Examining the clinical learning environment through the architectural avenue

Abstract

Medical education has traditionally focused on the learners, the educators, and the curriculum, while tending to overlook the role of the designed environment. Experience indicates, however, that processes and outcomes of medical education are sensitive to the qualities and disposition of the spaces in which it occurs. This includes the clinical education within the patient care environment, termed the clinical learning environment (CLE). Recognition of this has informed the design of some new clinical learning spaces for the past decade. Competency-based clinical education can drive design requirements that differ materially from those associated with general purpose educational or clinical spaces. In this article, we outline two conceptual frameworks: (i) materialist spatiality and (ii) actor-network theory and consider how they can guide the design of spaces to support competency-based medical education and to guide the evaluation and discussion of the educational impacts of the spaces once built. We illustrate the use of these frameworks through discussion of the educational ambitions that underpinned the design of some recent clinical educational spaces. We close with practical points for consideration by educators and designers.     

Managing the learning environment in undergraduate medical education: the Sheffield approach

This paper describes one possible model for e-learning in undergraduate medical education with an emphasis on supporting and managing curriculum development. The University of Sheffield School of Medicine is undergoing a major revision of is undergraduate medical curriculum, prompted by requirements of the professional regulatory body, the General Medical Council (GMC), and the Quality Assurance Agency for Higher Education (QAA). A computer-based system was developed to provide more efficient administration of the current course and more effective delivery of educational materials to students. The Sheffield Networked Learning Environment (NLE) has been developed in collaboration with other medical schools. A new 'revised' curriculum, due to start in 2003, will be intensively supported by an NLE which has been extensively tested and modified through pilot studies in the current curriculum.     

The clinical learning environment

Abstract

Learning in a clinical context is foundational in the training of health professionals; there is simply no alternative. The subject of the clinical learning environment (CLE) is at the forefront of discussions. In this introduction to a themed issue on the CLE, we present an expanded conceptual model that approaches the CLE through six different lenses, termed “avenues:” architectural, digital, diversity and inclusion, education, psychological, and sociocultural, with each avenue represented by a paper. The aim is to facilitate dialog around the contributions of different academic disciplines to research on the CLE. Collectively the papers highlight the overlap between the various “avenues” in how they influence each other, and how they collectively have shaped the work to understand and improve the CLE. The expectation is that the various avenues can add to existing knowledge and create new ideas for interventions to improve the clinical learning environment across nations for learners and teachers with the ultimate aim of improving patient care. Research and efforts to improve the CLE are critical to learning, professional socialization and well-being for trainees as they learn and participate in patient care, and to the quality of care they will deliver over decades of practice after graduation.     

Psychology and learning: The role of the clinical learning environment

Abstract

The clinical learning environment for the postgraduate education of physicians significantly influences the learning process and the outcomes of learning. Two critical aspects of the learning environment, when viewed through a psychology lens are (1) constructs from psychology relevant to learning, such as cognitive load theory and learner self-efficacy; and (2) psychological attributes of the context in which learning occurs such as psychological safety and “Just Culture”. In this paper, we address selected psychological aspects of the clinical learning environment, with a particular focus on the establishment and sustainment of psychological safety in the clinical learning environment for physicians. Psychological safety is defined as individuals’ perceptions that they can speak out in the learning or working context without consequences for their professional standing or risks to their status on work teams or groups. We close with seven critical strategies for use by educators, learners, health systems leaders, and other stakeholders to contribute to a clinical environment that optimizes learning. These dimensions can also provide avenues for future research to enhance the community’s understanding of psychological constructs operating in the clinical learning environment.     

Inclusion in the clinical learning environment: Building the conditions for diverse human flourishing

Abstract

Aim: While diversity, equity, and inclusion are much proclaimed aspirational goals in education programs, the clinical learning environment (CLE) frequently falls short of meaningful incorporation of these concepts in processes, policies, and local culture. In this paper, we explore how inclusion, diversity, and equity can and should be defined and operationalized within medical education.

