Dealing with the tension: how residents seek autonomy and participation in the workplace

Cherry-picking learning tasks in the orchard of postgraduate medical education - a socio-cultural perspective

'@ReneeStalmeijer and @SNEMeeuwissen use a socio‐cultural perspective, empirical examples, and the cherry‐picking metaphor, to explore interactions between trainees and healthcare teams that impact trainees’ selection of learning tasks during workplace learning

Trainee selection of tasks in postgraduate medical education: Is there a role for 'cherry-picking' to optimise learning?

PURPOSE

Learning is optimised when postgraduate trainees engage in clinical tasks in their zone of proximal development (ZPD). However, workplace learning environments impose additional non-learning goals and additional tasks that may lead to trainees engaging in tasks that do not fall within their ZPD. We do not fully understand how trainees select clinical tasks in the workplace learning environment. If we knew the goals and factors they consider when selecting a task, we could better equip trainees with strategies to select tasks that maximise learning. We explored how postgraduate trainees select clinical tasks using echocardiography interpretation as a model.

METHODS

Canadian General Cardiology residents and Echocardiography fellows were invited to participate in semi-structured interviews. Aligning with a theory-informed study, two independent researchers used a deductive, directed content analysis approach to identify codes and themes.

RESULTS

Eleven trainees from seven Canadian universities participated (PGY4 = 4, PGY5 = 3, PGY6 = 1 and echocardiography fellows = 3). Goals included learning content, fulfilling assessment criteria and contributing to clinical demands. Trainees switched between goals throughout the day, as it was too effortful for them to engage in tasks within their ZPD at all times. When trainees had sufficient mental effort available, they selected higher complexity tasks that could advance learning content. When available mental effort was low, trainees selected less complex tasks that fulfilled numerically based assessment goals or contributed to clinical demands. Trainees predominantly used perceived complexity of the echocardiogram as a factor to select tasks to achieve their desired goals.

CONCLUSION

Postgraduate trainees select tasks within their ZPD that enable them to maximise learning when they perceive to have sufficient mental effort available and workplace affordances are adequate. These findings can inform individual and systemic strategies to maximise learning when selecting tasks.

A model for improving the learning environment in high-stress and emotion-bound clinical settings

INTRODUCTION

In clinical settings, it is necessary to create a clinical learning environment that provides the ground for the learners to acquire competencies especially in high-stress and emotion-bound clinical settings.

METHODS

In the present study, a model for improving the learning environment in high-stress and emotion-bound clinical settings was designed by conducting a multi-method study in the form of three sub-studies.

RESULTS

This model was designed with 3 pivotal concepts; organizing learning opportunities around safe care, fair participation in learning opportunities and creating a positive emotional climate and 6 peripheral concepts; designing physical space and appropriate equipment for education and care, preparing learners to attend the clinical setting, preparing learners to participate in learning opportunities, balancing the learner role and the care provided by the learners, the presence of a competent educator and providing education to all learners, and acquiring the ability to manage emotions by learners, faculty and staff.

CONCLUSIONS

The implementation of the model obtained from this study provides the basis for solving the challenges of clinical learning environments, especially in high-stress and emotion-bound clinical settings, and improves clinical education and the realization of educational and care outcomes.

Learning in a real-life escape room: an explorative study on the supervisory relationship in GP residency during the COVID-19 pandemic

BACKGROUND

The relationship between supervisors and residents plays a prominent role in the professional development of general practice (GP) residents. When disruptions occur in the normal course of healthcare, due to effects of e.g. war or emerging epidemics, we need to consider how this may affect the training of the next generation of general practitioners. As both supervisors and residents face new and unprecedented challenges that impact overall quality of the training. In this study, we examined the characteristics of the supervisory relationship in GP training during the disruptions early on during COVID-19. Our aim was to understand better how resident learning is affected in these circumstances, which is a first step in enabling supervisors, residents and faculty to anticipate disruptive situations better in the future.

METHODS

We conducted a qualitative case study with a constructivist approach. Seven GP residents at the start of their second placement, and their 10 supervisors participated in this study. Participants came from a University Medical Centre in the Netherlands. Semi-structured interviews were held between September 2020 and February 2021. The subjects were (1) interviewed individually about what they had learned regarding COVID-19, and (2) they were interviewed in supervisory pairs about how they had learned. Data were iteratively analysed; thematic analysis for (1) and template analysis in (2).

RESULTS

We identified notable changes in the supervisor-resident relationship attributable to COVID-19. Supervisors and residents were confronted with an all-encompassing uncertainty in the workplace, and disruptive changes in patient care and learning opportunities for residents. Supervisors and residents addressed these emerging workplace challenges through three types of collaboration, (1) getting the job done; (2) residents' learning; and (3) collective learning. Each type had a different focus and distinctive characteristics of the supervisory relationship.

CONCLUSION

With the outbreak of COVID-19, supervisors and residents were faced with disruptive uncertainty. In these circumstances, learning occurred not only between residents and their supervisors, but also with non-supervising GPs and assistants in collective learning. We propose to complement collective learning in the workplace with reflection between residents and supervisors at the training institution.

