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Exploring clinical learning environments for postgraduate medical education
University College Cork
Background: The premise that trainees learn through work underpins the design of postgraduate medical education (PGME). The clinical learning environment (CLE) is the foundation of PGME and represents the social, cultural and physical context wherein trainees learn through supervised patient encounters. Social theories of learning emphasise the role of the environment in workplace learning which, in PGME, occurs through trainee participation and engagement in the daily work of a doctor. There is a gap in the existing literature about priorities and challenges in clinical environments. Consequently, frontline practitioners and stakeholders in PGME may be at a loss about where to focus their efforts to improve trainee learning. Further exploration of clinical learning environments is needed to support the appropriate targeting of effort and resources, to achieve maximum impact. Supervisors are central to workplace learning in postgraduate medical education. The processes involved in clinical supervision are not fully understood, and limited theory is available that explains how workplace learning occurs through supervisor-trainee interactions. Theoretical explanations about learning through supervisor-trainee interaction and the role of the environment in this process are needed to support improvement. For these reasons, this doctoral research programme aimed to answer two overarching questions; 1) On what aspects of the clinical environment should we focus on to better support trainee learning? And 2) How does supervised workplace learning happen and what is the role of the environment in this process? Methods: This research programme involved three studies situated within the critical realist paradigm. A Group Concept Mapping (GCM) was the first study, to identify the priorities and challenges associated with postgraduate medical education within clinical environments. Findings from Study 1 was used, amongst other things, to narrow the focus of Study 2, a Realist Review of workplace learning that occurs during informal supervisor and trainee interactions. Study 2 produced a Realist Theory which was tested and refined in Study 3 through a Multiple Case Study. 1) Group Concept Mapping is an integrated mixed methods approach to generating expert group consensus. A multidisciplinary group of experts were invited to participate in the GCM process via an online platform. Multidimensional scaling and hierarchical cluster analysis were used to analyse participant inputs regarding barriers, facilitators and priorities for trainee learning in clinical environments. 2) Realist Review is an interpretative theory-driven narrative summary of the literature describing how, why, and in what circumstances complex social interventions work. The steps and procedures outlined in the RAMESES Publication Standards for Realist Synthesis were followed and involved the translation of findings from ninety empirical studies into context, mechanism, and outcome configurations. 3) Multiple Case Study is an empirical inquiry that is used to contribute to our knowledge of complex social phenomena and allows preservation of the characteristics of real-world events. Fifty supervisor and trainee participants were interviewed across four clinical departments and specialties. Data analysis were conducted through pattern matching and cross-case analysis within and across the four cases. Results: 1) Group Concept Mapping: Participants identified facilitators and barriers in ten domains within clinical learning environments. Domains rated most important were those which related to trainees’ connection to and engagement with more senior doctors. Organisation and conditions of work and Time to learn with senior doctors during patient care were rated as the most challenging areas in which to make improvements. 2) Realist Review: The realist review described a realist theory of supervised workplace learning categorising three processes; Supervised Participation in Practice, Mutual Observation of Practice and Dialogue about Practice. These processes are underpinned by interrelated mechanisms which are led by supervisor, trainee or both; Entrustment, Support Seeking, Monitoring, Modelling, Meaning Making and Feedback. The results of the review detail how contexts at individual and interpersonal, and local and systems levels, trigger or inhibit these mechanisms and shape their outcomes. These outcomes include both key educational objectives of PGME and safe, high-quality patient care. 3) Multiple Case Study: This study illustrated the context-specificity of supervised workplace learning and indicated that trainees and supervisors experience supervised workplace learning differently across clinical environments, the level of trainee oversight may be excessive (for real-world reasons), and local contexts limit, in particular, the mechanism of Entrustment to generate its intended outcomes. Conclusion: Supervised workplace learning emerges from the context in which it happens. A better understanding of supervised workplace learning and the role of the environment in this process is a critical adjunct to efforts to improve postgraduate medical education. This doctoral thesis generated a deeper insight into supervised workplace learning and how to contextualise, through the components of clinical learning environments, the mechanisms and outcomes of this social phenomenon. Layers of contexts shape how trainees learn with, from and about supervisors. At the centre is the supervisor-trainee relationship; at a higher level, local and systems contexts compounding, even more, the complexity of this relationship. The final output of the synthesised literature and empirically tested and refined realist theory contributes to a more consistent conceptualisation of trainee learning through supervisor interaction. The detailed information presented in this thesis about the process of supervised workplace learning including its contexts and outcomes will allow supervisors, trainees, researchers, policymakers, and managers to appraise postgraduate medical education and have a better chance to make improvements successfully.
Postgraduate medical education , Clinical learning environment , Supervised workplace learning
Wiese, A. 2018. Exploring clinical learning environments for postgraduate medical education. PhD Thesis, University College Cork.