Clinical sensemaking: Advancing a conceptual learning model of clinical reasoning.

CONTEXT: Much remains unanswered regarding how clinical reasoning is learned in the clinical environment. This study attempts to unravel how novice medical students learn to reason, by examining how they make sense of the clinical patient encounter. METHOD: The current study was part of a greater research project employing constructivist grounded theory (CGT) to develop a learning model of clinical reasoning. Introducing the sensemaking perspective, as a sensitising concept, we conducted a second level analytic phase with CGT, to further advance our previously developed model. This involved re-examining collected data from semi-structured interviews, participant observations and field interviews of novice students during their early clinical clerkships. RESULTS: A learning model of how medical students make sense of the patient encounter emerged from the analysis. At its core lie three interdependent processes that co-constitute the students' clinical sensemaking activity. Framing the situation is the process whereby students discern salient situational elements, place them into a meaningful relationship and integrate them into a clinical problem. Inquiring into the situation is the process whereby students gain further insight into the situation by determining which questions need to be asked. Lastly, taking meaningful action is the process whereby students carve out a pathway of action, appropriate for the circumstances. Tensions experienced during these processes impair clinical sensemaking. CONCLUSIONS: The study provides an empirically informed learning model of clinical reasoning, during the early curricular stages. The model attempts to capture the complexity of medical practice, as students learn to recognise and respond to what constitutes the essence of a clinical situation. In this way, it contributes to a conceptual shift in how we think and talk about clinical reasoning. It introduces the concept of clinical sensemaking, as the act of carving a tangible clinical problem out of an often undetermined clinical situation and pursuing justified action.

Designing for student autonomy combining theory and clinical practice - a qualitative study with a faculty perspective.

BACKGROUND: Although extensive research exists about students' clinical learning, there is a lack of translation and integration of this knowledge into clinical educational practice. As a result, improvements may not be implemented and thus contribute to students' learning. The present study aimed to explore the nature of clinical faculty members' learning related to how they apply research about student autonomy. METHODS: A course, "Designing learning for students' development of autonomy in clinical practice" was conducted for faculty responsible for students' clinical education. Within the frame of the course the participants designed a project and planned how they would implement it in their clinical context. Fourteen clinical faculty members participated in the study. The participants' interpretation of the educational intervention, which combines complex theory with the equally complex clinical practice, was explored by studying how the participants' approaches and understanding of the facilitation of autonomy were manifested in their projects. The projects in the form of reports and oral presentations were analyzed using qualitative content analysis together with an abductive approach. FINDINGS: One identified domain was "Characteristics of the design and content of the projects". This domain was signified by two themes with different foci: Preparing the soil for facilitating student autonomy; and Cultivating opportunities for students to actively strive for autonomy. A second identified domain, "Embracing the meaning of facilitating autonomy" was connected to participants understanding of theories underlying how to support the development of autonomy. This domain contained two themes: Connection between activities and autonomy is self-evident and Certain factors can explain and facilitate development of autonomy. CONCLUSION: Education directed to strategic clinical faculty members to develop evidence-based approaches to student learning can be productive. To succeed there is a need to emphasize faculty members individual understanding of actual research as well as learning theories in general. Faculty trying to reinforce changes are dependent on their own mandate, the structure in the clinic, and recognition of their work in the clinical context. To achieve a potential continuity and sustainability of implemented changes the implementation processes must be anchored throughout the actual organization.

An exploration of students' use of digital resources for self-study in anatomy: a survey study.

BACKGROUND: The development of technology has provided new ways for active engagement and for visualizing structures in anatomy education including digital resources that may be used outside of the classroom. To support students' learning, there is a need to better understand students' experiences of using digital resources. This study aimed to identify which resources students use, their preferences, the purpose of using them, and barriers to adopting tools for self-study of anatomy. METHODS: A mixed -methods approach combining qualitative and quantitative data was used to collect and analyse data. Two consecutive cohorts of first-semester medical students (n = 278) were invited to complete an anonymized survey. The survey consisted of itemized questions, free-text space for comments, and one open-ended question. Descriptive statistics were used for demographics and itemized answers. Comments and free-text answers were analysed qualitatively using abductive inference. RESULTS: One hundred and twenty-seven students completed the survey (response rate 45%). Most students (46%) reported that they spend more than 30 h/per week on self-study. They used a variety of digital resources for different purposes. Most students used digital resources to prepare for examinations, when they encountered difficulties and after going through a section. Students reported that they would use digital resources to a greater extent if they were offered an introduction, if resources were more accessible, and if they could interact with a tutor. The free-text responses revealed that digital resources helped students understand anatomy, allowed them to make active choices, provided tools for repetition and memorization, accelerated and simplified the learning process, and complemented other learning resources. CONCLUSIONS: Digital resources may support the understanding of anatomy by offering alternative modes of learning and providing a valuable complement to other learning resources. Educators should consider how digital resources are introduced and offer support and feedback.

