'I feel like I sleep here': how space and place influence medical student experiences

Bridging School and Practice? Barriers to the Integration of 'Boundary Objects' for Learning and Assessment in Clinical Nursing Education

Introduction

In clinical health professions education, portfolios, assignments and assessment standards are used to enhance learning. When these tools fulfill a bridging function between school and practice, they can be considered 'boundary objects'. In the clinical setting, these tools may be experienced as time-consuming and lacking value. This study aimed to investigate the barriers to the integration of boundary objects for learning and assessment from a Cultural-Historical Activity Theory (CHAT) perspective in clinical nursing education.

Methods

Nineteen interviews and five observations were conducted with team leads, clinical educators, supervisors, students, and teachers to obtain insight into intentions and use of boundary objects for learning and assessment. Boundary objects (assessment standards, assignments, feedback/reflection/patient care/development plan templates) were collected. The data collection and thematic analysis were guided by CHAT.

Results

Barriers to the integration of boundary objects included: a) conflicting requirements in clinical competency monitoring and assessment, b) different application of analytical skills, and c) incomplete integration of boundary objects for self-regulated learning into supervision practice. These barriers were amplified by the simultaneous use of boundary objects for learning and assessment. Underlying contradictions included different objectives between school and practice, and tensions between the distribution of labor in the clinical setting and school's rules.

Discussion

School and practice have both convergent and divergent priorities around students' clinical learning. Boundary objects can promote continuity in learning and increase students' understanding of clinical practice. However, effective integration requires for flexible rules that allow for collaborative learning around patient care.

Placement or displacement: An ethnographic study of space in the clinical learning environment

PURPOSE

This paper aims to examine the spatial attributes in the hospital ward environment and their impact on medical students' learning and experience of the clinical workplace.

MATERIALS AND METHODS

An ethnographic study was conducted in a Scottish teaching hospital, combining observations and interviews over a period of 10 months. Two teaching wards served as the field-sites where approximately 120 h of non-participant observations took place sequentially. In addition, 34 individual interviews were conducted with identified key informants that included medical students, junior doctors, postgraduate trainees, consultant supervisors, ward nurses and hospital pharmacist. A combination of Actor-network Theory (ANT) and Social cognitive theory (SCT) was applied to analyse data pertaining to spatial attributes and their relevance to clinical teaching and learning.

RESULTS

Analysis of the observational and interview data led to generation of the following themes: spatial attributes in the clinical workplace can enable or constrain teaching and learning opportunities, inadequate spaces impact students' and junior doctors' sense of value, short clinical rotations influence a sense of ownership of doctors' spaces, and contested nature of space in the clinical environment. Several illustrations of the field-sites help to contextualise the themes and aid in understanding the participants' experiences and perceptions.

CONCLUSIONS

Our findings suggest a complex entanglement of space with medical students learning and wellbeing in the clinical workplace. Provision of suitable spaces needs to be a core consideration to realise the full potential of work-based learning in medicine.

Home Away from Home: How Undergraduate and Graduate Students Experience Space and Place in a new Health Sciences Building

Buildings contribute in crucial ways to how students experience learning spaces. Four schools within a faculty (nursing, nutrition, occupational and public health, and midwifery) moved into a new Health Sciences building Fall of 2019. This new building created a unique opportunity to explore the intersection between higher education and learning space design, informed by concepts of space and place, and students' profession specific and interprofessional learning experiences in a new Health Sciences building. A qualitative descriptive design was used. All undergraduate and graduate students within the four schools were invited to participate. Focus groups were undertaken to gain a rich understanding of students' experiences and views of their space and place of learning. Data collection involved focus group data from profession specific participant users and interprofessional participant users. Inductive thematic analysis of focus group transcripts generated an initial coding scheme, key themes, and data patterns. Codes were sorted into categories and then organized into meaningful clusters. A building planning development project document relating to the vision, intentions, design, and planning for the new building provided content from which to view the study findings. The study data contributed to the conversation about space and place and its influence on higher learning within specific intraprofessional and interprofessional student groups and provided insight into the process of actualizing a vision for a new learning space and the resultant experiences and perceptions of students within that space/place.

Analysis of physical learning spaces in a university hospital: A case study

BACKGROUND

Attributes of physical learning spaces can facilitate or hinder learning. There are few studies about this topic in hospitals. The objective of this study was to explore the characteristics of physical learning spaces in a university hospital.

METHODS

The setting was a large research-oriented public university hospital in Mexico City, affiliated with the National Autonomous University of Mexico. An intrinsic case study design was conducted with two instruments: a questionnaire to identify physical learning spaces and their attributes; the Learning Space Rating System (LSRS), an instrument used to evaluate spaces' characteristics that promote effective learning.