Designing the learning of intraprofessional collaboration among medical residents

BACKGROUND

To preserve quality and continuity of care, collaboration between primary-care and secondary-care physicians is becoming increasingly important. Therefore, learning intraprofessional collaboration (intraPC) requires explicit attention during postgraduate training. Hospital placements provide opportunities for intraPC learning, but these opportunities require interventions to support and enhance such learning. Design-Principles guide the design and development of educational activities when theory-driven Design-Principles are tailored into context-sensitive Design-Principles. The aim of this study was to develop and substantiate a set of theory-driven and context-sensitive Design-Principles for intraPC learning during hospital placements.

METHODS

Based on our earlier research, we formulated nine theory-driven Design-Principles. To enrich, refine and consolidate these principles, three focus group sessions with stakeholders were conducted using a Modified Nominal Group Technique. Next, two work conferences were conducted to test the feasibility and applicability of the Design-Principles for developing intraPC educational activities and to sharpen the principles into a final set of Design-Principles.

RESULTS

The theoretical Design-Principles were discussed and modified iteratively. Two new Design-Principles were added during focus group 1, and one more Design-Principle was added during focus group 2. The Design-Principles were categorised into three clusters: (i) Culture: building collaborative relations in a psychologically safe context where patterns or feelings of power dynamics between primary and secondary care physicians can be discussed; (ii) Connecting Contexts: making residents and supervisors mutually understand each other's work contexts and activities; and (iii) Making the Implicit Explicit: having supervising teams act as role models demonstrating intraPC and continuously pursuing improvement in intraPC to make intraPC explicit. Participants were unanimous in their view that the Design-Principles in the Culture cluster were prerequisites to facilitate intraPC learning.

CONCLUSION

This study led to the development of 12 theory-driven and context-sensitive Design-Principles that may guide the design of educational activities to support intraPC learning during hospital placements.

Supervisory dyads' communication and alignment regarding the use of workplace-based observations: a qualitative study in general practice residency

BACKGROUND

In medical residency, performance observations are considered an important strategy to monitor competence development, provide feedback and warrant patient safety. The aim of this study was to gain insight into whether and how supervisor-resident dyads build a working repertoire regarding the use of observations, and how they discuss and align goals and approaches to observation in particular.

METHODS

We used a qualitative, social constructivist approach to explore if and how supervisory dyads work towards alignment of goals and preferred approaches to performance observations. We conducted semi-structured interviews with supervisor-resident dyads, performing a template analysis of the data thus obtained.

RESULTS

The supervisory dyads did not frequently communicate about the use of observations, except at the start of training and unless they were triggered by internal or external factors. Their working repertoire regarding the use of observations seemed to be primarily driven by patient safety goals and institutional assessment requirements rather than by providing developmental feedback. Although intended as formative, the institutional test was perceived as summative by supervisors and residents, and led to teaching to the test rather than educating for purposes of competence development.

CONCLUSIONS

To unlock the full educational potential of performance observations, and to foster the development of an educational alliance, it is essential that supervisory dyads and the training institute communicate clearly about these observations and the role of assessment practices of- and for learning, in order to align their goals and respective approaches.

Learning the ropes: strategies program directors use to facilitate organizational socialization of newcomer residents, a qualitative study

BACKGROUND

Many residents experience their transitions, such as from medical student to resident, as demanding and stressful. The challenges they face are twofold: coping with changes in tasks or responsibilities and performing (new) social roles. This process of 'learning the ropes' is known as Organizational Socialization (OS). Although there is substantial literature on transitions from the perspective of residents, the voices of program directors (PDs) who facilitate and guide residents through the organizational socialization process have not yet been explored. PDs' perspectives are important, since PDs are formally responsible for Postgraduate Medical Education (PGME) and contribute, directly or indirectly, to residents' socialization process. Using the lens of OS, we explored what strategies PDs use to facilitate organizational socialization of newcomer residents.

METHODS

We conducted semi-structured interviews with 17 PDs of different specialties. We used a theory-informing inductive data analysis study design, comprising an inductive thematic analysis, a deductive interpretation of the results through the lens of OS and, subsequently, an inductive analysis to identify overarching insights.

RESULTS

We identified six strategies PDs used to facilitate organizational socialization of newcomer residents and uncovered two overarching insights. First, PDs varied in the extent to which they planned their guidance. Some PDs planned socialization as an explicit learning objective and assigned residents' tasks and responsibilities accordingly, making it an intended program outcome. However, socialization was also facilitated by social interactions in the workplace, making it an unintended program outcome. Second, PDs varied in the extent to which they adapted their strategies to the newcomer residents. Some PDs used individualized strategies tailored to individual residents' needs and skills, particularly in cases of poor performance, by broaching and discussing the issue or adjusting tasks and responsibilities. However, PDs also used workplace strategies requiring residents to adjust to the workplace without much intervention, which was often viewed as an implicit expectation.

