Making decisions "in the dark": Learning through uncertainty in clinical practice during Covid-19

Purpose

The purpose of this study was to explore how decision making and informal and incidental learning (IIL) emerged in the clinical learning environment (CLE) during the height of the Covid-19 pandemic. The authors' specific interest was to better understand the IIL that took place among frontline physicians who had to navigate a CLE replete with uncertainty and complexity with the future goal of creating experiences for medical students that would simulate IIL and use uncertainty as a catalyst for learning.

Method

Using a modified constructivist, grounded theory approach, we describe physicians' IIL while working during times of heightened uncertainty. Using the critical incident technique, we conducted 45-min virtual interviews with seven emergency department (ED) and five intensive care unit (ICU) physicians, who worked during the height of the pandemic. The authors transcribed and restoried each interview before applying inductive, comparative analysis to identify patterns, assertions, and organizing themes.

Results

Findings showed that the burden of decision making for physicians was influenced by the physical, emotional, relational, and situational context of the CLE. The themes that emerged for decision making and IIL were interdependent. Prominent among the patterns for decision making were ways to simplify the problem by applying prior knowledge, using pattern recognition, and cross-checking with team members. Patterns for IIL emerged through trial and error, which included thoughtful experimentation, consulting alternative sources of information, accumulating knowledge, and "poking at the periphery" of clinical practice.

Conclusions

Complexity and uncertainty are rife in clinical practice and this study made visible decision-making patterns and IIL approaches that can be built into formal curricula. Making implicit uncertainty explicit by recognizing it, naming it, and practicing navigating it may better prepare learners for the uncertainty posed by the clinical practice environment.

Informal and Incidental Learning in the Clinical Learning Environment: Learning Through Complexity and Uncertainty During COVID-19

In the time of the COVID-19 pandemic, where clinical environments are plagued by both uncertainty and complexity, the importance of the informal and social aspects of learning among health care teams cannot be exaggerated. While there have been attempts to better understand the nuances of informal learning in the clinical environment through descriptions of the tacit or hidden curriculum, incidental learning in medical education has only been partially captured in the research. Understood through concepts borrowed from the Cynefin conceptual framework for sensemaking, the early stages of the pandemic immersed clinical teams in complex and chaotic situations where there was no immediately apparent relationship between cause and effect. Health care teams had to act quickly amidst the chaos: they had to first act, make sense of, and respond with intentionality. Informal and incidental learning (IIL) emerged as a byproduct of acting with the tools and knowledge available in the moment. To integrate the informal, sometimes haphazard nature of emergence among health care teams, educators require an understanding of IIL. This understanding can help medical educators prepare health professions learners for the cognitive dissonance that accompanies uncertainty in clinical practice. The authors introduce IIL as an explanatory framework to describe how teams navigate complexity in the clinical learning environment and to better inform curricular development for health professions training that prepares learners for uncertainty. While further research in IIL is needed to illuminate tacit knowledge that makes learning explicit for all audiences in the health professions, there are opportunities to cultivate learners' skills in formal curricula through various learning interventions to prime them for IIL when they enter complex clinical learning environments.

The Many Faces of Action Learning

Action Learning draws its roots from different philosophies of learning and change, which in turn, influence its design and practice. This article identifies common factors and differences among three different ‘schools’ of practice (Scientific, Experiential and Critical Reflection). It then distinguishes Action Learning from the other action approaches in this volume.

Trends in Managerial Reinvention

Managers are reinventing business, technology, the corporation, and themselves. This author identifies four trends in managerial reinvention through a review of selected recent journals: renewing entrepreneurial focus, refraining the manager's leadership role, reimagining organizational life, and reconnecting to the socio-political-economic-cultural context. The author then maps challenges for managerial learning in light of the learning organization by examining each trend at four learning levels: individual, team, organizational, and societal. The article concludes with a discussion of challenges common to each learning level for all four trends.

Teams as Learners

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Sculpting the Learning Community: New Forms of Working and Organizing

Schools are communities in which learning is supposed to take place, but they do not always function well as learning communities. The hope for the future is to enhance the likelihood that schools will be designed and run for the kind of learning that is needed in the 21st century, which will surely move far beyond the current knowledge era.

Cross-cultural issues in professional development

Cross-cultural issues pervade choices made in regard to who gets "developed" professionally, for what end, and in what manner. This article is a case study of professional development in a health and family planning project in Nepal. The case study examines issues of interaction between "developers" and "developees," particularly differences in a fundamental way of thinking, influence of the dominant paradigm and ways and means of collaboration in cross-cultural interaction. The author analyzes cross-cultural collaboration in terms of three paradigms for the teaching/learning process: the technical, the interpretive and the strategic. Choice points are identified that required sensitivity to cross-cultural issues. The article concludes with a look at the impact of professional developmental in "developing" countries the building of a new professional identity in paraprofessionals.