RESULTS

49 medical students and 60 internal medicine residents responded to the questionnaire. The attributes with the highest importance for students were: instructor physical availability, silence, comfort of the seating furniture, and Internet access. The study authors directly performed an evaluation of the learning spaces using the LSRS tool, the sections' scores were: clinical ward discussion room (74%), external consultation unit (71%), auditorium (70%), classroom (68%), library (66%), and the hospitalization room (61%).

CONCLUSIONS

Physical learning spaces in medical training can be formally assessed to identify the attributes that students consider relevant for learning and provide needed information for redesign and reuse of spaces. Medical education scholars and trainees should be involved in the design and evaluation of university and hospital buildings.

The visual vernacular: embracing photographs in research

The increasing use of digital images for communication and interaction in everyday life can give a new lease of life to photographs in research. In contexts where smartphones are ubiquitous and many people are "digital natives", asking participants to share and engage with photographs aligns with their everyday activities and norms more than textual or analogue approaches to data collection. Thus, it is time to consider fully the opportunities afforded by digital images and photographs for research purposes. This paper joins a long-standing conversation in the social science literature to move beyond the "linguistic imperialism" of text and embrace visual methodologies. Our aim is to explain the photograph as qualitative data and introduce different ways of using still images/photographs for qualitative research purposes in health professions education (HPE) research: photo-documentation, photo-elicitation and photovoice, as well as use of existing images. We discuss the strengths of photographs in research, particularly in participatory research inquiry. We consider ethical and philosophical challenges associated with photography research, specifically issues of power, informed consent, confidentiality, dignity, ambiguity and censorship. We outline approaches to analysing photographs. We propose some applications and opportunities for photographs in HPE, before concluding that using photographs opens up new vistas of research possibilities.

'Whispers and shadows': A critical review of the professional identity literature with respect to minority physicians

OBJECTIVES

Professional identity formation (PIF) is a growing area of research in medical education. However, it is unclear whether the present research base is suitable for understanding PIF in physicians considered to be under-represented in medicine (URM). This meta-ethnography examined the qualitative PIF literature from 2012 to 2019 to assess its capacity to shine light on the experiences of minoritised physicians.

METHODS

Data were gathered using a search of six well-known medical education journals for the term 'professional identit*' in titles, keywords, abstracts and subheadings, delineated with the date range of 2012-2019. All non-relevant abstracts were removed and papers were then further reduced to those that focused only on learners' experiences. This left 67 articles in the final dataset, which were analysed using a collaborative approach among a team of researchers. The team members used their professional expertise as qualitative researchers and personal experiences as minoritised individuals to synthesise and interpret the PIF literature.

RESULTS

Four conceptual categories were identified as impacting PIF: Individual versus Sociocultural Influences; the Formal versus the Hidden Curriculum; Institutional versus Societal Values; and Negotiation of Identity versus Dissonance in Identity. However, a major gap was identified; only one study explored experiences of PIF in URM physicians and there was an almost complete absence of critical stances used to study PIF. Combined, these findings suggest that PIF research is building on existing theories without questioning their validity with reference to minoritised physicians.

CONCLUSIONS

From a post-colonial perspective, the fact that race and ethnicity have been largely absent, invisible or considered irrelevant within PIF research is problematic. A new line of inquiry is needed, one that uses alternative frameworks, such as critical theory, to account for the ways in which power and domination influence PIF for URM physicians in order to foreground how larger sociohistorical issues influence and shape the identities of minoritised physicians.

Change is never easy: How management theories can help operationalise change in medical education

CONTEXT

Medical education is neither simple nor stable, and is highly contextualised. Hence, ways of perceiving multiple connections and complexity are fundamental when seeking to describe, understand and address concerns and questions related to change.

PROPOSAL

In response to calls in the literature, we introduce three examples of contemporary organisational theory which can be used to understand and operationalise change within medical education. These theories, institutional logics, paradox theory and complexity leadership theory, respectively, are relatively unknown in medical education. However, they provide a way of making sense of the complexity of change creatively. Specifically, they cross-cut different levels of analysis and allow us to 'zoom in' to micro levels, as well as to 'zoom out' and connect what is happening at the individual level (the micro level) to what happens at a wider institutional and even national or international level (the macro level), thereby providing a means of understanding the interactions among individuals, teams, organisations and systems. We highlight the potential value of these theories, provide a brief discussion of the few studies that have used them in medical education, and then briefly critique each theory.

CONCLUSIONS

We hope that by drawing the attention of readers to the potential of these management theories, we can unlock some of the complexity of change in medical education, support new ways of thinking and open new avenues for research.

