Widening how we see the impact of culture on learning, practice and identity development in clinical environments

Using theoretical engagement to understand workplace learning across contexts-Bringing worlds apart together

The pivotal importance of workplace learning (WPL) within health professions education has elevated its understanding and improvement to a major research priority. From a sociocultural learning theory perspective, WPL is inherently situated and context-specific. This means that the health care settings in which (future) health care professionals are trained will impact how and what is learned. However, to what extent is the research performed thus far transferable across professional contexts, cultures and borders? To what extent has WPL research sufficiently addressed the contextual characteristics of WPL to enable the evaluation of its transferability? To what extent have methodological and theoretical approaches enabled the building of understanding across contexts? We propose that heightening the transferability of WPL research as well as opening up the conversation to more diverse WPL contexts, settings and cultures will require mapping context and theoretical engagement. To explore what theoretical engagement may afford to our understanding of the influence of context on WPL, we use two theories: Landscapes of Practice and Figured Worlds. These theories with sociocultural groundings provide concrete lenses to understand the interplay between the individual and the context. We conclude with implications for research and practice and advocate for more attention to research practices that may deepen our understanding and heighten the transferability of workplace learning research.

Professional Identity Formation in Allied Health: A Systematic Review with Narrative Synthesis

Phenomenon: Professional identity formation is a key component of health professional education. Changing expectations of healthcare requires more than competencies, but also an ingrained responsibility to patients, with our values and behaviors aligned with community expectations of patient-centered health professionals. Research into professional identity formation has focused on nursing and medical training, and, although allied health professionals make up one third of the workforce, research is uneven across these disciplines. Health professions educators from these under-researched disciplines have less guidance for how to support students' professional identity, meaning students may graduate with less mature professional identities. This systematic literature review synthesizes the research on professional identity formation across nine similar allied health disciplines. The purpose is to guide health professions educators in the formation of professional identity in allied health students. Approach: We carried out a systematic literature review, registered on Prospero, following the PRIMSA framework, to find, appraise, and synthesize research on professional identity for nine allied health professions. We synthesized extracted data using a narrative synthesis with convergent qualitative meta-integration of qualitative and quantitative data. Results: Our database searches combined with ancestry and forward searching resulted in 70 studies that met inclusion criteria. Studies came from 17 countries, from seven of the included disciplines (art therapy, dietetics, occupational therapy, physiotherapy, podiatry, psychology, and speech pathology) and from undergraduate, postgraduate, and new graduate perspectives. We found professional identity was influenced by the places of learning (curriculum and clinical experiences or placements), interactions with people (relationships with academics, peers, supervisors, patients,and role models), and educational practices engaged (dialogue, reflection, processing challenges), each acting on the individual person (student or new graduate) who also brought unique characteristics and experiences. Insights: This model of influences can inform health professions education to enable students to develop and graduate with a stronger professional identity formation.

Challenges to Students' Learning and Wellbeing During Placement Abroad: A Qualitative Study Using Rich Pictures

Introduction

Undergraduate healthcare students on placement abroad can experience challenges that affect their wellbeing, personal and professional development. These challenges may result in students taking a more peripheral role in workplace activities, which negatively impacts learning. We studied how personal and professional challenges affect students' learning and wellbeing during a clinical placement abroad.

Methods

We used the rich pictures drawing method to elicit semi-structured student interviews and capture personal and professional challenges within different contexts. Language, culture, education, and belonging were used as sensitizing concepts, underlying thematic analysis. We conducted a parallel and iterative analysis of the transcripts and rich pictures. Team discussions focused on developing patterns and further conceptualization of results.

Results

Based on thirteen student accounts, we identified four main themes: 'Learning to work in the international context'; 'Cultural differences shape professional identity'; 'Deliberate social connections'; and 'Personal growth through international experiences'. Active participation in local practices was crucial to overcome barriers in language, culture or education, and increase belonging. Local healthcare teams and peers supported students' wellbeing, personal and professional development by helping them establish their role as a learner, whilst exploring the scope and boundaries of their future profession.

Conclusions

Language, cultural and educational challenges can be considered an inevitable part of student placement abroad. Local peers and staff may support this transition and help recognize learning opportunities and challenges in the workplace. Clinical educators can facilitate learning and wellbeing by providing social support and guidance on professional behavior, including communication.

You Get What You Reward: A Qualitative Study Exploring Medical Student Engagement in 2 Different Assessment Systems

PURPOSE

Educational impact is dependent on student engagement. Assessment design can provide a scaffold for student engagement to determine the focus of student efforts. Little is known about how medical students engage with assessment. Therefore, we asked the following research question: How do medical students engage with the process of assessment and their assessment data in 2 clinical assessment systems?

