Becoming a physician for older patients: exploring the professional identity formation of medical students during a nursing home clerkship. A qualitative study

BACKGROUND

To prepare medical students for the growing population of older patients, an appropriate professional identity formation is desirable. The community of practice of medical school is primarily hospital-based and disease-oriented which will lead to the development of a physician who is mainly focused on cure. This focus alone however is not always appropriate for older persons' health care. The aim of this study is to explore the influence of participating in a nursing home community of practice on the professional identity formation of medical students.

METHODS

A qualitative study based on a constructivist research paradigm was conducted, using individual semi-structured, in-depth interviews and a visual narrative method (drawing) as a prompt. Thematic analysis was applied to structure and interpret the data. The study population consisted of fifth-year medical students participating in a six-week nursing home clerkship. Thirteen participants were purposefully sampled. The clerkship took place in nursing homes in the South-West of the Netherlands.

RESULTS

The medical students described the nursing home as the living environment of the patients. Actively participating in the patients' care and experiencing the daily life of the patients was meaningful for the physician the students want to become in five ways: (1) a physician with a complete picture; (2) a physician who is close; (3) a physician who is in dialogue; (4) a physician who is able to let go and (5) a physican who collaborates.

CONCLUSIONS

Caring for older patients in the nursing home influences the professional identity formation of medical students. Patient-centeredness, personal, holistic and tailored care, approachability and collaboration are important characteristics in becoming a physician for older persons' health care. The context of this care provides relevant learning experiences for this development and the becoming of a physician in general.

The expression of ultimate life goals in co-creative art processes with palliative cancer patients

BACKGROUND

Co-creation, characterized by artists and patients creating a joint work of art, may support patients with the integration of disruptive life events into their life story, such as living with cancer. Focusing on experiences of contingency and life goals could support this process. The research questions are: (1) 'how are patient's ultimate life goals and experiences of contingency expressed in the work of art as created in a process of co-creation?'; (2) 'how do the four phases of integration of experiences of contingency unfold during co-creation?'

METHODS

Ten patients who were in a palliative stage of cancer treatment completed co-creation processes. Audio recordings of these co-creation processes were imported in Atlas-Ti and analysed by applying directed content analysis. We searched for life goals and experiences of contingency in the four phases of co-creation; Art communications, Element compilation, Consolidation, Reflection.

RESULTS

Patients used 4-8 sessions (median 5 sessions) with a duration of 90-240 min each (median duration 120 min). All patients expressed their experience of contingency and their ultimate life goals within the four phases of co-creation and in their work of art. A case description is presented illustrating the co-creation process.

CONCLUSIONS

During co-creation, patients move through four phases in which experiences of contingency and ultimate life goals can be made explicit through art making and can be expressed in the work of art, supporting integration of experiences of contingency into one's life narrative.

Co-creative art processes with cancer patients from the artists' perspective: a qualitative study exploring resonance theory

PURPOSE

Co-creation, characterised by artists and patients creating a joint work of art, may support patients with the integration of life events into their life story, such as living with cancer. In the process of co-creation, resonance relationships between patients, artists and material may evolve that support integration. We aim to investigate if and if so, how resonance relationships occur from the perspective of the artist.

METHODS

We used the first 10 audio recordings of supervision sessions between eight artists and their two supervisors on ongoing co-creation processes with cancer patients. By conducting a qualitative template analysis in AtlasTi, we searched for the presence of resonance, as defined by its four main characteristics, Being affected, touched and moved; Self-efficacy and responding; Moments of uncontrollability; and Adaptive transformation. In addition, two case descriptions are presented.

RESULTS

We found resonance relationships to be present in the studied co-creation processes where moments of uncontrollability can lead to a next step in the process of co-creation and as such form an important factor within co-creation.

CONCLUSIONS

The current study suggests focus on elements of resonance relationships within co-creation, specifically practising with uncontrollability while working with art, could strengthen interventions targeting integration of life events in advanced cancer patients.