Safeguarding fairness in assessments-How teachers develop joint practices.

INTRODUCTION: In light of reforms demanding increased transparency of student performance assessments, this study offers an in-depth perspective of how teachers develop their assessment practice. Much is known about factors that influence assessments, and different solutions claim to improve the validity and reliability of assessments of students' clinical competency. However, little is known about how teachers go about improving their assessment practices. This study aims to contribute empirical findings about how teachers' assessment practice may change when shared criteria for assessing students' clinical competency are developed and implemented. METHODS: Using a narrative-in-action research approach grounded in narrative theory about human sense-making, one group including nine health professions teachers was studied over a period of 1 year. Drawing upon data from observations, interviews, formal documents and written reflections from these teachers, we performed a narrative analysis to reveal how these teachers made sense of experiences associated with the development and implementation of joint grading criteria for assessing students' clinical performances. RESULTS: The findings present a narrative showing how a shared assessment practice took years to develop and was based on the teachers changed approach to scrutiny. The teachers became highly motivated to use grading criteria to ensure fairness in assessments, but more importantly, to fulfil their moral obligation towards patients. The narrative also demonstrates how these teachers reasoned about dilemmas that arose when they applied standardised assessment criteria. DISCUSSION: The narrative analysis shows clearly how teachers' development and application of assessment standards are embedded in local practices. Our findings highlight the importance of teachers' joint discussions on how to interpret criteria applied in formative and summative assessments of students' performances. In particular, teachers' different approaches to assessing 'pieces of skills' versus making holistic judgements on students' performances, regardless of whether the grading criteria are clear and well-articulated on paper, should be acknowledged. Understanding the journey that these teachers made gives new perspectives as to how faculty can be supported when assessments of professionalism and clinical competency are developed.

Representation, interaction and interpretation. Making sense of the context in clinical reasoning.

BACKGROUND: All thinking occurs in some sort of context, rendering the relation between context and clinical reasoning a matter of significant interest. Context, however, has a notoriously vague and contested meaning. A profound disagreement exists between different research traditions studying clinical reasoning in how context is understood. However, empirical evidence examining the impact (or not) of context on clinical reasoning cannot be interpreted without reference to the meaning ascribed to context. Such meaning is invariably determined by assumptions concerning the nature of knowledge and knowing. The epistemology of clinical reasoning determines in essence how context is conceptualised. AIMS: Our intention is to provide a sound epistemological framework of clinical reasoning that puts context into perspective and demonstrates how context is understood and researched in relation to clinical reasoning. DISCUSSION: We identify three main epistemological dimensions of clinical reasoning research, each of them corresponding to fundamental patterns of knowing: the representational dimension views clinical reasoning as an act of categorisation, the interactional dimension as a cognitive state emergent from the interactions in a system, while the interpretative dimension as an act of intersubjectivity and socialisation. We discuss the main theories of clinical reasoning under each dimension and consider how the implicit epistemological assumptions of these theories determine the way context is conceptualised. These different conceptualisations of context carry important implications for the phenomenon of context specificity and for learning of clinical reasoning. CONCLUSION: The study of context may be viewed as the study of the epistemology of clinical reasoning. Making sense of 'what is going on with this patient' necessitates reading the context in which the encounter is unfolding and deliberating a path of response justified in that specific context. Mastery of the context in this respect becomes a core activity of medical practice.

The extraordinary makes the ordinary visible - nursing students' experiences of their learning in clinical practice during COVID-19: a qualitative study.

