Exploring clinical learning environments for postgraduate medical education

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

Supervised workplace learning in postgraduate training: A realist synthesis

This paper presents a realist synthesis of the literature that began with the objective of developing a theory of workplace learning specific to postgraduate medical education (PME). As the review progressed, we focused on informal learning between trainee and senior doctor or supervisor, asking what mechanisms occur between trainee and senior doctor that lead to the outcomes of PME, and what contexts shape the operation of these mechanisms and the outcomes they produce? Methods We followed the procedures outlined in the RAMESES Publication Standards for Realist Synthesis. We searched the English-language literature published between 1995 and 2017 for empirical papers related to informal workplace learning between supervisor and trainee, excluding formal interventions such as workplace-based assessment. We made a pragmatic decision to exclude general practice training to keep the review within manageable limits. Results We reviewed 5197 papers and selected 90. Synthesis revealed three workplace learning processes occurring between supervisors and trainees, each underpinned by a pair of mechanisms: supervised participation in practice (entrustment and support seeking); mutual observation of practice (monitoring and modelling), and dialogue during practice (meaning making and feedback). These mechanisms result in outcomes of PME, including safe participation in practice, learning skills, attitudes and behaviours and professional identity development. Contexts shaping the outcomes of these mechanisms were identified at individual, interpersonal, local and systems levels. Conclusions Our realist theory of workplace learning between supervisors and trainees is informed by theory and empirical research. It highlights the two-way nature of supervision, the importance of trainees’ agency in their own learning and the deleterious effect of fragmented working patterns on supervisor–trainee learning mechanisms. Further empirical research is required to test and refine this theory. In the meantime, it provides a useful framework for the design of supportive learning environments and for the preparation of supervisors and trainees for their roles in workplace learning

Protocol for a realist review of workplace learning in postgraduate medical education and training

Postgraduate medical education and training (PGMET) is a complex social process which happens predominantly during the delivery of patient care. The clinical learning environment (CLE), the context for PGMET, shapes the development of the doctors who learn and work within it, ultimately impacting the quality and safety of patient care. Clinical workplaces are complex, dynamic systems in which learning emerges from non-linear interactions within a network of related factors and activities. Those tasked with the design and delivery of postgraduate medical education and training need to understand the relationship between the processes of medical workplace learning and these contextual elements in order to optimise conditions for learning. We propose to conduct a realist synthesis of the literature to address the overarching questions; how, why and in what circumstances do doctors learn in clinical environments? This review is part of a funded projected with the overall aim of producing guidelines and recommendations for the design of high quality clinical learning environments for postgraduate medical education and training

Experience of enhanced near-peer support for new medical graduates of an Irish university: a phenomenological study

Context Factors contributing to the stressful transition from student to doctor include issues with preparedness for practice, adjusting to new status and responsibility, and variable support. Existing transitional interventions provide inconsistent participation, responsibility and legitimacy in the clinical environment. Enhanced support by near peers for new doctors may ease the transition. Irish medical graduates of 2020 commenced work early, creating an unprecedented period of overlap between new graduates and the cohort 1 year ahead.Objective To explore the experience of commencing practice for these new doctors with this increased near-peer support.Design We used interpretive phenomenological analysis as our methodological approach, informed by the cognitive apprenticeship model, to explore the experience of enhanced near-peer support at the transition to practice. Participants recorded audio diaries from their commencement of work, and a semistructured interview was conducted with each, after 3 months, concerning their experience of their overlap with the previous year’s interns.Setting University College Cork, one of six medical schools in Ireland.Participants Nine newly qualified medical doctors.Main outcome measures An exploration of their experience of transition to clinical practice, in the context of this enhanced near-peer support, will inform strategies to ease the transition from student to doctor.Results Participants felt reassured by having a near-peer in the same role and safe to seek their support. This empowered them to gradually assume increasing responsibility and to challenge themselves to further their learning. Participants perceived that commencing work before the annual change-over of other grades of doctor-in-training enhanced their professional identities and improved patient safety.Conclusions Enhanced near-peer support for new doctors offers a potential solution to the stressful transition to practice. Participants were legitimate members of the community of practice, with the status and responsibility of first-year doctors. Furthermore, this study reinforces the benefit of asynchronous job change-over for doctors-in-training

Maintenance of professional competence in Ireland: a national survey of doctors’ attitudes and experiences