Co-creative art processes with patients: A theoretical framework and qualitative study among artists

A cancer diagnosis may be experienced as a contingent life event. Co-creation—in which artists together with patients create a work of art reflecting on aspects of the patients’ life story—may be used to support patients to integrate such a contingent life event into their life story. We conducted a qualitative study in which we interviewed 10 professional artists to explore if co-creative art processes could facilitate integration of experiences of contingency in patients. Template analyses were performed in AtlasTi. We identified co-creation as a specific form of support to the process of integration of experiences of contingency. In the formation of a new life narrative, patients transcend the boundaries of their previous life narrative by changing their perspective. Self-transcendence forms a pivotal point in co-creation, which may be helpful for patients to integrate experiences of contingency into their life narratives.

This is what life with cancer looks like: exploring experiences of adolescent and young adults with cancer using two visual approaches

INTRODUCTION

Talking about illness experience can be challenging for adolescents and young adults (AYAs) with cancer. Visual tools, in addition to spoken language, might make this easier, such as rich pictures and photovoice. We aimed to obtain a comprehensive view of the cancer experience of AYAs by using rich pictures and photovoice.

METHODS

AYAs (18-35 years old) who had any type of cancer, or were in remission from cancer, were eligible. AYAs drew rich pictures about their experience of living with cancer and explained these during subsequent interviews. Some of the AYAs also participated in photovoice and spent two days with a photographer to make photos about their illness experience. Rich pictures and photos were first analyzed separately, using open coding, after which the identified themes were compared.

RESULTS

Twelve AYAs made rich pictures (RPs), of whom seven also participated in photovoice. The two most predominant themes emerging from the data were struggles related to the future and defining one's identity. The AYAs expressed concerns for the future related to relationships, education, and employment. Relating to defining one's identity, many AYAs expressed that the cancer had a negative impact on their body- and self-image. The main themes were visible in the RPs as well as in the photovoice; however, subtle differences in sub-themes were found.

CONCLUSIONS

We found that cancer has an effect on many aspects of AYAs' lives. Further research on how the identified themes play a role in the lives of AYAs with cancer is needed.

Symptom- and Prevention-Based Testing of COVID-19 in Nursing Home Residents: A Retrospective Cohort Study

Nursing homes (NH) residents with COVID-19 can either be tested because of presence of core symptoms (S-based) or because of transmission prevention (TP-based). The investigated study sample included all NH residents who underwent SARS-CoV-2 RT-PCR testing between March 16, 2020 and May 31, 2020 (n = 380). Clinical symptoms, temperature, and oxygen saturation were extracted from medical records, 7 days before to 14 days after testing. COVID-19 was confirmed in 81 (21%) residents; 36 (44%) S-based and 45 (56%) TP-based: 45. Cycle threshold (CT) values did not differ between the groups. In the 7 days prior to the test falling (32%), somnolence (25%) and fatigue (21%) occurred in both groups. Two days before the test, we observed a stronger decrease in oxygen saturation and an increase in temperature for the S-based group compared to the T-based group that remained up to 10 days after testing. Residents within the S-based group were 2.5 times more likely to increased mortality within 30 days than residents in the TP-based group (HR, 2.56; 95% 1.3–5.2). Although, 73% of the T-based group did eventually develop core symptoms. Thus, attention to falling and daily measures of temperature and oxygen saturation can contribute to earlier detection.

Educators' experiences with governance in curriculum change processes; a qualitative study using rich pictures

In the midst of continuous health professions curriculum reforms, critical questions arise about the extent to which conceptual ideas are actually put into practice. Curricula are often not implemented as intended. An under-explored aspect that might play a role is governance. In light of major curriculum changes, we explored educators' perspectives of the role of governance in the process of translating curriculum goals and concepts into institutionalized curriculum change at micro-level (teacher-student). In three Dutch medical schools, 19 educators with a dual role (teacher and coordinator) were interviewed between March and May 2018, using the rich pictures method. We employed qualitative content analysis with inductive coding. Data collection occurred concurrently with data analysis. Different governance processes were mentioned, each with its own effects on the curriculum and organizational responses. In Institute 1, participants described an unclear governance structure, resulting in implementation chaos in which an abstract educational concept could not be fully realized. In Institute 2, participants described a top-down and strict governance structure contributing to relatively successful implementation of the educational concept. However it also led to demotivation of educators, who started rebelling to recover their perceived loss of freedom. In Institute 3, participants described a relatively fragmentized process granting a lot of freedom, which contributed to contentment and motivation but did not fully produce the intended changes. Our paper empirically illustrates the importance of governance in curriculum change. To advance curriculum change processes and improve their desired outcomes it seems important to define and explicate both hard and soft governance processes.