BACKGROUND: The COVID-19 crisis had a significant impact on health care and nursing education as a large part of it is carried out in clinical practice. However, it is not known how the learning situations during the pandemic affected students' learning. To deepen the understanding of students' learning, learning theories within a constructive paradigm is used as a framework for this study. The purpose of the study was to explore nursing students´ perceptions of their learning in clinical practice during COVID-19. METHODS: In this interpretative qualitative study, seven focus group discussions were conducted with 21 nursing students at different stages of the nursing programme, all of whom performed clinical practice during the outbreak of COVID-19. The analysis of the discussions was performed with interpretative content analysis related to theoretical assumptions about learning. RESULTS: The learning situation was characterised by chaos and confusion affecting both the students' opportunities to learn and what they learned. Despite the uncertainty the students appreciated having experienced this unique situation, which contributed to valuable learning. Things otherwise taken for granted or not encountered before became visible. The learning processes were characterised by complexity and challenges that hindered or stimulated learning. It depended on the student's approach and the management of the clinical education. Concerns about one´s own and relatives' health, and not being able to finish studies, also affected learning. The students learned about important measures during a pandemic regarding hygiene, care organisation, communication, and the multifaceted role of the nurse. CONCLUSION: Unpredictable situations such as a pandemic can lead to unique learning since "the extraordinary makes the ordinary visible". The students learned things additional to the formal learning outcomes, and the experiences strengthened their will to become nurses. Challenges due to a crisis can become important driving forces for learning, if not experienced as overwhelming. Some students felt they received space for own initiatives and responsibility while others felt lost and abandoned. Preparing for a crisis means preparing for an unknown future. Students therefore need to experience dilemmas and uncertain situations and reflect in a safe environment.

Three-dimensional visualisation of authentic cases in anatomy learning - An educational design study.

BACKGROUND: Many studies have investigated the value of three-dimensional (3D) images in learning anatomy. However, there is a lack of knowledge about students learning processes using technology and 3D images. To understand how to facilitate and support the learning of anatomy, there is a need to know more about the student perspectives on how they can use and benefit from 3D images. METHODS: This study used designed educational sessions informed by Educational Design Research to investigate the role of technology-enhanced 3D images in students' anatomy learning. Twenty-four students representing different health professions and multiple study levels, and one tutor, participated in the study. A visualisation table was used to display the images of real patient cases related to disorders associated with the abdomen and the brain. Students were asked to explore the images on their own and audio/video capture was used to record their words and actions. Directly following the session, students were interviewed about their perceptions and different ways of learning and studying anatomy. The tutor was interviewed about his reflections on the session and his role as a facilitator on two occasions. Content analysis was used in its manifest and latent form in the data analysis. RESULT: Two main categories describing the students' and tutor's accounts of learning using the visualisation table were identified: 1. Interpreting 3D images and 2. Educational sessions using visualisation tables. Each category had signifying themes representing interpretations of the latent meaning of the students' and tutor's accounts. These were: Realism and complexity; Processes of discernment; References to previous knowledge; Exploring on one's own is valuable; Context enhances learning experiences; Combinations of learning resources are needed and Working together affects the dynamics. CONCLUSIONS: This study identifies several important factors to be considered when designing effective and rewarding educational sessions using a visualization table and 3D images in anatomy education. Visualisation of authentic images has the potential to create interest and meaningfulness in studying anatomy. Students need time to actively explore images but also get tutor guidance to understand. Also, a combination of different resources comprises a more helpful whole than a single learning resource.

Lifelong learning and nurses' continuing professional development, a metasynthesis of the literature.

BACKGROUND: Continuing professional development (CPD) is central to nurses' lifelong learning and constitutes a vital aspect for keeping nurses' knowledge and skills up-to-date. While we know about the need for nurses' continuing professional development, less is known about how nurses experience and perceive continuing professional development. A metasynthesis of how nurses experience and view continuing professional development may provide a basis for planning future continuing professional development interventions more effectively and take advantage of examples from different contexts. The aim of this paper is to conduct such a metasynthesis, investigating the qualitative research on nurses' experiences of continuing professional development. METHODS: A metasynthesis of the qualitative literature was conducted. A total of 25 articles fulfilled the inclusion criteria and were reviewed. RESULTS: We determined five overarching themes, Organisational culture shapes the conditions, Supportive environment as a prerequisite, Attitudes and motivation reflect nurse's professional values, Nurses' perceptions of barriers and Perceived impact on practice as a core value. This metasynthesis highlights that nurses value continuing professional development and believe that it is fundamental to professionalism and lifelong learning. Moreover CPD is identified as important in improving patient care standards. CONCLUSIONS: Based on the metasynthesis, we argue that access to continuing professional development could be made more attainable, realistic and relevant. Expediently, organizations should adequately fund and make continuing professional development accessible. In turn, nurses should continue to actively engage in continuing professional development to maintain high standards of nursing care through competent practice. This paper highlights the perceived benefits and challenges of continuing professional development that nurses face and offers advice and understanding in relation to continuing professional development. We believe that this metasynthesis contributes with insights and suggestions that would be valuable for nurses and policy makers and others who are involved in nurse education and continuing professional development.