CONCLUSIONS

PDs' used both intentional and unintentional strategies to facilitate socialization in residents, which may imply that socialization can occur irrespective of the PD's strategy. PDs' strategies varied from an individual-centered to a workplace-centered approach to socialization. Further research is needed to gain a deeper understanding of residents' perceptions of PD's efforts to facilitate their socialization process during transitions.

Effect of resident complement on timeliness of stroke team activation in an academic emergency department

OBJECTIVES

Investigations of the impact of residents on emergency department (ED) timeliness of care typically focus only on global ED flow metrics. We sought to describe the association between resident complement/supervisory ratios and timeliness of ED care of a specific time-sensitive condition, acute stroke.

METHODS

We matched ED stroke patient arrivals at 1 academic stroke center against resident and attending staffing and constructed a Cox proportional hazards model of door-to-activation (DTA) time (ie, ED arrival ["door"] to stroke team activation). We considered multiple predictors, including calculated ratios of residents supervised by each attending physician.

RESULTS

Among 462 stroke activation patients in 2014-2015, DTA ranged from 1 to 217 minutes, 72% within 15 minutes. The median number of emergency and off-service residents supervised per attending were 1.7 (interquartile range [IQR], 1.3-2.3) and 0.7 (IQR, 0-1), respectively. A 1-resident increase in off-service residents was associated with a 24% decrease (hazard ratio [HR], 0.76; 95% confidence interval [CI], 0.64-0.90) in the probability of stroke team activation at any given time. An independent 1-resident increase in the number of emergency residents was associated with a 13% increase (HR, 1.13; 95% CI, 1.01-1.25) in timely activation.

CONCLUSION

Timeliness of care for acute stroke may be impacted by how academic EDs configure the complement and supervisory structures of residents. Higher supervisory demands imposed by increasing the proportion of rotating off-service residents may be associated with slower stroke recognition and DTA times, but this effect may be offset when more emergency residents are present.

The Supervisor's Toolkit: Strategies of Supervisors to Entrust and Regulate Autonomy of Residents in the Operating Room

OBJECTIVE

To identify what strategies supervisors use to entrust autonomy during surgical procedures and to clarify the consequences of each strategy for a resident's level of autonomy.

BACKGROUND

Entrusting autonomy is at the core of teaching and learning surgical procedures. The better the level of autonomy matches the learning needs of residents, the steeper their learning curves. However, entrusting too much autonomy endangers patient outcome, while entrusting too little autonomy results in expertise gaps at the end of training. Understanding how supervisors regulate autonomy during surgical procedures is essential to improve intraoperative learning without compromising patient outcome.

METHODS

In an observational study, all the verbal and nonverbal interactions of 6 different supervisors and residents were captured by cameras. Using the iterative inductive process of conversational analysis, each supervisor initiative to guide the resident was identified, categorized, and analyzed to determine how supervisors affect autonomy of residents.

RESULTS

In the end, all the 475 behaviors of supervisors to regulate autonomy in this study could be classified into 4 categories and nine strategies: I) Evaluate the progress of the procedure: inspection (1), request for information (2), and expressing their expert opinion (3); II) Influence decision-making: explore (4), suggest (5), or declare the next decision (6); III) Influence the manual ongoing action: adjust (7), or stop the resident's manual activity (8); IV) take over (9).

CONCLUSIONS

This study provides new insights into how supervisors regulate autonomy in the operating room. This insight is useful toward analyzing whether supervisors meet learning needs of residents as effectively as possible.

Medical interns; the neglected learners of the maternity ward learning environment

BACKGROUND

Clinical training during internship is an important part of medical education. The maternity ward is a clinical environment in which medical students pass their obstetrics and gynecology internship to obtain competencies in this field. The present study was conducted to explain medical interns' manner of learning in the maternity ward.

MATERIAL AND METHODS

The present study was conducted using a qualitative approach with the inductive content analysis method. This study observed the maternity wards of teaching hospitals affiliated to medical sciences universities of Isfahan and Shahrekord. Data were collected through observation and semi-structured individual interviews.

RESULTS

Two main categories and seven subcategories emerged from the analysis of the data. Inadequate participation in learning opportunities included the following three subcategories: the incongruousness of the learning opportunities with the educational goals, inadequate readiness for participation in learning opportunities, and the overlap between learning opportunities and diminished autonomous practice. Inadequate formal and structured education included the following four subcategories: inadequate learning support and direction, subordinate roles and aimless presence, the pale educational role played by the attendants and senior residents, and learning through the support of midwifery educators.

CONCLUSION

Participation in and access to learning opportunities in the maternity ward are very difficult for interns. Interns, therefore, need to attend the maternity ward by a structured program and in the company of training supervisors or competent educators to obtain the required competencies in pregnancy and childbirth.

Residents' Perceptions of Faculty Behaviors and Resident Burnout: a Cross-Sectional Survey Study Across a Large Health Care Organization

BACKGROUND

Data suggests the learning environment factors influence resident well-being. The authors conducted an assessment of how residents' perceptions of faculty-resident relationships, faculty professional behaviors, and afforded autonomy related to resident burnout.