Repeated use of rich pictures to explore changes in subjective experiences over time of patients with advanced cancer

BACKGROUND

The combination of verbal and visual tools may help unravel the experiences of advanced cancer patients. However, most previous studies have focused on a specific symptom, at only one moment in time. We recently found that a specific visual tool, originating from systems thinking, that is, rich pictures (RPs), could provide a more comprehensive view of the experiences of patients with advanced cancer.

AIMS

To examine whether the repeated use of RPs can make changes in subjective experiences of patients living with advanced cancer visible over time.

METHODS AND RESULTS

We performed a prospective study with a generic qualitative approach that was mostly informed by the process of grounded theory. We invited patients to make an RP twice, at the start of the study, and again after 2 months. Both RP drawing sessions were directly followed by a semi-structured interview. Patients with all types of solid tumors, above the age of 18, and with a diagnosis of advanced, incurable cancer, were eligible. Eighteen patients participated and 15 patients were able to draw an RP twice. In eight RP-sets, considerable differences between the first and second RP were noticeable. Two patterns were distinguished: (1) a change (decline or improvement) in physical health (five patients), and/or (2) a change in the way patients related to cancer (three patients).

CONCLUSION

RPs are a valuable qualitative research method that can be used to explore the experiences of patients with advanced cancer, not only at a single point in time but also over time.

'I found myself a despicable being!': Medical students face disturbing moral dilemmas

CONTEXT

The psychological realm of medical students' moral experiences is explored tangentially in medical education literature, often in the context of ethics or professionalism education. This study deepens our understanding by (a) investigating the nature of moral dilemmas experienced at the onset of clinical practice, (b) exploring students' emotional response to these dilemmas, and (c) examining how students perceive the influence of these dilemmas on their professional development.

METHODS

This is a cross-sectional qualitative study carried out in 2017 that applied thematic template analysis to individual interviews performed with last-year medical students. The interviews followed the drawing of a Rich Picture representing moral dilemmas experienced by medical students at the onset of clinical practice.

RESULTS

Moral dilemmas have four intertwined dimensions. The first relates to students' struggle to prioritise, balance and apply conflicting moral values; the second comprises the clash between students' inner motivation and the external constraints that limit the moral action; the third refers to the conflict between students' current attitudes with the desired/idealised attitudes of the doctor they intend to become; and the fourth corresponds to weighting conflicting ethical principles during the moral decision. Students' emotional responses are intense and long-lasting, and with a remarkable residue effect, particularly when the moral decision does not align with their moral beliefs. Moral dilemmas are impactful experiences that affect the professional development of medical students and can culminate in both detachment and growth in moral courage.

CONCLUSION

Moral dilemmas are memorable, complex and emotionally intense experiences that impact the professional development of medical students. Understanding students' moral dilemmas can help educators to devise pedagogical activities to anticipate and reflect on these experiences. These activities should happen under the guidance of a non-judgemental facilitator, capable of listening and legitimating students' thoughts and feelings while providing insights to nurture their professional development.

Narrative recognition and identification: a qualitative pilot study into reading literary texts with advanced cancer patients

Purpose

Patients with advanced cancer can experience their disease as a contingent life event. The sudden interruption of their life stories can obscure life goals and disrupt meaning making. In the context of the research project “In search of stories,” we aim to investigate the reading and discussion of selected stories which present ways of dealing with a contingent life event. In addition, we examine the use of a newly developed guide for reading these exemplary texts together with advanced cancer patients.