Grounding judgement in context: A conceptual learning model of clinical reasoning.

CONTEXT: Contemporary research on clinical reasoning focuses on cognitive problem-solving processes. However, the decisive role that clinical context plays in clinical reasoning is often overlooked. We explored how novice learners make sense of the patient encounter in the clinical situation. In particular, we examined medical students' own judgements concerning diagnostic and management decisions and how the clinical context impacts on this. We aimed to produce a conceptual model of how students learn clinical reasoning in the clinical environment. METHOD: We used grounded theory methodology to develop a conceptual learning model. A total of 23 medical students in their third academic year were recruited. Qualitative data were gathered from semi-structured interviews, participant observations and field interviews, during clinical clerkships. RESULTS: Learners participating in the clinical environment experienced tensions, called 'Disjunctions.' These disjunctions emerged in the context of the student-patient encounter and in particular in situations where an element from the interaction with the patient was perceived as being inconsistent with existing frames of reference. We categorised the sources of disjunctions into four subcategories: (a) observing the manifestations of clinical signs in reality; (b) fitting the symptoms to a diagnosis; (c) considering management decisions, and (d) communicating a medical decision to the patient. Disjunctions involved an affective component and were associated with feelings of uncertainty. These tensions provoked reactions from the learners, leading them to reassess and modify held assumptions in order to accommodate the encountered inconsistent elements. This facilitated changes in judgement. When making a judgement, participants learned to take into consideration situational elements. CONCLUSIONS: Students experience disjunctions in the clinical environment as they encounter situations that challenge their frames of reference. These disjunctions carry significant learning potential. This study can contribute to knowledge concerning the role of the patient encounter in advancing clinical reasoning by transforming problematic habits of the mind.

Longitudinal mentorship to support the development of medical students' future professional role: a qualitative study.

BACKGROUND: Mentoring has been employed in medical education in recent years, but there is extensive variation in the published literature concerning the goals of mentoring and the role of the mentor. Therefore, there is still a need for a deeper understanding of the meaning of mentoring for medical students' learning and development. The aim of this qualitative study is to explore how formal and longitudinal mentoring can contribute to medical students' professional development. METHODS: Sixteen medical students at a Swedish university were interviewed individually about their experiences of combined group and one-to-one mentoring that is given throughout their studies. The mentoring programme was focused on the non-medical skills of the profession and used CanMEDS roles of a physician for students' self-assessment. Data were analysed using a latent, interpretive approach to content analysis. RESULTS: The results comprise three themes: Integrating oneself with one's future role as a physician, Experiencing clinical reality with the mentor creates incentives to learn and Towards understanding the professional competence of a physician. The mentorship enabled the students to create a view of their future professional role and to integrate it with their own personalities. The students' understanding of professional competence and behaviour evolved during the mentorship and they made advances towards understanding the wholeness of the profession. This approach to mentorship supported different components of the students' professional development; the themes Integrating oneself with one's future role and Towards understanding the professional competence of a physician can be regarded as two parallel processes, while the third theme, Experiencing clinical reality with the mentor creates incentives to learn, promotes these processes. CONCLUSIONS: Formalized and longitudinal mentoring focusing on the non-medical skills can be recommended to help medical students to integrate their professional role with themselves as individuals and promote understanding of professional competence in the process of becoming a physician.

Clinical supervision in primary health care; experiences of district nurses as clinical supervisors - a qualitative study.