Methods: Three cases, organized around Hafferty’s curricular framework (formal, informal, and hidden), we illustrate lapses and potential best practices in inclusion in the CLE.

Results: The essential “best-practice” of programs inclusive of diverse individuals is the design of policies, processes, and behavioral norms co-creatively with all community members. Potential pitfalls to greater inclusion include nostalgic reference to “the past”, a neutrality that is operationalized without the rudder of explicit values and not recognizing that ethical obligations between teachers, learners, and programs are at the heart of the discussion of how inclusive learning and work environments are built.

Conclusion: Inclusive CLE’s provide space for co-creation, understand the need to ensure the voices of the vulnerable (i.e. learners) are heard and valued and through this promote the flourishing of diverse human capital, in keeping with a model that views diversity as a key attribute or organizational excellence.     

Managing and supporting medical education with a virtual learning environment: the Edinburgh Electronic Medical Curriculum

Virtual learning environments (VLEs) can be a compelling and powerful way to support and manage contemporary medical education. A VLE purposively aligned to a course can integrate and normalize procedures and provide a central access point and reference mechanism for all of a course's component communities. The Edinburgh Electronic Medical Curriculum (EEMeC), developed in-house to support the Edinburgh under-graduate course, has proved to be a great success with students, teaching and administrative staff. It exists in a 'blended' relationship with the course, which uses both face-to-face and online delivery modes. This paper maps out the process of the EEMeC system's development and describes a number of factors that have contributed to its success.     

Learning and professional acculturation through work: Examining the clinical learning environment through the sociocultural lens

Abstract

Purpose: We examined studies of the clinical learning environment from the fields of sociology and organizational culture to (i) offer insight into how workplace culture has informed research on postgraduate trainee learning and professional development; (ii) highlight limitations of the literature; and (iii) suggest practical ways to apply sociocultural concepts to challenges in the learning environment.

Materials and methods: Concepts were explored by participants at a consensus conference in October 2018.

Results: We identified three enduring foci for research using a sociocultural lens: the hidden curriculum, exploration of medical errors, and the impact of time pressures on the relational nature of clinical education. Limitations included the lower value attributed to informal learning and a pejorative valuation of the hidden curriculum; and disconnect between practices in clinical settings and the priorities of the larger organization.

Conclusions: Research on the learning environment using a sociocultural lens suggest workplace goals, norms and practices determined which learners engage in learning-relevant activities, to what extent, and the degree of guidance provided, with these factors creating “tacit” curricula that may support or compete with formal learning goals. We close with guidance on how sociocultural constructs could inform research to improve the learning environment.     

Effectiveness of clinical rotations as a learning environment for achieving competences

Competences are becoming more and more prominent in undergraduate medical education. Workplace learning is regarded as crucial in competence learning. Assuming that effective learning depends on adequate supervision, feedback and assessment, the authors studied the occurrence of these three variables in relation to a set of clinical competences. They surveyed students at the end of their rotation in surgery, internal medicine or paediatrics asking them to indicate for each competence how often they had received observed and unobserved supervision, the seniority of the person who provided most of their feedback, and whether the competence was addressed in formal assessments. Supervision was found to be scarce and mostly unobserved. Senior staff did not provide much feedback, and assessment mostly targeted patient-related competences. For all variables, the variation between students exceeded that between disciplines. We conclude that conditions for adequate workplace learning are poorly met and that clerkship experiences show huge inter-student variation.     

Communication,learning and assessment: Exploring the dimensions of the digital learning environment

Abstract

Advances in technology make it possible to supplement in-person teaching activities with digital learning, use electronic records in patient care, and communicate through social media. This relatively new “digital learning environment” has changed how medical trainees learn, participate in patient care, are assessed, and provide feedback. Communication has changed with the use of digital health records, the evolution of interdisciplinary and interprofessional communication, and the emergence of social media. Learning has evolved with the proliferation of online tools such as apps, blogs, podcasts, and wikis, and the formation of virtual communities. Assessment of learners has progressed due to the increasing amounts of data being collected and analyzed. Digital technologies have also enhanced learning in resource-poor environments by making resources and expertise more accessible. While digital technology offers benefits to learners, the teachers, and health care systems, there are concerns regarding the ownership, privacy, safety, and management of patient and learner data. We highlight selected themes in the domains of digital communication, digital learning resources, and digital assessment and close by providing practical recommendations for the integration of digital technology into education, with the aim of maximizing its benefits while reducing risks.     