Methods

This qualitative study describes the experiences of five patients with advanced cancer who participated in a guided reading and discussion about selected literary texts. The intervention consisted of reading a selected story, after which each patient was interviewed, using the reading guide as a conversation template. The interviews were then thematically analyzed for their conceptual content using a template analysis.

Results

All five conversations showed some form of recognition in reaction to the chosen text, which led to personal identification of experiences of contingency, such as loss of life goals, impending death, or feelings of uncertainty. Besides the important role of identification, revealed by the responses to the questions in the reading guide, the discussion of the text helped them articulate their own experience and sources of meaning. Diverse worldviews came to the fore and concepts of meaning such as fate, life goals, quality of life, and death.

Conclusions

First experiences with our newly developed reading guide designed to support a structured reading of stories containing experiences of contingency suggest that it may help patients to express their own experiences of contingency and to reflect on these experiences.

Implications for Cancer Survivors

The intervention tested in this study may contribute to supportive care for survivors with advanced cancer, but further research is needed to evaluate its effect on quality of life.

Medical Education Empowered by Theater (MEET)

The medical education community acknowledges the importance of including the humanities in general, and the liberal arts in particular, in the education of health professionals. Among the liberal arts, theater is especially helpful for educators wanting to bring experiences that are both real and challenging to the learning encounter in an interactive, engaging, and reflective way. In this Perspective, the authors share what they have learned after working together with a company of actors for 8 years (2012-2019) in different obligatory and elective curricular activities. Influenced by Freire's Pedagogy of the Oppressed and the ideas of Boal's Theatre of the Oppressed, Medical Education Empowered by Theater (MEET) embraces social accountability and applies the concept of sensible cognition to empower medical students as the protagonists of their learning and professional development to become agents of change-both in patients' lives and in health care systems. The MEET theoretical framework builds on the concepts of liberation, emancipatory education, critical pedagogy, and participatory theater to offer medical students and teachers an opportunity to problematize, criticize, and hopefully reform the hierarchical and often oppressive structures of medical education and practice. MEET sessions include activating previous knowledge and experiences, warm-up exercises, different improvisational exercises, debriefing, and synthesis. Vital to the praxis of MEET is applying theater-teaching traditions to develop capacities important in medicine: presence, empathy, improvisation, communication (verbal and nonverbal), and scenic intelligence (i.e., the capacity to self-assess one's performance while performing). The authors believe that theater offers a venue to integrate both the personal and professional development of students into a process of reflection and action, targeting the transformation of the medical culture toward social justice.

Trainee-environment interactions that stimulate motivation: A rich pictures study

CONTEXT

Staying motivated when working and learning in complex workplaces can be challenging. When complex environments exceed trainees' aptitude, this may reduce feelings of competence, which can hamper motivation. Motivation theories explain how intrapersonal and interpersonal aspects influence motivation. Clinical environments include additional aspects that may not fit into these theories. We used a systems approach to explore how the clinical environment influences trainees' motivation and how they are intertwined.

METHODS

We employed the rich pictures drawing method as a visual tool to capture the complexities of the clinical environment. A total of 15 trainees drew a rich picture representing a motivating situation in the workplace and were interviewed afterwards. Data collection and analysis were performed iteratively, following a constructivist grounded theory approach, using open, focused and selective coding strategies as well as memo writing. Both drawings and the interviews were used to reach our results.

RESULTS

Trainees drew situations pertaining to tasks they enjoyed doing and that mattered for their learning or patient care. Four dimensions of the environment were identified that supported trainees' motivation. First, social interactions, including interpersonal relationships, supported motivation through close collaboration between health care professionals and trainees. Second, organisational features, including processes and procedures, supported motivation when learning opportunities were provided or trainees were able to influence their work schedule. Third, technical possibilities, including tools and artefacts, supported motivation when tools were used to provide trainees with feedback or trainees used specific instruments in their training. Finally, physical space supported motivation when the actual setting improved the atmosphere or trainees were able to modify the environment to help them focus.