BACKGROUND: Learning in the clinical environment is an important part of nursing education. Several recent studies focusing on clinical learning have been based on hospital settings. Little is known about primary health care (PHC) as clinical environment where district nurses (DNs) or nurses supervise students. It is important to understand more about opportunities and difficulties in supervising in this area in order to develop PHC as an optimal learning environment for nursing students. The main objective of this study was to gain an understanding of supervisors' experiences of supervising undergraduate students at PHC units. METHODS: A qualitative research approach was used to collect data and analyse supervisors' experiences. Six focus groups were carried out with 24 supervisors. Focus group data were audio-taped. The data were analysed using an inductive content analysis. RESULTS: Three themes illustrated supervisors' experiences: abandonment, ambivalence and sharing the holistic approach. Supervisors felt abandoned by their managers, colleagues and nurse teachers from universities. They experienced ambivalence due to simultaneously being supervisors for students and carrying out their daily work with patients. At the same time, they were proud to be DNs and willing to share their unique role to apply a holistic approach and continuity in patient care with students. CONCLUSION: When supervising students in PHC, social support and communication between supervisors and their colleagues and management as well as nurse teachers need to be taken into consideration both at universities and at primary health care units.

Supervisors' pedagogical role at a clinical education ward - an ethnographic study.

BACKGROUND: Clinical practice is essential for health care students. The supervisor's role and how supervision should be organized are challenging issues for educators and clinicians. Clinical education wards have been established to meet these challenges and they are units with a pedagogical framework facilitating students' training in real clinical settings. Supervisors support students to link together theoretical and practical knowledge and skills. From students' perspectives, clinical education wards have shown potential to enhance students' learning. Thus there is a need for deeper understanding of supervisors' pedagogical role in this context. We explored supervisors' approaches to students' learning at a clinical education ward where students are encouraged to independently take care of patients. METHOD: An ethnographic approach was used to study encounters between patients, students and supervisors. The setting was a clinical education ward for nursing students at a university hospital. Ten observations with ten patients, 11 students and five supervisors were included in the study. After each observation, individual follow-up interviews with all participants and a group interview with supervisors were conducted. Data were analysed using an ethnographic approach. RESULTS: Supervisors' pedagogical role has to do with balancing patient care and student learning. The students were given independence, which created pedagogical challenges for the supervisors. They handled these challenges by collaborating as a supervisory team and taking different acts of supervision such as allowing students their independence, being there for students and by applying patient-centredness. CONCLUSION: The supervisors' pedagogical role was perceived as to facilitate students' learning as a team. Supervisors were both patient- and student-centred by making a nursing care plan for the patients and a learning plan for the students. The plans were guided by clinical and pedagogical guidelines, individually adjusted and followed up.

Outcome based education enacted: teachers' tensions in balancing between student learning and bureaucracy.

This paper reports on how teachers within health sciences education translate outcome-based education (OBE) into practice when they design courses. The study is an empirical contribution to the debate about outcome- and competency-based approaches in health sciences education. A qualitative method was used to study how teachers from 14 different study programmes designed courses before and after OBE was implemented. Using an interpretative approach, analysis of documents and interviews was carried out. The findings show that teachers enacted OBE either to design for more competency-oriented teaching-learning, or to further detail knowledge and thus move towards reductionism. Teachers mainly understood the outcome-based framework as useful to support students' learning, although the demand for accountability created tension and became a bureaucratic hindrance to design for development of professional competence. The paper shows variations of how teachers enacted the same outcome-based framework for instructional design. These differences can add a richer understanding of how outcome- or competency-based approaches relate to teaching-learning at a course level.

Patients' approaches to students' learning at a clinical education ward--an ethnographic study.

BACKGROUND: It is well known that patients' involvement in health care students' learning is essential and gives students opportunities to experience clinical reasoning and practice clinical skills when interacting with patients. Students encounter patients in different contexts throughout their education. However, looking across the research providing evidence about learning related to patient-student encounters reveals a lack of knowledge about the actual learning process that occurs in encounters between patients and students. The aim of this study was to explore patient-student encounters in relation to students' learning in a patient-centered health-care setting. METHODS: An ethnographic approach was used to study the encounters between patients and students. The setting was a clinical education ward for nursing students at a university hospital with eight beds. The study included 10 observations with 11 students and 10 patients. The observer followed one or two students taking care of one patient. During the fieldwork observational and reflective notes were taken. After each observation follow-up interviews were conducted with each patient and student separately. Data were analyzed using an ethnographic approach. RESULTS: The most striking results showed that patients took different approaches in the encounters with students. When the students managed to create a good atmosphere and a mutual relationship, the patients were active participants in the students' learning. If the students did not manage to create a good atmosphere, the relationship became one-way and the patients were passive participants, letting the students practice on their bodies but without engaging in a dialogue with the students. CONCLUSIONS: Patient-student encounters, at a clinical education ward with a patient-centred pedagogical framework, can develop into either a learning relationship or an attending relationship. A learning relationship is based on a mutual relationship between patients and students resulting in patients actively participating in students' learning and they both experience it as a joint action. An attending relationship is based on a one-way relationship between patients and students resulting in patients passively participating by letting students to practice on their bodies but without engaging in a learning dialogue with the students.