METHODS

All residents at one organization were surveyed in 2019 using two items from the Maslach Burnout Inventory and the faculty relationship subscale of the Johns Hopkins Learning Environment Scale (JHLES, range 6 to 30). Residents were also asked about faculty professional behaviors (range 0 to 30), and satisfaction with autonomy across various clinical settings.

RESULTS

A total of 762/1146 (66.5%) residents responded to the survey. After adjusting for age, gender, postgraduate year, and specialty, lower (less favorable) JHLES-faculty relationship subscale score (parameter estimate, - 3.08, 95% CI - 3.75, - 2.41, p < 0.0001), fewer observed faculty professional behaviors (parameter estimate, - 3.34, 95% CI - 4.02, - 2.67, p < 0.0001), and lower odds of satisfaction with autonomy in the intensive care settings (OR 0.46, 95% CI 0.30, 0.70, p = 0.001), but not other care settings, were reported by residents with burnout in comparison to those without. Similar relationships were observed when emotional exhaustion and depersonalization were analyzed separately as continuous variables.

CONCLUSION

In this cohort, resident perceptions of faculty relationships, faculty professional behaviors, and satisfaction with autonomy in the intensive care unit were associated with resident burnout. Additional longitudinal studies are needed to elucidate the direction of these relationships and determine if faculty development can reduce resident burnout.

Fingerprints of Teaching Interactions: Capturing and Quantifying How Supervisor Regulate Autonomy of Residents in the Operating Room

OBJECTIVE

Supervisors and residents agree that entrusted autonomy is central to learning in the Operating Room (OR), but supervisors and residents hold different opinions about entrustment: residents regularly experience that they receive insufficient autonomy while supervisors feel their guiding is not appreciated as teaching. These opinions are commonly grounded on general experiences and perceptions, instead of real-time supervisors' regulatory behaviors as procedures unfold. To close that gap, we captured and analyzed when and to what level supervisors award or restrain autonomy during procedures. Furthermore, we constructed fingerprints, an instrument to visualize entrustment of autonomy by supervisors in the OR that allows us to reflect on regulation of autonomy and discuss teaching interactions.

DESIGN

All interactions between supervisors and residents were captured by video and transcribed. Subsequently a multistage analysis was performed: (1) the procedure was broken down into 10 steps, (2) for each step, type and frequency of strategies by supervisors to regulate autonomy were scored, (3) the scores for each step were plotted into fingerprints, and (4) fingerprints were analyzed and compared.

SETTING

University Medical Centre Groningen (the Netherlands).

PARTICIPANTS

Six different supervisor-resident dyads.

RESULTS

No fingerprint was alike: timing, frequency, and type of strategy that supervisors used to regulate autonomy varied within and between procedures. Comparing fingerprints revealed that supervisors B and D displayed more overall control over their program-year 5 residents than supervisors C and E over their program-year 4 residents. Furthermore, each supervisor restrained autonomy during steps 4 to 6 but with different intensities.

CONCLUSIONS

Fingerprints show a high definition view on the unique dynamics of real-time autonomy regulation in the OR. One fingerprint functions as a snapshot and serves a purpose in one-off teaching and learning. Multiple snapshots of one resident quantify autonomy development over time, while multiple snapshots of supervisors may capture best teaching practices to feed train-the-trainer programs.

An act of performance: Exploring residents' decision-making processes to seek help

CONTEXT

Residents are expected to ask for help when feeling insufficiently confident or competent to act in patients' best interests. While previous studies focused on the perspective of supervisor-resident relationships in residents' help-seeking decisions, attention for how the workplace environment and, more specifically, other health care team members influence these decisions is limited. Using a sociocultural lens, this study aimed to explore how residents' decision-making processes to seek help are shaped by their workplace environment.

METHODS

Through a constructivist grounded theory methodology, we purposively and theoretically sampled 18 residents: 9 juniors (postgraduate year 1/2) and 9 seniors (postgraduate year 5/6) at Amsterdam University Medical Centers. Using semi-structured interviews, participating residents' decision-making processes to seek help during patient care delivery were explored. Data collection and analysis were iterative; themes were identified using constant comparative analysis.

RESULTS

Residents described their help-seeking decision-making processes as an 'act of performance': they considered how asking for help could potentially impact their assessments. They described this act of performance as the product of an internal 'balancing act' with at its core the non-negotiable priority for providing safe and high-quality patient care. With this in mind, residents weighed up demonstrating the ability to work independently, maintaining credibility and becoming an accepted member of the health care team when deciding to seek help. This 'balancing act' was influenced by sociocultural characteristics of the learning environment, residents' relationships with supervisors and the perceived approachability of other health care team members.

CONCLUSIONS

This study suggests that sociocultural forces influence residents to experience help-seeking as an act of performance. Especially, a safe learning environment resulting from constructive relationships with supervisors and the approachability of other health care team members lowered the barriers to seek help. Supervisors could address these barriers by having regular conversations with residents about when to seek help.