METHOD

This multi-institutional, cross-sectional constructivist grounded theory study of fourth-year undergraduate medical students at the University of Washington and Cleveland Clinic Lerner College of Medicine assessed 2 different assessment systems: traditional tiered grading, in which clerkship grades were summative, and programmatic assessment, in which students received low-stake, narrative feedback across clerkships with progress based on aggregated performance data in student portfolios. All fourth-year students were invited to participate in one-on-one semistructured interviews guided by student engagement theory between September 2022 and January 2023. Verbatim transcripts underwent iterative, qualitative analysis.

RESULTS

Twenty-two medical students were interviewed, 13 from a traditional grading assessment system and 9 from a programmatic assessment system. Three major ways in which assessment systems affected how students engaged with their assessments were categorized into the affective, cognitive, and behavioral domains of engagement: as a sociocultural statement of value, as the cognitive load associated with the assessment system and practices themselves, and as the locus of power and control in learning and authentic practice.

CONCLUSIONS

Medical students' beliefs about assessment goals, cognitive burden of assessment, and relationships with others significantly affected their engagement with their assessments. In assessment systems that reward grading and an archetypal way of being, students report engaging by prioritizing image over learning. In programmatic assessment systems, students describe more fully and authentically engaging in their assessment for and as learning. Systems of assessment communicate what is rewarded, and you get what you reward.

Renewing the Nursing Culture: Sustaining the Professional Community of Practice Through the Role of the Preceptor

Culture is the driving frame within which all human action takes form. This article explores the elements and characteristics of culture and applies them to the nursing professional community of practice. As it drills down to the work in the cultural context, it argues for the central role of the preceptor in evidencing the influence of culture. For onboarding nurses and the nursing community, the preceptor becomes the carrier of culture, demonstrating the impact of culture in a way that exhibits its influence and impact on nursing practice and patient care.

Nurse anaesthetists' experiences of student nurse anaesthetist learning during clinical practice: a qualitative interview study

BACKGROUND

The professional role of a nurse anaesthetist involves taking a pedagogical approach towards students, including supervision during clinical practice. Although supervisors are facilitators of student learning, they are offered little training in adult learning principles. The aim of this study was to describe supervisors' experience of student nurse anaesthetist learning during clinical practice in the operating room.

METHOD

In this qualitative interview study, 12 semi-structured individual interviews were carried out with clinical supervising nurse anaesthetists. The data were analysed inductively using thematic analysis.

RESULTS

The results are illustrated with one theme and five sub-themes. The clinical learning situation of student nurse anaesthetists is described as a reflection of different cultures coming together. The operating room environment is a new context to students, and students enter with different clinical background and experiences. There is tension in facilitating student learning due to demands for productivity; supervisors suggest the use of separate operating rooms with a special focus on learning in the future.

CONCLUSION

Clinical practice facilitates student learning and is a parallel process to routine care. Thus, it requires the cultures of higher education and healthcare organizations to co-exist. This is illustrated with the theme "Contributing to students' future professional roles by bridging the hospital and university cultures". In the operating room, student learning is challenged by a new context and time pressure as shown by subthemes. To overcome challenges and support student learning in the operating room from a supervisors' perspective, interprofessional student teams are suggested as a future approach and need to be further investigated.

Do you see what I see? Feeding interprofessional workplace learning using a diversity of theories

In this Commentary, Stalmeijer and Varpio highlight the importance of using different theoretical frameworks to make visible the potential of and need for research into interprofessional learning and guidance during workplace-based learning in the health professions.

Striving to thrive or striving to survive: Professional identity constructions of medical trainees in clinical assessment activities

CONTEXT

Assessment plays a key role in competence development and the shaping of future professionals. Despite its presumed positive impacts on learning, unintended consequences of assessment have drawn increasing attention in the literature. Considering professional identities and how these can be dynamically constructed through social interactions, as in assessment contexts, our study sought to understand how assessment influences the construction of professional identities in medical trainees.

METHODS

Within social constructionism, we adopted a discursive, narrative approach to investigate the different positions trainees narrate for themselves and their assessors in clinical assessment contexts and the impact of these positions on their constructed identities. We purposively recruited 28 medical trainees (23 students and five postgraduate trainees), who took part in entry, follow-up and exit interviews of this study and submitted longitudinal audio/written diaries across nine-months of their training programs. Thematic framework and positioning analyses (focusing on how characters are linguistically positioned in narratives) were applied using an interdisciplinary teamwork approach.