CONCLUSIONS

Different clinical environment dimensions can support motivation and be modified to create optimal motivating situations. To understand motivational dynamics and support trainees to navigate through postgraduate medical education, we need to take all clinical environment dimensions into account.

"My right-hand man" versus "We barely make use of them": change leaders talking about educational scientists in curriculum change processes-a Membership Categorization Analysis

Health professions education scholarship units (HPESUs) are increasingly becoming a standard for medical schools worldwide without having much information about their value and role in actual educational practices, particularly of those who work in these units, the educational scientists. We conducted a linguistic analysis, called Membership Categorization Analysis, of interviews with leaders of recent curriculum changes to explore how they talk about educational scientists in relation to these processes. The analysis was conducted on previously collected interview data with nine change leaders of major undergraduate medical curriculum change processes in the Netherlands. We analyzed how change leaders categorize HPESUs and educational scientists (use of category terms) and what they say about them (predicates). We noticed two ways of categorizing educational scientists, with observable different predicates. Educational scientists categorized by their first name were suggested to be closer to the change process, more involved in decisional practices and positively described, whereas those described in more generic terms were represented in terms of relatively passive and unspecified activities, were less explicit referenced for their knowledge and expertise and were predominantly factually or negatively described. This study shows an ambiguous portrayal of educational scientists by leaders of major curriculum change processes. Medical schools are challenged to establish medical curricula in consultation with a large, diverse and interdisciplinary stakeholder group. We suggest that it is important to invest in interpersonal relationships to strengthen the internal collaborations and make sure people are aware of each other's existence and roles in the process of curriculum development.

Medical student views of and responses to expectations of professionalism

CONTEXT

To earn society's trust, medical students must develop professional values and behaviours via a transformative process, from lay person to doctor. Yet students are expected to epitomise the values and behaviours of a doctor from the outset of medical school, leading them to feel 'judged all the time' (in terms of their professionalism). Our aim, therefore, is to extend knowledge exploring the expectations communicated to and perceived by medical students and to provide a conceptually framed understanding of students' associated emotional tensions.

METHODS

We used a qualitative exploratory case study methodology within a constructivist paradigm to explore the messages communicated about professionalism and students' perceived expectations of professionalism in one medical school. Data were collected in the form of: (i) regulatory and medical school documents, and (ii) focus groups with 23 participants in their first 2 years at medical school. We used thematic analysis for data interpretation and two theoretical lenses, Amalberti et al.'s framework of system migration for health care and Sinclair's adaptation of Goffman's dramaturgical theory, to critically analyse the results.

RESULTS

We found messages and perceived expectations of knowledge and competence, and the need to ensure trust. We also identified that the expectations of patients, doctors, society, family and friends are just as, if not more, influential than policy and regulatory expectations for early years' medical students. Moreover, we found tensions, with students feeling that the expectations of them from others were unrealistic for their level of training. With this came a sense of pressure to meet expectations that participants responded to by acting as if already competent.

CONCLUSIONS

Our findings suggest that external forces (expectations) drive early years' students to act as if competent. Although this is part of student identity formation it could also have implications for patient safety and therefore necessitates recognition and support from educators.

Social Interactions of Clerks: The Role of Engagement, Imagination, and Alignment as Sources for Professional Identity Formation

PURPOSE

Participating in clinical practice shapes students' identities, but it is unclear how students build meaningful relationships while "dipping into" various social contexts. This study explored with whom students interacted, which social relationships they built, and how these relationships contributed to the formation of a professional identity.

METHOD

In this longitudinal study at University Medical Center Groningen, University of Groningen, the Netherlands, 9 undergraduate medical students recorded experiences of thinking about themselves as future professionals (September 2015 to March 2017). The authors conducted template analysis using both open coding and a priori themes derived from Wenger's modes of belonging to communities of practice: engagement, imagination, and alignment.

RESULTS

The authors received 205 recorded experiences. While rotating, students used engagement, imagination, and alignment to give meaning to clinical workplace social interactions. Participants considered relationships with doctors, patients, and peers as preconditions for engaging in meaningful experiences. Although imagination and alignment were less represented, discussing imagination with peers and physicians stimulated a deeper understanding of what it means to become a physician. Explicitly being invited "to the table" and awareness of the benefits of being a clerk were instances of alignment that stimulated the development of identities as future doctors.