El estado de la investigación en educación en cirugía general en Colombia (2000-2020): un análisis bibliométrico

Introducción. Se desconoce el estado de la investigación en educación médica en cirugía general (IEMC) en Colombia en el siglo XXI. El objetivo de esta revisión bibliométrica de la literatura es realizar un análisis de las publicaciones relacionadas con la IEMC en Colombia a partir del año 2000. Métodos. Se incluyeron artículos originales, escritos en español o inglés, publicados por grupos de investigación que cuentan al menos con un investigador colombiano como autor principal o coautor. Se definieron variables demográficas e indicadores bibliométricos para cada estudio y autor. Resultados. Un total de 63 estudios fueron incluidos. Estas publicaciones se enfocaron predominantemente en investigación sobre bienestar, enseñanza clínica y simulación a nivel de postgrado. El 36 % de los artículos sobre IEMC fueron publicados en revistas sin indexación (ISI/SCOPUS); 13 artículos (20,6 %) fueron publicados en revistas en el cuartil 1 (Q1). El promedio de citas por artículo fue 9,3. Discusión. La producción intelectual en educación en cirugía en Colombia tiene bajo impacto a nivel internacional. Los hallazgos encontrados pueden ser utilizados para organizar y priorizar la investigación en educación quirúrgica en el país.

Residents Think in the "Now" and Supervisors Think Ahead in the Operating Room. A Survey Study About Task Perception of Residents and Supervising Surgeons

OBJECTIVE

Progressive autonomous task performance is the cornerstone of teaching residents in the operating room, where they are entrusted with autonomy when they meet their supervisors' preferences. To optimize the teaching, supervisors need to be aware of how residents experience parts of the procedure. This study provides insight into how supervisors and residents perceive different tasks of a single surgical procedure.

DESIGN

In this qualitative survey study a cognitive task analysis (CTA) of supervisors and residents for the 47 tasks of an uncemented total hip arthroplasty was executed. Both groups rated the level of attention they would assign to each task and were asked to explain attention scores of 4 or 5.

SETTING

University Medical Centre Groningen (the Netherlands) and its 5 affiliated teaching hospitals.

PARTICIPANTS

Seventeen supervising surgeons and 21 residents.

RESULTS

Normal attention (median attention score 3) was assigned by supervisors to 34 tasks (72.3%) and by residents to 35 tasks (74.5 %). Supervisors rated 12 tasks (25.6%) and residents 9 tasks (19.1%) with a median attention score of 4. In general, supervisors associated high attention with patient outcome and prevention of complications, while residents associated high attention with "effort."

CONCLUSIONS

Supervisors and residents assigned attention to tasks for different reasons. Supervisors think ahead and emphasize patient outcome and prevention of complications when they indicate high attention, while residents think in the "now" and raise attention to execute the tasks themselves. The results of this study allow residents and supervisors to anticipate preferences: residents are able to appreciate why supervisors increase attention to specific tasks, and supervisors obtain information on which tasks require individual guidance of residents. This information can contribute to improve the learning climate in the operating room and task-specific procedural training.

Provoking a Conversation Around Students' and Supervisors' Expectations Regarding Workplace Learning

Construct: This study presents a tool that can facilitate a conversation about students' and supervisors' expectations concerning responsibilities during workplace learning. Background: It is often unclear who is responsible for facilitating learning opportunities in the workplace. In order to increase learning opportunities, it is important that expectations are discussed and alignment is reached between the student's and supervisor's expectations. This study collected and interpreted validity evidence for a tool that aims to provoke such a conversation. Approach: Three types of validity evidence were collected: response process, content, and consequences evidence. Educational leaders, medical teachers, and students of four medical schools were involved. The data collection consisted of cognitive interviews, a modified Delphi approach (with three rounds of inquiry), completed tools, and narrative comments. Findings: This study showed that the expectations of most students and supervisors were not initially aligned. The conversation, for which the tool aims to be a catalyst, facilitated better alignment of expectations about responsibilities during workplace learning. Moreover, the students' perceived degree of consensus and satisfaction after the conversation were very high. Conclusions: This study underlined the relevance and usefulness of a tool that facilitates conversation about expectations regarding responsibilities, potentially enhancing learning opportunities at the workplace.

Trainee-environment interactions that stimulate motivation: A rich pictures study

CONTEXT

Staying motivated when working and learning in complex workplaces can be challenging. When complex environments exceed trainees' aptitude, this may reduce feelings of competence, which can hamper motivation. Motivation theories explain how intrapersonal and interpersonal aspects influence motivation. Clinical environments include additional aspects that may not fit into these theories. We used a systems approach to explore how the clinical environment influences trainees' motivation and how they are intertwined.

METHODS

We employed the rich pictures drawing method as a visual tool to capture the complexities of the clinical environment. A total of 15 trainees drew a rich picture representing a motivating situation in the workplace and were interviewed afterwards. Data collection and analysis were performed iteratively, following a constructivist grounded theory approach, using open, focused and selective coding strategies as well as memo writing. Both drawings and the interviews were used to reach our results.