Students' experiences of learning manual clinical skills through simulation.

Learning manual skills is a fundamental part of health care education, and motor, sensory and cognitive learning processes are essential aspects of professional development. Simulator training has been shown to enhance factors that facilitate motor and cognitive learning. The present study aimed to investigate the students' experiences and thoughts about their learning through simulation skills training. The study was designed for an educational setting at a clinical skills centre. Ten third-year undergraduate nursing students performed urethral catheterisation, using the virtual reality simulator UrecathVision™, which has haptic properties. The students practised in pairs. Each session was videotaped and the video was used to stimulate recall in subsequent interviews. The interviews were analysed using qualitative content analysis. The analysis from interviews resulted in three themes: what the students learn, how the students learn, and the simulator's contribution to the students' learning. Students learned manual skills, how to perform the procedure, and professional behaviour. They learned by preparing, watching, practising and reflecting. The simulator contributed by providing opportunities for students to prepare for the skills training, to see anatomical structures, to feel resistance, and to become aware of their own performance ability. The findings show that the students related the task to previous experiences, used sensory information, tested themselves and practised techniques in a hands-on fashion, and reflected in and on action. The simulator was seen as a facilitator to learning the manual skills. The study design, with students working in pairs combined with video recording, was found to enhance opportunities for reflection.

Children's experiences of a participation approach to asthma education.

AIM AND OBJECTIVES: To explore the participation and responses of children to an asthma education programme that was developed with the aid of children with asthma. In a larger perspective, the aim was to understand how educational approaches can be designed to help children learn to live and cope with asthma. BACKGROUND: A literature search showed that programmes where children participate in the development of educational materials or programmes are lacking. DESIGN: An exploratory descriptive design was chosen to get an in-depth understanding of the communication and collaboration between children and healthcare personnel. METHODS: Data were collected through observations, tape recordings of the conversations and notes of the interactions between the children and the healthcare personnel and analysed by content analysis. RESULTS: The significance of the asthma education programme emerged in four themes: (i) children are learning from each other: in a positive learning climate, the children were able to express emotional themes that they may not have communicated before; (ii) children are learning through an interaction with the educational material: the children discussed stories and pictures in a fellow interplay: when one child expressed something, another child would recognise it and continue the story; (iii) children are learning from their interaction with healthcare personnel and vice versa: adjusting the vocabulary according to the children's experiences, they were met on their level of understanding; and (iv) children can express and discuss their understanding of asthma. CONCLUSIONS: The unique aspect about this programme is that it emanates from children's perspectives. The children were actively involved and learnt from each other's shared knowledge and experiences, which is a good source of meaningful learning and empowering processes. RELEVANCE TO CLINICAL PRACTICE: Future educational approaches should use children's perspectives in a manner in which their questions, thoughts and daily challenges are emphasised.

Students' learning in clinical practice - a scoping review of characteristics of research in the Nordic countries.

RATIONALE: The complex nature of student learning in clinical practice calls for a comprehensive pedagogical framework on how to create optimal learning affordances. PURPOSE: The purpose of this study was to describe characteristics of conducted research regarding investigated research questions, distribution of different health care student groups, and employed methodological approaches. METHODS: A scoping review was chosen to capture the multifaceted characteristics in the field of learning in clinical practice. Funded local projects were analysed to provide significant core concepts for the literature search. A systematic search and review of articles published 2000-2019 in the Nordic countries was conducted according to PRISMA- ScR (23). The search was made in Medline (OVID), SveMed+ and CINAHL and resulted in 3126 articles. After screening of the titles and abstracts 988 articles were included for further review. The abstracts of all these articles were reviewed against established inclusion and exclusion criteria and 391 articles were included. Characteristics of purposes and research questions were analysed with a qualitative content approach resulting in identified subject areas including significant categories. Health care student groups and methodological approaches were also identified. RESULTS: Subjects predominating the research were organisation of clinical practice, supervision, and students' experience followed by interprofessional learning and learning environment. Co-operation, university-clinical setting, and patients' role were investigated to a small extent. Sparsely occurring subjects were also specific learning outcomes and evidence-based knowledge. Nursing students were involved in 74% of the studies, medical students in 20%, and other professions around 8%. Qualitative approaches were most common. CONCLUSION: Health care students' learning in clinical practice has been researched to a large extent within the Nordic countries and important subject areas are well represented. The research displays a great potential to extract and describe factors to create a pedagogical framework with significant meaning to support students' learning.

