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

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

Using paradox theory to understand responses to tensions between service and training in general surgery.

CONTEXT: The tension between service and training in pressured health care environments can have a detrimental impact on training quality and job satisfaction. Yet the management literature proposes that competing demands are inherent in organisational settings: it is not the demands as such that lead to negative outcomes but how people and organisations react to opposing tensions. We explored how key stakeholders responded to competing service-training demands in a surgical setting that had recently gone through a highly-publicised organisational crisis. METHODS: This was an explanatory case study of a general surgery unit. Public documents informed the research questions and the data were triangulated with semi-structured interviews (n = 14) with key stakeholders. Data coding and analysis were initially inductive but, after the themes emerged, we used a paradox lens to group themes into four contextual dimensions: performing, organising, belonging and learning. RESULTS: Tensions were apparent in the data, with managers, surgeons and trainees or residents in conflict with each other because of different goals or priorities and divergent perspectives on the same issue of balancing service and training (performing). This adversely impacted on relationships across and within groups (belonging, learning) and led to individuals prioritising their own goals rather than working for the 'greater good' (performing, belonging). Yet although relationships and communication improved, the approach to getting a better balance maintained the 'compartmentalisation' of training (organising) rather than acknowledging that training and service cannot be separated. DISCUSSION: Stakeholder responses to the tensions provided temporary relief but were unlikely to lead to real change if the tension between service and training was considered to be an interdependent and persistent paradox. Reframing the service-training paradox in this way may encourage adjusting responses to create effective working partnerships. Our findings add to the body of knowledge on this topic, and will resonate with all those engaged in surgical and other postgraduate training.

Conceptions of how a learning or teaching curriculum, workplace culture and agency of individuals shape medical student learning and supervisory practices in the clinical workplace.

The role of workplace supervisors in the clinical education of medical students is currently under debate. However, few studies have addressed how supervisors conceptualize workplace learning and how conceptions relate to current sociocultural workplace learning theory. We explored physician conceptions of: (a) medical student learning in the clinical workplace and (b) how they contribute to student learning. The methodology included a combination of a qualitative, inductive (conventional) and deductive (directed) content analysis approach. The study triangulated two types of interview data from 4 focus group interviews and 34 individual interviews. A total of 55 physicians participated. Three overarching themes emerged from the data: learning as membership, learning as partnership and learning as ownership. The themes described how physician conceptions of learning and supervision were guided by the notions of learning-as-participation and learning-as-acquisition. The clinical workplace was either conceptualized as a context in which student learning is based on a learning curriculum, continuity of participation and partnerships with supervisors, or as a temporary source of knowledge within a teaching curriculum. The process of learning was shaped through the reciprocity between different factors in the workplace context and the agency of students and supervising physicians. A systems-thinking approach merged with the "co-participation" conceptual framework advocated by Billet proved to be useful for analyzing variations in conceptions. The findings suggest that mapping workplace supervisor conceptions of learning can be a valuable starting point for medical schools and educational developers working with changes in clinical educational and faculty development practices.

Development and psychometric evaluation of the Undergraduate Clinical Education Environment Measure (UCEEM).

BACKGROUND: There is a paucity of instruments designed to evaluate the multiple dimensions of the workplace as an educational environment for undergraduate medical students. AIM: The aim was to develop and psychometrically evaluate an instrument to measure how undergraduate medical students perceive the clinical workplace environment, based on workplace learning theories and empirical findings. METHOD: Development of the instrument relied on established standards including theoretical and empirical grounding, systematic item development and expert review at various stages to ensure content validity. Qualitative and quantitative methods were employed using a series of steps from conceptualization through psychometric analysis of scores in a Swedish medical student population. RESULTS: The final result was a 25-item instrument with two overarching dimensions, experiential learning and social participation, and four subscales that coincided well with theory and empirical findings: Opportunities to learn in and through work & quality of supervision; Preparedness for student entry; Workplace interaction patterns & student inclusion; and Equal treatment. Evidence from various sources supported content validity, construct validity and reliability of the instrument. CONCLUSION: The Undergraduate Clinical Education Environment Measure represents a valid, reliable and feasible multidimensional instrument for evaluation of the clinical workplace as a learning environment for undergraduate medical students. Further validation in different populations using various psychometric methods is needed.

Patient-centred learning in practice. A mixed methods study of supervision and learning in student clinics.

OBJECTIVE: Patient-centred learning (PCL) allows medical students to practice a patient-centred approach; however, didactic characteristics of PCL have yet to be fully elucidated. Clinical placements structured as a student clinic (SC) enable authentic student-patient learning relations through enhanced student responsibility and can serve as examples of PCL. We explored the didactic characteristics of supervision and learning in SCs to provide recommendations for PCL-oriented medical education. METHODS: Triangulation mixed methods study based on qualitative data collected from in-depth interviews with clinical teachers and quantitative data collected from student evaluations of supervision and learning in the SCs. RESULTS: Supervision and learning in SCs were characterized by 1) a focus on student-patient compatibility and patient needs and resources, which indicated PCL, 2) person-centred explorative supervision to adjust challenges to students' needs and resources, and 3) support of student autonomy to take responsibility for patient treatment. CONCLUSION: PCL was facilitated by clinical teachers through a dual person-centred didactic approach combined with autonomy-supportive didactic practice. This enabled the integration of patients' and students' needs and resources in clinical teaching. PRACTICE IMPLICATIONS: Clinical teachers can stimulate student-patient learning relations by selecting patients, exploring students' needs and resources, and supporting student autonomy through reflective practice and backup.

Medical students' views of clinical environments.

BACKGROUND: Monitoring the quality of clinical learning environments (CLEs) is immensely important in medical education. Objective indicators of the quality of the CLE can be used to measure learner perceptions and to inform educational improvements; however, many established tools were not designed for use in clinical settings and are not theoretically grounded. Our aim was to apply a new tool to the new context of a UK setting to explore the perceptions of senior medical students in a number of different CLEs. Monitoring the quality of clinical learning environments is immensely important in medical education METHODS: The four-factor Undergraduate Clinical Education Environment Measure (UCEEM) was translated into English, and used to gather final-year medical students' perceptions of four different specialties they had rotated through: Emergency Medicine (EM), General Surgery (GS), Medicine for the Elderly (ME), and Obstetrics and Gynaecology (O&G). The UCEEM was distributed in paper form. Students were asked to complete it in relation to two of the four specialties. RESULTS/FINDINGS: Year-5 medical students (n = 132) returned a completed UCEEM. For opportunities to learn in and through work experience EM was reported the most positively. ME was perceived to be the most prepared for student entry. Students reported being well received by staff and made to feel part of the team within GS, EM and ME, but less so in O&G. DISCUSSION: UCEEM appears to be a useful tool for evaluating medical student perceptions of CLEs. Theoretically robust, UCEEM is straightforward to administer and to score. It has the potential to be used by time-pressured educators to collect baseline and comparative data for evaluation and improvement purposes.