RESULTS

Trainees drew situations pertaining to tasks they enjoyed doing and that mattered for their learning or patient care. Four dimensions of the environment were identified that supported trainees' motivation. First, social interactions, including interpersonal relationships, supported motivation through close collaboration between health care professionals and trainees. Second, organisational features, including processes and procedures, supported motivation when learning opportunities were provided or trainees were able to influence their work schedule. Third, technical possibilities, including tools and artefacts, supported motivation when tools were used to provide trainees with feedback or trainees used specific instruments in their training. Finally, physical space supported motivation when the actual setting improved the atmosphere or trainees were able to modify the environment to help them focus.

CONCLUSIONS

Different clinical environment dimensions can support motivation and be modified to create optimal motivating situations. To understand motivational dynamics and support trainees to navigate through postgraduate medical education, we need to take all clinical environment dimensions into account.

The regulation of learning in clinical environments: A comment on 'Beyond the self'

In this commentary, the authors highlight the importance of analyzing real time social interactions to discover strategies clinical students and residents use to self‐ and co‐regulate their learning.

Exploring the evolving concept of 'patient ownership' in the era of resident duty hour regulations-experience of residents and faculty in an internal medicine night float system

BACKGROUND

Despite the use of 'patient ownership' as an embodiment of professionalism and increasing concerns over its loss among trainees, how its development in residents has been affected by duty hour regulations has not been well described. In this qualitative study, we aim to outline the key features of patient ownership in internal medicine, factors enabling its development, and how these have been affected by the adoption of a night float system to comply with duty hour regulations.

METHODS

In this qualitative descriptive study, we interviewed 18 residents and 12 faculty internists at one university centre and conducted a thematic analysis of the data focused on the concept of patient ownership.

RESULTS

We identified three key features of patient ownership: personal concern for patients, professional capacity for autonomous decision-making, and knowledge of patients' issues. Within the context of a night float system, factors that facilitate development of patient ownership include improved fitness for duty and more consistent interactions with patients/families resulting from working the same shift over consecutive days (or nights). Conversely, the increase in patient handovers, if done poorly, is a potential threat to patient ownership development. Trainees often struggle to develop ownership when autonomy is not supported with supervision and when role-modelling by faculty is lacking.

DISCUSSION

These features of patient ownership can be used to frame discussions when coaching trainees. Residency programs should be mindful of the downstream effects of shift-based scheduling. We propose strategies to optimize factors that enable trainee development of patient ownership.

Disentangling residents' engagement with communities of clinical practice in the workplace

Maximising the potential of the workplace as a learning environment entails understanding the complexity of its members' interactions. Although some articles have explored how residents engage with supervisors, nurses and pharmacists individually, there is little research on how residents enter into and engage with the broader community of clinical practice (CoCP). To this end, we designed a constructivist grounded theory study that took place at Universidad Javeriana in Bogotá, Colombia. We conducted semi-structured interviews with 13 residents from different training levels and disciplines during the first weeks of their new rotations. During the interviews, we used the Pictor technique as a visual aid to collect data. Using iterative data collection and analysis, constant comparison methods and theoretical sampling, we constructed the final results. When entering a CoCP, residents experienced recurring and intertwined processes including: exploring how their goals and interest are aligned with those of the CoCP; identifying the relevant CoCP members in the workplace environment; and understanding how these members could assist their successful engagement with the community's practices. Residents entered a CoCP with the intention of either having a central or a peripheral trajectory in it. The final resident participation and role resulted from negotiations between the resident and the CoCP members. Optimising workplace learning includes being mindful as to how each member of the healthcare team influence residents' engagement on practice, and on understanding the nuances of residents' participatory trajectories while interacting with them. Understanding such nuances could be key to align CoCPs' learning affordances and residents' goals and intentions.

Beyond mistreatment: Learner neglect in the clinical teaching environment

Medical student mistreatment has been recognized as a deterrent to education as it interferes with the learning process and contributes to student burnout and attrition. Medical schools and leaders in undergraduate medical education have expended tremendous effort in addressing this phenomenon in hopes of eradicating mistreatment. However, there is a spectrum of behaviors that negatively impact the learning environment beyond that which is considered frank mistreatment. In this conceptual article, the authors propose the concept of learner neglect for the consideration by educators and researchers. This is a term for a range of behaviors exhibited intentionally or unintentionally by a supervisor that prevent a learner from reaching his or her potential. While the behaviors may overlap with mistreatment, they do not always fit within the definition of mistreatment. This concept is illustrated in the context of optimal and suboptimal teaching behaviors that commonly occur within the ecosystem of clinical education. Descriptions and examples are provided for both intentional and unintentional learner neglect. The authors hypothesize possible short- and long-term impacts of learner neglect, describe contributors to its prevalence, and offer questions for key stakeholders to consider in an effort to recognize, study, and ameliorate this issue within medical education programs.

How postgraduate trainees from different health professions experience the learning climate within an operating theater: a mixed-methods study

BACKGROUND

The learning climate within a learning environment is a key factor to determine the potential quality of learning. There are different groups of postgraduate trainees who study primarily in the operating theater (OT), which is a complex, high-stake environment. This study created and validated an interprofessional measure of the OT educational climate and explored how postgraduate trainees from different health professions experienced the learning climate within the operating theater.