How students discern anatomical structures using digital three-dimensional visualizations in anatomy education.

Learning anatomy holds specific challenges, like the appreciation of three-dimensional relationships between anatomical structures. So far, there is limited knowledge about how students construct their understanding of topographic anatomy. By understanding the processes by which students learn anatomical structures in 3D, educators will be better equipped to offer support and create successful learning situations. Using video analysis, this study investigates how students discern anatomical structures. Sixteen students at different levels of education and from different study programs were recorded audiovisually while exploring 3D digital images using a computerized visualization table. Eleven hours of recorded material were analyzed using interaction analysis and phenomenography. Seven categories were identified during data analysis, describing the qualitatively different patterns of actions that students use to make sense of anatomy: decoding the image; positioning the body in space; purposeful seeking, using knowledge and experience; making use of and creating variation; aimless exploration, and arriving at moments of understanding. The results suggest that anatomy instruction should be organized to let the students decide how and at what pace they examine visualized images. Particularly, the discovery process of decoding and positioning the body in space supports a deep learning approach for learning anatomy using visualizations. The students' activities should be facilitated and not directed.

The core of mentorship: medical students' experiences of one-to-one mentoring in a clinical environment.

Mentoring has been used in different health care educational programmes, but the core of mentorship, i.e., facilitating the development of medical students' professional competence, has not been explored in depth in the literature. In order to create effective and meaningful mentoring programmes, there is a need for deeper knowledge of the meaning of formal mentorship and, for this, the students' experiences are important. A mentoring program was set up where all medical students were offered a mentor during their first clinical courses; years 3-4. The mentors were physicians and their role as mentors was to support the students and act as sounding-boards, not to teach or assess knowledge. This study aimed to get a deeper understanding of the meaning of mentorship seen from the perspective of undergraduate medical students. A qualitative approach with individual interviews (N = 12) and inductive content analysis was chosen to investigate and interpret the meaning of mentorship. The results comprise three overarching themes: Space, Belief in the future and Transition. Having a mentor gave a sense of security and constituted a 'free zone' alongside the undergraduate programme. It gave hope about the future and increased motivation. The students were introduced to a new community and began to identify themselves as doctors. We would argue that one-to-one mentoring can create conditions for medical students to start to develop some parts of the professional competences that are more elusive in medical education programmes, such as reflective capacity, emotional competence and the feeling of belonging to a community.

Health Care Leaders' Perspectives on How Continuous Professional Development Can Be Promoted in a Hospital Organization.

INTRODUCTION: Leaders play a central role in continuous learning processes aimed to improve health care. However, knowledge of how leaders with power and influence in hospital organizations promote the means for continuous learning in practice is scarce. This study aims to explore how key stakeholders in a hospital organization think about approaches and roles when promoting the reflective practice in small groups as means for continuous professional development in their organizations. METHODS: Six key stakeholders from a regional hospital (two department directors, two ward managers, and two resident supervisors) were recruited through purposive sampling. Semi-structured interviews were conducted, and an abductive content analysis was performed. RESULTS: In the current study, leaders stressed that cultural and structural conditions at all levels in the system were important for the practice of small-group learning. Yet, their suggested approaches referred exclusively to a limited part of the system and were directed to staff at lower hierarchical levels within their jurisdictions. DISCUSSION: The identified gap between the suggested approaches and the claimed conditions for implementing a new strategy for continuous professional development among leaders in a health care organization illuminates difficulties in the implementation process. Providing adequate conditions at all levels of the system demands implementation approaches that include the entire hospital system. This requires that leaders first recognize their need to learn and apply a systemic perspective, and second, that they can create such learning opportunities for themselves.