretical preclinical training and the clinical phase. This means that in the preclinical phase training is more practice-oriented and in the clinical phase a more structured form of training takes place. In the first years of study, students are prepared for the clinical phase by discussing patient cases and practicing skills in simulation centers. In addition, the clinical working environment is increasingly used as a learning environment. Developments have also been made regarding examinations: in addition to knowledge and skills, students and residents are now also assessed regarding performance in practice. Using more realistic assessments, e.g., Objective Structured Clinical Examinations and Workplace-based Assessments, students are evaluated more on their actual performance in practice. By means of the Entrustable Professional Activities method, students are gradually given more responsibility in order to prepare them for their future tasks.

Should we use preceptorships in undergraduate nursing education?

BACKGROUND

Clinical learning experiences are the cornerstone of undergraduate nursing education as they allow students to apply theory to practice and help them develop as competent practitioners who are prepared for the realities of diverse, complex, and ever-changing practice environments.

PROBLEM

The traditional clinical teaching model, where small groups of students work with educators who are on-site facilitating learning, has numerous issues and thus there have been calls for reform. This Creative Controversy focuses on one reform option, the alternative clinical teaching model of preceptorships, which has gained popularity in recent years.

APPROACH

Current evidence surrounding preceptorships in undergraduate education was examined and critiqued.

CONCLUSION

Despite their popularity, there is a lack of robust evidence surrounding preceptorships and the motivations for using this model remain questionable. Future study is needed so preceptorships are implemented according to evidence-based teaching practices and not clouded by inappropriate motivations. The author challenges readers to question their practices and work to positively contribute to the science and practice of nursing education.

You say it, we say it, but how do we use it? Communities of practice: A critical analysis

OBJECTIVES

As educational theories are increasingly used in medical education research there are concerns over how these theories are used, how well they are presented and what the authors intend. Communities of practice (CoP) is one example of an often-used theory and conceptual framework. This paper presents a critical analysis of how CoP theory is used in medical education research.

METHODS

A critical literature analysis was undertaken of articles published between 1998 and 2018 in eight internationally recognised medical education journals. From a total of 541 articles, 80 articles met the inclusion criteria and were analysed and mapped according to various patterns of use.

RESULTS

We discerned five categories of use, two misleading and cosmetic, off target and cosmeticising, and three functional, framing, lensing and transferring. A considerable number of articles either misrepresented the point of communities of practice or used it in a cosmetic fashion. The remainder used the theory to frame an ongoing study in relation to other work, as a lens through which to design the study and collect or analyse data, or as a way of discussing or demonstrating the transferability of the findings.

CONCLUSIONS

We conclude that almost half of the reviewed articles did not offer a functional and rigorous definition of what is meant by CoP; instead, they used it in a potentially misleading or cosmetic manner. This study therefore calls on editors, reviewers and authors alike to increase clarity and quality in the application of CoP theory in medical education.

Finding your feet: student participation during initiation of international clinical placements : Student participation during initiation

INTRODUCTION

International placements challenge students to find the right level of participation, as local practices, language and time pressure may affect their engagement in patient-related tasks or team activities. This study sought to unpack the initiation process during international clinical placements with the ultimate aim to achieve active student participation.

METHODS

Following a constructivist grounded theory approach, we conducted two individual interviews with 15 undergraduate healthcare students (before departure and whilst on placement). To identify emerging themes, we applied an iterative process of data collection and constant comparative analysis. Several team discussions informed further analysis, allowing us to reach a more conceptual level of theory.

RESULTS

From our findings we constructed a four-phase model of healthcare students' initiation of international clinical placements, which brings into focus how the phases of 'orientation', 'adjustment' and 'contribution to patient care' build up towards a 'sense of belonging'. We identified several factors that induced active student participation in practice, such as a favourable workplace setting, opportunities for learning and a local support network.

DISCUSSION

Active student participation is aimed at different goals, depending on the four phases of initiation that eventually lead to a sense of belonging and support workplace learning.

Everywhere and nowhere: Work-based learning in healthcare education

The shortage of healthcare professions is a global issue, which has highlighted the need to establish effective practice learning. In 2015 the UK government introduced a change to the way that healthcare education is funded. A subsequent fall in applications to healthcare programmes and high levels of vacancies across the sector in the UK have led to widespread concern about workforce shortages, especially nurses. Subsequently, initiatives that both address the shortage and aim to bridge the gap between registered nurse and healthcare support worker have been introduced, presenting opportunities to further develop the clinical workplace as a learning environment for employees. A sample of nine healthcare professionals was recruited; seven nurses and two allied health professionals. Semi-structured interviews were conducted between March and June 2018. These were recorded verbatim, transcribed and thematically analysed. Respondents identified opportunities for work-based learning and factors for success. The importance of an effective learning culture, commitment to work-based learning and time were identified as factors for success. Despite the richness of learning opportunities in healthcare, respondents identified challenges for both learners and supervisors in identifying these opportunities in the workplace. These findings have immediate relevance to healthcare education systems internationally. Areas for future research include the relationship between supervisor and learner and further insight into why the busiest areas might be identified as more effective learning environments.