Understanding experiences of medical students' clinical learning in the paediatric environment

Abstract

INTRODUCTION: Clinical placements form the cornerstone of medical student training to become a doctor. For most medical programmes, this will be the place where students will spend the majority of their time throughout their degree. Yet the clinical setting has multiple challenges as a learning environment. Patient safety is the ultimate goal and medical education may not always be a key priority for clinicians with competing demands upon their time. Changes in postgraduate training structures, acute hospital provision and patient demographics may also impact on training opportunities for medical students. Frustrations may arise for both the students and the clinicians, which in turn can further impact medical student education.

AIM: The aim was to increase the understanding of factors which medical students experience within the paediatric clinical learning environment (CLE) which influence their learning both positively and negatively. The research objectives were:

-To explore student experiences of learning in the paediatric clinical environment

-To determine clinician approaches to medical student learning within the clinical setting

-To identify barriers and enablers towards student learning during clinical placements

METHOD: A case study design was used. Semi-structured interviews were conducted with 13 medical students in their 5th year of a 6-year degree during their paediatric clinical placement and 11 clinicians working within paediatrics ranging from newly qualified doctors through to consultant paediatricians. The audio data was transcribed and thematically analysed.

RESULTS: Student themes - Students underwent a journey of progression as a learner during their time in clinical placements, from initially needing more guidance and support to being able to access learning more autonomously. There could be variation between students as to which point in this progression they were, meaning they could require differing levels of support. Students experienced a lack of identity within the clinical setting which negatively influenced their confidence accessing learning opportunities. They felt uncertainty around the division of responsibility for student learning between themselves and the clinical staff which impacted upon their engagement and the interactions they had with clinicians. Conflict existed between their learning goals of knowledge versus understanding, driven by their need to pass exams but also prepare to become a doctor. Approaching these in parallel was a challenge. Clinician themes - Clinicians perceived clinical care as a competing priority which superseded the provision of undergraduate education. Clinicians had strong intrinsic and extrinsic motivation to provide high quality teaching to medical students. Their own experiences as learners were strongly influential upon their approach to teaching and attitudes towards students. Clinicians felt a sense of responsibility for the students having a positive learning experience but were able to justify avoidance of teaching by a sense of ‘someone else’ being better placed to do it. Confusion existed around the overall goal of the clinical placement for students.

Implications: These findings encourage improved guidance for how students should be supported to learn during their clinical placements. Students will not all be able to access learning with the same degree of ease and clinicians and the learning environment must be able to flex to provide increased support when necessary. Expecting students to ‘rise to the challenge’ may not be realistic for all and certain students below a ‘learning threshold’ may miss out on learning opportunities, with a spiralling effect on their access to future learning opportunities. This study recognises the key role that clinicians play as gatekeepers of students’ learning in the clinical setting, both through their actions and attitudes, and emphasises the importance of clinicians finding ways to ‘give permission’ to students to engage in the clinical environment, in line with legitimate peripheral participation theory. Clinicians are strongly motivated to teach and primarily driven in their approach by their own learning experiences. This ‘Schweitzer effect’ of experiences breeding behaviour necessitates a longitudinal approach to developing educator identity in clinicians alongside their professional identity formation to optimise role modelling and enable clinicians to integrate teaching within their clinical commitments. Better engagement with teaching has the potential to positively impact clinician’s experience of the work environment.