CONCLUSIONS

To understand the nature of professional identity formation, Wenger's modes of belonging must be considered. Where engagement is very prevalent, imagination and alignment are less spontaneously mentioned and therefore more difficult to foster. Looking for ways to support imagination and alignment is important for students' sensemaking process of becoming a doctor.

Rich pictures: a companion method for qualitative research in medical education

CONTEXT

Within the social sciences, researchers increasingly build on visual methods to explore complex phenomena and understand how people experience and give meaning to this complexity. Amongst the variety of visual methods available, rich pictures are beginning to gain traction in health professions education (HPE) research.

APPROACH

A rich picture is a pictorial representation of a particular situation, including what happened, who was involved, how people felt, how people acted, how people behaved, and what external pressures they acted upon. Rich pictures expand our perspective; they may highlight connections, illuminate the big picture and reveal unexpected emotions. Although new methods bring excitement to the field, it is our responsibility to also be cautious and insightful about their limitations. Rich pictures are a method in evolution in HPE research, with many unknowns about what is possible and what is optimal.

PURPOSE

In the current paper, we aim to map out the background, describe the process and share some reflective insights of using rich pictures as a data collection method.

Living with advanced cancer: Rich Pictures as a means for health care providers to explore the experiences of advanced cancer patients

Background

To provide holistic care to patients with advanced cancer, health care professionals need to gain insight in patients’ experiences across the different domains of health. However, describing such complex experiences verbally may be difficult for patients. The use of a visual tool, such as Rich Pictures (RPs) could be helpful. We explore the use of RPs to gain insight in the experiences of patients with advanced cancer.

Methods

Eighteen patients with advanced cancer were asked to draw a RP expressing how they experienced living with cancer, followed by a semi‐structured interview. Qualitative content analysis, including the examination of all elements in the drawings and their interrelationships, was used to analyze the RPs, which was further informed by the interviews.

Results

The RPs clearly showed what was most important to an individual patient and made relations between elements visible at a glance. Themes identified included: medical aspects, the experience of loss, feelings related to loss, support from others and meaningful activities, and integration of cancer in one's life. The added value of RPs lies in the ability to represent these themes in one single snapshot.

Conclusions

RPs allow for a complementary view on the experiences of advanced cancer patients, as they show and relate different aspects of patients’ lives. A RP can provide health care professionals a visual summary of the experiences of a patient. For patients, telling their story to health care professionals might be facilitated when using RPs.

Navigating the Complexities of Undergraduate Medical Curriculum Change: Change Leaders' Perspectives

PURPOSE

Changing an undergraduate medical curriculum is a recurring, high-stakes undertaking at medical schools. This study aimed to explore how people leading major curriculum changes conceived of the process of enacting change and the strategies they relied on to succeed in their efforts.

METHOD

The first author individually interviewed nine leaders who were leading or had led the most recent undergraduate curriculum change in one of the eight medical schools in the Netherlands. Interviews were between December 2015 and April 2016, using a semistructured interview format. Data analysis occurred concurrently with data collection, with themes being constructed inductively from the data.

RESULTS

Leaders conceived of curriculum change as a dynamic, complex process. They described three major challenges they had to deal with while navigating this process: the large number of stakeholders championing a multitude of perspectives, dealing with resistance, and steering the change process. Additionally, strategies for addressing these challenges were described. The authors identified an underlying principle informing the work of these leaders: being and remaining aware of emerging situations, and carefully constructing strategies for ensuring that the intended outcomes were reached and contributed to the progress of the change process.

DISCUSSION

This empirical, descriptive study enriches the understanding of how institutional leaders navigate the complexities of major medical curriculum changes. The insights serve as a foundation for training and coaching future change leaders. To broaden the understanding of curriculum change processes, future studies could investigate the processes through alternative stakeholder perspectives.