METHODS

An explanatory, sequential mixed-method design was used. The quantitative phase used and validated a newly developed questionnaire, the Operating Theater Educational Climate Test (OTECT), to evaluate the perceptions of anesthesia residents, surgical residents and student registered nurse anesthetists. In the qualitative phase, three mono-professional focus groups participants' opinions on the factors influencing their learning climate were explored.

RESULTS

The OTECT questionnaire was found to be valid. The questionnaire response rate was 78.9% (142 respondents from 180). Questionnaire results indicated similar perceptions of the OT learning climate by learners from all disciplines. Focus groups revealed three major influencing factors on the experienced learning climate: 1) nature of work in the OT, 2) the role of the supervisor, and 3) the interprofessional dimension of work in the OT.

CONCLUSIONS

The OT learning climate was perceived similarly by trainees from three health profession. The high stakes nature of the OT inhibited learning most as it impacted both trainees and supervisors. The results can be applied to improve the overall learning environment in the OT for all groups of learners.

Learning and professional acculturation through work: Examining the clinical learning environment through the sociocultural lens

Purpose: We examined studies of the clinical learning environment from the fields of sociology and organizational culture to (i) offer insight into how workplace culture has informed research on postgraduate trainee learning and professional development; (ii) highlight limitations of the literature; and (iii) suggest practical ways to apply sociocultural concepts to challenges in the learning environment. Materials and methods: Concepts were explored by participants at a consensus conference in October 2018. Results: We identified three enduring foci for research using a sociocultural lens: the hidden curriculum, exploration of medical errors, and the impact of time pressures on the relational nature of clinical education. Limitations included the lower value attributed to informal learning and a pejorative valuation of the hidden curriculum; and disconnect between practices in clinical settings and the priorities of the larger organization. Conclusions: Research on the learning environment using a sociocultural lens suggest workplace goals, norms and practices determined which learners engage in learning-relevant activities, to what extent, and the degree of guidance provided, with these factors creating "tacit" curricula that may support or compete with formal learning goals. We close with guidance on how sociocultural constructs could inform research to improve the learning environment.

Supervised workplace learning in postgraduate training: a realist synthesis

Context

This paper presents a realist synthesis of the literature that began with the objective of developing a theory of workplace learning specific to postgraduate medical education (PME). As the review progressed, we focused on informal learning between trainee and senior doctor or supervisor, asking what mechanisms occur between trainee and senior doctor that lead to the outcomes of PME, and what contexts shape the operation of these mechanisms and the outcomes they produce?

Methods

We followed the procedures outlined in the RAMESES Publication Standards for Realist Synthesis. We searched the English‐language literature published between 1995 and 2017 for empirical papers related to informal workplace learning between supervisor and trainee, excluding formal interventions such as workplace‐based assessment. We made a pragmatic decision to exclude general practice training to keep the review within manageable limits.

Results

We reviewed 5197 papers and selected 90. Synthesis revealed three workplace learning processes occurring between supervisors and trainees, each underpinned by a pair of mechanisms: supervised participation in practice (entrustment and support seeking); mutual observation of practice (monitoring and modelling), and dialogue during practice (meaning making and feedback). These mechanisms result in outcomes of PME, including safe participation in practice, learning skills, attitudes and behaviours and professional identity development. Contexts shaping the outcomes of these mechanisms were identified at individual, interpersonal, local and systems levels.

Conclusions

Our realist theory of workplace learning between supervisors and trainees is informed by theory and empirical research. It highlights the two‐way nature of supervision, the importance of trainees’ agency in their own learning and the deleterious effect of fragmented working patterns on supervisor–trainee learning mechanisms. Further empirical research is required to test and refine this theory. In the meantime, it provides a useful framework for the design of supportive learning environments and for the preparation of supervisors and trainees for their roles in workplace learning.

The authors describe a realist theory of learning between supervisor and postgraduate trainee in the workplace, emphasising the role of individual, interpersonal, local and systems contexts in shaping key mechanisms and their outcomes.

Unravelling residents' and supervisors' workplace interactions: an intersubjectivity study

CONTEXT

Successful engagement between residents and supervisors lies at the core of workplace learning, a process that is not exempt from challenge. Clinical encounters have unique learning potential as they offer opportunities to achieve a shared understanding between the resident and supervisor of how to accomplish a common goal. How residents and supervisors develop such a mutual understanding is an issue that has received limited attention in the literature. We used the 'intersubjectivity' concept as a novel conceptual framework to analyse this issue.

METHODS

We conducted a constructivist grounded theory study in an anaesthesiology department in Bogota, Colombia, using focus groups and field observations. Eleven residents of different training levels and 18 supervisors with varying years of teaching experience participated in the study. Through iterative data analysis, collection and constant comparison, we constructed the final results.