Objectives Programmes to ensure doctors’ maintenance of professional competence (MPC) have been established in many countries. Since 2011, doctors in Ireland have been legally required to participate in MPC. A significant minority has been slow to engage with MPC, mirroring the contested nature of such programmes internationally. This study aimed to describe doctors’ attitudes and experiences of MPC in Ireland with a view to enhancing engagement.Participants All registered medical practitioners in Ireland required to undertake MPC in 2018 were surveyed using a 33-item cross-sectional mixed-methods survey designed to elicit attitudes, experiences and suggestions for improvement.Results There were 5368 responses (response rate 42%). Attitudes to MPC were generally positive, but the time, effort and expense involved outweighed the benefit for half of doctors. Thirty-eight per cent agreed that MPC is a tick-box exercise. Heavy workload, travel, requirement to record continuing professional development activities and demands placed on personal time were difficulties cited. Additional support, as well as higher quality, more varied educational activities, were among suggested improvements. Thirteen per cent lacked confidence that they could meet requirements, citing employment status as the primary issue. MPC was particularly challenging for those working less than full-time, in locum or non-clinical roles, and taking maternity or sick leave. Seventy-seven per cent stated a definite intention to comply with MPC requirements. Being male, or having a basic medical qualification from outside Ireland, was associated with less firm intention to comply.Conclusions Doctors need to be convinced of the benefits of MPC to them and their patients. A combination of clear communication and improved relevance to practice would help. Addition of a facilitated element, for example, appraisal, and varied ways to meet requirements, would support participation. MPC should be adequately resourced, including provision of high-quality free educational activities. Systems should be established to continually evaluate doctors’ perspectives

Doctors\u27 attitudes to, beliefs about, and experiences of the regulation of professional competence: A scoping review protocol

Background: Historically, individual doctors were responsible for maintaining their own professional competence. More recently, changing patient expectations, debate about the appropriateness of professional self-regulation, and high-profile cases of malpractice have led to a move towards formal regulation of professional competence (RPC). Such programmes require doctors to demonstrate that they are fit to practice, through a variety of means. Participation in RPC is now part of many doctors’ professional lives, yet it remains a highly contested area. Cost, limited evidence of impact, and lack of relevance to practice are amongst the criticisms cited. Doctors’ attitudes towards RPC, their beliefs about its objectives and effectiveness, and their experiences of trying to meet its requirements can impact engagement with the process. We aim to conduct a scoping review to map the empirical literature in this area, to summarise the key findings, and to identify gaps for future research. Methods: We will conduct our review following the six phases outlined by Arksey and O’Malley, and Levac. We will search seven electronic databases: Academic Search Complete, Business Source Complete, CINAHL, PsycINFO, PubMed, Social Sciences Full Text, and SocINDEX for relevant publications, and the websites of medical regulatory and educational organisations for documents. We will undertake backward and forward citation tracking of selected studies and will consult with international experts regarding key publications. Two researchers will independently screen papers for inclusion and extract data using a piloted data extraction tool. Data will be collated to provide a descriptive summary of the literature. A thematic analysis of the key findings will be presented as a narrative summary of the literature. Discussion: We believe that this review will be of value to those tasked with the design and implementation of RPC programmes, helping them to maximise doctors’ commitment and engagement, and to researchers, pointing to areas that would benefit from further enquiry. This research is timely; internationally existing programmes are evolving, new programmes are being initiated, and many jurisdictions do not yet have programmes in place. There is an opportunity for learning across different programmes and from the experiences of established programmes. Our review will support that learning. Systematic review registration: PROSPERO does not register scoping reviews

A national stakeholder consensus study of challenges and priorities for clinical learning environments in postgraduate medical education

Background: High quality clinical learning environments (CLE) are critical to postgraduate medical education (PGME). The understaffed and overcrowded environments in which many residents work present a significant challenge to learning. The purpose of this study was to develop a national expert group consensus amongst stakeholders in PGME to; (i) identify important barriers and facilitators of learning in CLEs and (ii) indicate priority areas for improvement. Our objective was to provide information to focus efforts to provide high quality CLEs. Methods: Group Concept Mapping (GCM) is an integrated mixed methods approach to generating expert group consensus. A multi-disciplinary group of experts were invited to participate in the GCM process via an online platform. Multi-dimensional scaling and hierarchical cluster analysis were used to analyse participant inputs in regard to barriers, facilitators and priorities. Results: Participants identified facilitators and barriers in ten domains within clinical learning environments. Domains rated most important were those which related to residents’ 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 difficult areas in which to make improvements. Conclusions: High quality PGME requires that residents engage and connect with senior doctors during patient care, and that they are valued and supported both as learners and service providers. Academic medicine and health service managers must work together to protect these elements of CLEs, which not only shape learning, but impact quality of care and patient safety