'You put up a certain attitude': a 6-year qualitative study of emotional socialisation

CONTEXT

Emotions play a central role in the professional development of doctors; however, research into how students are socialised to deal with emotions throughout medical school is still lacking.

OBJECTIVES

This study aimed to gain a better understanding of the emotional socialisation of medical students (e.g. how they learn to express and respond to emotions evoked in clinical practice in the process of becoming a doctor).

METHODS

In this longitudinal study, 12 medical students participated in annual, individual, semi-structured interviews, capturing the full 6-year medical school period. We carried out a thematic analysis, which was iterative and inductive.

RESULTS

The socialisation of emotion in the process of becoming a doctor happens in a complex interplay between student and context. We identified two modes of emotional socialisation (e.g. explicit and implicit teaching about emotions), the latter including how the people observed by students express their emotions and how they respond to the emotions expressed by students. Although the main message conveyed to students still seemed one about hiding or suppressing emotion, we found that students were able to identify and build upon the emotional expression and responses they observed in positive role models and managed to create their own opportunities to express their emotions. We found large differences between students in how they perceived, presented and developed themselves.

CONCLUSIONS

Students differ in how they respond to and what they need from their environment and thus may benefit from tailored supervision in learning how to experience, express and respond to emotion. Providing students with real and authentic responsibility for patients and allowing them time and opportunity to talk about emotion might help them to create an emotional space.

Context, culture and beyond: medical oaths in a globalising world

The authors argue oath taking to be an expression of context specific social processes and that seemingly universal concepts might be conceived variably.

How to…choose between different types of data

This article, on how to choose the types of data that are most appropriate to your study, is the third in a series that aims to support researchers within clinical education who are new to qualitative research. Although individual or focus group interviews may seem to be the most obvious source of data in qualitative research, we describe some alternative data sources and how they can be of value in answering certain research questions. We provide examples of how research participants may tell you about their experiences through audio diaries, how they may show you what is going on by drawing a picture, and how you can study what actually happens in practice by observing how people interact, move, dress and use space. By doing so, we hope to catch your interest and inspire you to think of all the different possibilities when setting up a qualitative study. In qualitative research, almost everything in the real world can serve as data.

'Oh my God, I can't handle this!': trainees' emotional responses to complex situations

CONTEXT

Dealing with emotions is critical for medical trainees' professional development. Taking a sociocultural and narrative approach to understanding emotions, we studied complex clinical situations as a specific context in which emotions are evoked and influenced by the social environment. We sought to understand how medical trainees respond to emotions that arise in those situations.

METHODS

In an international constructivist grounded theory study, 29 trainees drew two rich pictures of complex clinical situations, one exciting and one frustrating. Rich pictures are visual representations that capture participants' perceptions about the people, situations and factors that create clinical complexity. These pictures were used to guide semi-structured, individual interviews. We analysed visual materials and interviews in an integrated way, starting with looking at the drawings, doing a 'gallery walk', and using the interviews to inform the aesthetic analysis.

RESULTS

Participants' drawings depicted a range of personal emotions in response to complexity, and disclosed unsettling feelings and behaviours that might be considered unprofessional. When trainees felt confident, they were actively participating, engaged in creative problem-solving strategies, and emphasised their personal involvement. When trainees felt the situation was beyond their control, they described how they were running away from the situation, hiding themselves behind others or distancing themselves from patients or families.

CONCLUSIONS

A sense of control seems to be a key factor influencing trainees' emotional and behavioural responses to complexity. This is problematic, as complex situations are by their nature emergent and dynamic, which limits possibilities for control. Following a social performative approach to emotions, we should help students understand that feeling out of control is an inherent property of participating in complex clinical situations, and, by extension, that it is not something they will 'grow out of' with expertise.

Authoring the identity of learner before doctor in the figured world of medical school

INTRODUCTION

Students enter the 'figured world' of medical school with preconceptions of what it means to be a doctor. The meeting of these early preconceptions and their newly developing identities can create emotional tensions. The aim of this study was to advance our understanding of how such tensions were experienced and managed. Using figured worlds as a theoretical framework we explored students' interactions of preconceptions with their newly developing professional identities in their first year at medical school. Advancing our understanding of this phenomena provided new insights into the complex process of identity formation.