RESULTS

We found that residents and supervisors achieved a shared understanding by adapting to one another in the process of providing patient care. Continuous changes in the composition of resident-supervisor dyads exposed them to many procedural variations, to which they responded by engaging in various adaptation patterns that included compliance by residents with supervisors' directions, negotiation by residents of supervisors' preferences, and the sharing of decision making. In the process, the resident played an increasingly key role as a member of the supervisory dyad. Additionally, experiencing these adaptation patterns repeatedly resulted in the creation of a working repertoire: an attuned working code used by the members of each supervisory dyad to work together as a team.

CONCLUSIONS

The development of shared understanding between residents and supervisors entailed experiencing diverse adaptation patterns which resulted in the creation of working repertoires. Seeing supervisory interactions as adaptation processes has essential theoretical and practical implications regarding workplace learning in postgraduate settings. Our findings call for further exploration to understand learning in postgraduate education as a social process.

Context matters when striving to promote active and lifelong learning in medical education

WHERE DO WE STAND NOW?: In the 30 years that have passed since The Edinburgh Declaration on Medical Education, we have made tremendous progress in research on fostering 'self-directed and independent study' as propagated in this declaration, of which one prime example is research carried out on problem-based learning. However, a large portion of medical education happens outside of classrooms, in authentic clinical contexts. Therefore, this article discusses recent developments in research regarding fostering active learning in clinical contexts.

SELF-REGULATED, LIFELONG LEARNING IN MEDICAL EDUCATION

Clinical contexts are much more complex and flexible than classrooms, and therefore require a modified approach when fostering active learning. Recent efforts have been increasingly focused on understanding the more complex subject of supporting active learning in clinical contexts. One way of doing this is by using theory regarding self-regulated learning (SRL), as well as situated learning, workplace affordances, self-determination theory and achievement goal theory. Combining these different perspectives provides a holistic view of active learning in clinical contexts. ENTRY TO PRACTICE, VOCATIONAL TRAINING AND CONTINUING PROFESSIONAL DEVELOPMENT: Research on SRL in clinical contexts has mostly focused on the undergraduate setting, showing that active learning in clinical contexts requires not only proficiency in metacognition and SRL, but also in reactive, opportunistic learning. These studies have also made us aware of the large influence one's social environment has on SRL, the importance of professional relationships for learners, and the role of identity development in learning in clinical contexts. Additionally, research regarding postgraduate lifelong learning also highlights the importance of learners interacting about learning in clinical contexts, as well as the difficulties that clinical contexts may pose for lifelong learning. However, stimulating self-regulated learning in undergraduate medical education may also make postgraduate lifelong learning easier for learners in clinical contexts.

A Cognitive Apprenticeship-Based Faculty Development Intervention for Emergency Medicine Educators

In just a few years of preparation, emergency medicine (EM) trainees must achieve expertise across the broad spectrum of skills critical to the practice of the specialty. Though education occurs in many contexts, much learning occurs on the job, caring for patients under the guidance of clinical educators. The cognitive apprenticeship framework, originally described in primary and secondary education, has been applied to workplace-based medical training. The framework includes a variety of teaching methods: scaffolding, modeling, articulation, reflection, and exploration, applied in a safe learning environment. Without understanding these methods within a theoretical framework, faculty may not apply the methods optimally. Here we describe a faculty development intervention during which participants articulate, share, and practice their own applications of cognitive-apprenticeship methods to learners in EM. We summarize themes identified by workshop participants, and provide suggestions for tailoring the application of these methods to varying levels of EM learners. The cognitive-apprenticeship framework allows for a common understanding of the methods used in clinical teaching toward independence. Clinical educators should be encouraged to reflect critically on their methods, while being offered the opportunity to share and learn from others.

Improvement in Context: Exploring Aims, Improvement Priorities, and Environmental Considerations in a National Sample of Programs Using "Small Data"

BACKGROUND

In 2013, the Accreditation Council for Graduate Medical Education (ACGME) transitioned into a new accreditation system to reduce burden, focus on outcomes, and promote innovation and improvement. One component is a self-study that includes aims, an environmental assessment, and setting improvement priorities. The ACGME initiated voluntary site visits following the self-study.

OBJECTIVE

We explored common themes in program aims and assessment of their environment.

METHODS

Using grounded theory, inductive and deductive qualitative methods, and truth grounding, we analyzed data from voluntary site visits of 396 core and subspecialty programs between June 2015 and September 2017, with a focus on common themes.

RESULTS

We report common themes for aims and the dimensions of the environmental assessment. Themes for strengths include a collegial, supportive learning environment; responsive leaders; and experiences that prepare residents for unsupervised practice. Improvement priorities encompass low learner engagement and "content mismatch" in didactic education, balancing education and service at a time of growing clinical volumes, and improving the utility of assessment systems. Common opportunities encompass collaborations that improve education, involving alumni and harnessing technology to enrich education, while threats include an unsustainable effort for many program leaders, clinical pressures on faculty, and loss of external sites important for education. Linked dimensions of the environmental assessment suggest benefit in a growing focus on learners, and approaches to ensure a humanistic learning environment that allows for growth, self-determination, and inclusion.

CONCLUSIONS

The findings highlight actionable themes for the environmental assessment. We discuss implications for programs, institutions, and the ACGME.