Evaluating an interprofessional education curriculum: A theory-informed approach

Background: This paper retrospectively reports on an evaluation framework applied to a local interprofessional education (IPE) curriculum design. The theoretically informed IPE curriculum spans the undergraduate health and social care programmes of over 10 professions as a curriculum theme. The teaching design and its impact were informed by psycho-social and learning theories.

Aims: This meta-analysis is presented to share the importance of longitudinal IPE, whole curriculum evaluation for comparisons and to advance our understandings of what works and why.

Method: The meta-analysis used the Presage, Process and Product conceptual framework outlined by Biggs in 1993, and the Kirkpatrick in 1996, evaluation outcome model. Data are shared on the final overall learning from evaluating the teaching and the outcomes from students, teachers, practitioners, patients and carers.

Results: The evaluation highlighted cyclical issues relating to students experiences, facilitators abilities and highlights the challenges of learning in practice which was highly praised by students. The problems and challenges were solved through the application of theory to illuminate our understandings.

Conclusion: We lament at missed opportunities for the application of theoretically informed research questions that still require to be addressed. However, we share this framework as having offered a complete and comprehensive evaluation process.     

Humans and machines: Moving towards a more symbiotic approach to learning clinical reasoning

Abstract

Artificial intelligence is a growing phenomenon that is driving major changes to how we deliver healthcare. One of its most significant and challenging contributions is likely to be in diagnosis. Artificial intelligence is challenging the physician’s exclusive role in diagnosis and in some areas, its diagnostic accuracy exceeds that of humans. We argue that we urgently need to consider how we will incorporate AI into our teaching of clinical reasoning in the undergraduate curriculum; students need to successfully navigate the benefits and potential issues of new and developing approaches to AI in clinical diagnosis. We offer a pedagogical framework for this challenging change to our curriculum.     

Attitudes to concept maps as a teaching/learning activity in undergraduate health professional education: influence of preferred approach to learning

Pre-prepared concept maps that organise knowledge in a non-linear fashion appeal to a variety of cognitive learning styles and may thus represent an educational tool that supports 'teaching to all types'. However, another central cognitive factor, learning approach, may have a bearing on student take-up of this learning resource. Student attitudes to pre-prepared concept maps introduced in Stage 2 MPharm and BSc Pharmacology lectures were therefore examined in relation to the principal learning orientations according to Duff's 30-item revised approaches to study inventory (RASI). Approximately one half of students (49.6 +/- 4.5%) reported pre-prepared concept maps to be useful to their learning (n = 121). When preferred learning approach was examined, derived from the highest RASI score per individual and excluding ties, 31.9 +/- 4.3%, 29.3 +/- 4.2% and 38.8 +/- 4.5% of students demonstrated a preference for the deep approach (DA), strategic approach (STA) and surface approach (SUA), respectively (P > 0.05, chi2 goodness-of-fit test, n = 116). There was a weak but statistically significant association between preferred learning approach identified by Duff's 30-item RASI and the self-reported usefulness of concept maps (P < 0.05, chi2 test of independence; Cramer's V = 0.235; lambda = 0.193). In contrast, gender was not significantly associated with attitude to concept maps in this student cohort. A preliminary analysis of standardised residuals based on observed and expected frequencies revealed that the greatest contributions to this significant association were: a positive influence of DA and a negative influence of STA, respectively, on attitude to concept maps. These data now indicate a contribution of the principal learning orientations vis-à-vis student attitudes to pre-prepared concept maps when employed alongside more traditional teaching/learning activities in medical and biomedical science education, and may further suggest a role for concept maps in the support of deep learning.