RESULTS

We identified two key narrative plotlines, striving to thrive and striving to survive, across trainees' assessment narratives from 60 interviews and 133 diaries. Elements of growth, development, and improvement were identified as trainees narrated striving to thrive in assessment. Neglect, oppression and perfunctory narratives were elaborated as trainees narrated striving to survive from assessment. Nine main character tropes adopted by trainees with six key assessor character tropes were identified. Bringing these together we present our analysis of two exemplary narratives with elaboration of their wider social implications.

CONCLUSION

Adopting a discursive approach enabled us to better understand not only what identities are constructed by trainees in assessment contexts but also how they are constructed in relation to broader medical education discourses. The findings are informative for educators to reflect on, rectify and reconstruct assessment practices for better facilitating trainee identity construction.

Veterinary professional identity: Conceptual analysis and location in a practice theory framework

Professional, social, and cultural issues and phenomena of veterinary practice are now established areas of commentary and interest in research, education, professional publications and even in the mainstream media. Despite the availability of theoretically informed literature in diverse relevant domains and disciplines including professional practice, workplace learning, and medical sociology and anthropology, commentary and research on veterinary practice issues and phenomena remains dominated by clinician-educators and clinician-policymakers. Reflecting the clinical disciplinary traditions, there is a resulting over-representation of individualistic, positivist perspectives and under-theorized research studies. In this paper we provide an interdisciplinary theoretical framework for veterinary practice and veterinary professional identity grounded in a practice theory perspective. We begin by arguing for the need for such a framework by scoping veterinary practice in its contemporary social context. We go on to provide a sociocultural framing of veterinary practice, underlining the mutual constitution of individuals and the social world through participation in practices and taking into consideration important concepts including knowledge, institutions, ethics, and embodiment. We assert the importance of professional identity as a core phenomenon of veterinary practice, constituted by making meaning of professional practice experiences, especially through narrative and dialogue. This practice theory framework for veterinary practice and veterinary professional identity development provides rich opportunities for understanding, researching, and enacting diverse activities and phenomena, especially learning, development and change within and beyond formal educational settings.

Teacher, Gatekeeper, or Team Member: supervisor positioning in programmatic assessment

Competency-based assessment is undergoing an evolution with the popularisation of programmatic assessment. Fundamental to programmatic assessment are the attributes and buy-in of the people participating in the system. Our previous research revealed unspoken, yet influential, cultural and relationship dynamics that interact with programmatic assessment to influence success. Pulling at this thread, we conducted secondary analysis of focus groups and interviews (n = 44 supervisors) using the critical lens of Positioning Theory to explore how workplace supervisors experienced and perceived their positioning within programmatic assessment. We found that supervisors positioned themselves in two of three ways. First, supervisors universally positioned themselves as a Teacher, describing an inherent duty to educate students. Enactment of this position was dichotomous, with some supervisors ascribing a passive and disempowered position onto students while others empowered students by cultivating an egalitarian teaching relationship. Second, two mutually exclusive positions were described-either Gatekeeper or Team Member. Supervisors positioning themselves as Gatekeepers had a duty to protect the community and were vigilant to the detection of inadequate student performance. Programmatic assessment challenged this positioning by reorientating supervisor rights and duties which diminished their perceived authority and led to frustration and resistance. In contrast, Team Members enacted a right to make a valuable contribution to programmatic assessment and felt liberated from the burden of assessment, enabling them to assent power shifts towards students and the university. Identifying supervisor positions revealed how programmatic assessment challenged traditional structures and ideologies, impeding success, and provides insights into supporting supervisors in programmatic assessment.

Learning in and across communities of practice: health professions education students' learning from boundary crossing

Learning to adapt to new contexts is crucial in health professions education (HPE). Boundaries between and within contexts challenge continuity in students' learning processes. Little is known about how HPE students can make these "boundary experiences" productive for learning. We investigated how and what nursing students learn from boundary experiences while they are simultaneously growing into a community of practice (CoP). Using a boundary-crossing lens, experiences of discontinuity were identified in pre-placement and post-placement interviews and diary fragments with 14 nursing students during their placement in an academic hospital. We found that students experience discontinuity as a result of different approaches to nursing care and to learning, both between (academic and clinical) settings and within a setting. When students feel safe enough, they can convert boundary experiences into meaningful learning situations, such as critical discussions with staff. Successfully overcoming boundary experiences improves students' understanding of healthcare and professional development and helps them to develop a personal approach to learning. Students critically address boundary experiences when they are motivated to learn and when they perceive a violation of ethical standards but not when they are concerned that it will affect their assessment. Objects designed to bridge theory and practice can generate additional barriers. This study adds to the HPE literature by demonstrating the learning potential of boundaries and to the broader literature by showing how responses to boundary experiences are intertwined with the process of growing into a CoP. The findings can be used to design future boundary objects.