Doctors' identity transitions: Choosing to occupy a state of 'betwixt and between'

CONTEXT

During transitions, doctors engage in identity work to adapt to changes in multiple domains. Accompanied by this are dynamic 'liminal' phases. Definitions of liminality denote a state of being 'betwixt and between' identities. From a social constructionist perspective, being betwixt and between professional identities may either involve a sense of disrupted self, requiring identity work to move through and out of being betwixt and between (ie, temporary liminality), or refer to the experiences of temporary workers (eg, locum doctors) or those in dual roles (eg, clinician-managers) who find themselves perpetually betwixt and between professional identities (ie, perpetual liminality) and use identity work to make themselves contextually relevant. In the health care literature, liminality is conceptualised as a linear process, but this does not align with current notions of transitions that are depicted as multiple, complex and non-linear.

METHODS

We undertook a longitudinal narrative inquiry study using audio-diaries to explore how doctors experience liminality during trainee-to-trained transitions. In three phases, we: (a) interviewed 20 doctors about his or her trainee-to-trained transitions; (b) collected longitudinal audio-diaries from 17 doctors for 6-9 months, and (c) undertook exit interviews with these 17 doctors. Data were analysed thematically, both cross-sectionally and longitudinally, using identity work theory as an analytical lens.

RESULTS

All participants experienced liminality. Our analysis enabled us to identify temporary and perpetual liminal experiences. Furthermore, fine-grained analysis of participants' identity talk enabled us to identify points in participants' journeys at which he or she rejected identity grants associated with his or her trained status and instead preferred to remain in and thus occupy liminality (ie, neither trainee nor trained doctor).

CONCLUSIONS

This paper is the first to explore longitudinally doctors' liminal experiences through trainee-to-trained transitions. Our findings also make conceptual contributions to the health care literature, as well as the wider interdisciplinary liminality literature, by adding further layers to conceptualisations and introducing the notion of occupying liminality.

Defining Barriers and Facilitators to Advancement for Women in Academic Surgery

IMPORTANCE

Sex equity is elusive in academic surgery departments across the United States. Persistent inequities remain a considerable problem and inhibit professional advancement for female surgeons. Identifying the factors that promulgate sex discrepancies may provide a framework for institutional growth and personal progress for women.

OBJECTIVE

To identify barriers and facilitators to success at the individual and organizational level to develop evidence-based interventions designed to close the sex gap in surgery.

DESIGN, SETTING, AND PARTICIPANTS

This qualitative study included 26 female participants who were current and former surgical faculty employed by Michigan Medicine, the health system of the University of Michigan, between 2000 and 2017. Semistructured personal interviews were conducted from June 28 to September 29, 2017, via telephone. Each interview lasted 45 minutes to 1 hour. Interviews were recorded and then transcribed for analysis.

MAIN OUTCOMES AND MEASURES

The interview included 7 questions referring to the surgeon's experience with the Michigan Medicine Department of Surgery and 7 questions referring to nonspecific areas of interest.

RESULTS

The 26 participants in this study ranged in age from 32 to 64 years, with faculty experience ranging from 3 to 22 years. Thematic analysis was used to locate, analyze, and report patterns within the data related to barriers and facilitators for women in academic medicine. Three major themes were identified by researchers. Participants reported that (1) organizational culture and institutional policies affect opportunities for advancement; (2) relational interactions with leadership, mentors, colleagues, and staff affect promotion and attrition; and (3) individual characteristics mediate the perception of professional and personal success.

CONCLUSIONS AND RELEVANCE

In this qualitative study of 26 female academic surgeons, a complex matrix of organizational and individual factors were found to contribute to sex inequities in academic surgery. This research may provide insight into the sex biases that inhibit advancement, may inform strategies that facilitate progress, and may inspire interventions that could help eliminate institutional and individual barriers to the academic success of women.

Examining the clinical learning environment through the architectural avenue

Medical education has traditionally focused on the learners, the educators, and the curriculum, while tending to overlook the role of the designed environment. Experience indicates, however, that processes and outcomes of medical education are sensitive to the qualities and disposition of the spaces in which it occurs. This includes the clinical education within the patient care environment, termed the clinical learning environment (CLE). Recognition of this has informed the design of some new clinical learning spaces for the past decade. Competency-based clinical education can drive design requirements that differ materially from those associated with general purpose educational or clinical spaces. In this article, we outline two conceptual frameworks: (i) materialist spatiality and (ii) actor-network theory and consider how they can guide the design of spaces to support competency-based medical education and to guide the evaluation and discussion of the educational impacts of the spaces once built. We illustrate the use of these frameworks through discussion of the educational ambitions that underpinned the design of some recent clinical educational spaces. We close with practical points for consideration by educators and designers.