METHODS

This was a qualitative study underpinned by a constructivist epistemology. We ran biannual focus groups with 23 first year students in one UK medical school. Data were recorded, transcribed and then template analysis used to undertake an inductive, iterative process of analysis until it was considered the template provided a detailed representation of the data.

RESULTS

Significant preconceptions associated with the identity of a doctor were 'to help' and 'to be a leader'. These early preconceptions were in conflict with realities of the figured world of medical school creating the emotional tensions of 'being unable to help' and 'lacking power', with implications for interactions with patients. By the end of year one students' negotiated tensions and 'self-authored' their identity as a learner as opposed to an imagined 'as if' identity of a doctor.

DISCUSSION

We revealed how preconceptions associated with becoming a doctor can conflict with a newly developing professional identity highlighting the importance of supporting students to embrace the formation of a 'learner' identity, a necessary part of the process of becoming a doctor.

Context matters when striving to promote active and lifelong learning in medical education

WHERE DO WE STAND NOW?: In the 30 years that have passed since The Edinburgh Declaration on Medical Education, we have made tremendous progress in research on fostering 'self-directed and independent study' as propagated in this declaration, of which one prime example is research carried out on problem-based learning. However, a large portion of medical education happens outside of classrooms, in authentic clinical contexts. Therefore, this article discusses recent developments in research regarding fostering active learning in clinical contexts.

SELF-REGULATED, LIFELONG LEARNING IN MEDICAL EDUCATION

Clinical contexts are much more complex and flexible than classrooms, and therefore require a modified approach when fostering active learning. Recent efforts have been increasingly focused on understanding the more complex subject of supporting active learning in clinical contexts. One way of doing this is by using theory regarding self-regulated learning (SRL), as well as situated learning, workplace affordances, self-determination theory and achievement goal theory. Combining these different perspectives provides a holistic view of active learning in clinical contexts. ENTRY TO PRACTICE, VOCATIONAL TRAINING AND CONTINUING PROFESSIONAL DEVELOPMENT: Research on SRL in clinical contexts has mostly focused on the undergraduate setting, showing that active learning in clinical contexts requires not only proficiency in metacognition and SRL, but also in reactive, opportunistic learning. These studies have also made us aware of the large influence one's social environment has on SRL, the importance of professional relationships for learners, and the role of identity development in learning in clinical contexts. Additionally, research regarding postgraduate lifelong learning also highlights the importance of learners interacting about learning in clinical contexts, as well as the difficulties that clinical contexts may pose for lifelong learning. However, stimulating self-regulated learning in undergraduate medical education may also make postgraduate lifelong learning easier for learners in clinical contexts.

How characteristic routines of clinical departments influence students' self-regulated learning: A grounded theory study

BACKGROUND

In clerkships, students are expected to self-regulate their learning. How clinical departments and their routine approach on clerkships influences students' self-regulated learning (SRL) is unknown.

AIM

This study explores how characteristic routines of clinical departments influence medical students' SRL.

METHODS

Six focus groups including 39 purposively sampled participants from one Dutch university were organized to study how characteristic routines of clinical departments influenced medical students' SRL from a constructivist paradigm, using grounded theory methodology. The focus groups were audio recorded, transcribed verbatim and were analyzed iteratively using constant comparison and open, axial and interpretive coding.

RESULTS

Students described that clinical departments influenced their SRL through routines which affected the professional relationships they could engage in and affected their perception of a department's invested effort in them. Students' SRL in a clerkship can be supported by enabling them to engage others in their SRL and by having them feel that effort is invested in their learning.

CONCLUSIONS

Our study gives a practical insight in how clinical departments influenced students' SRL. Clinical departments can affect students' motivation to engage in SRL, influence the variety of SRL strategies that students can use and how meaningful students perceive their SRL experiences to be.

Emotional Learning and Identity Development in Medicine: A Cross-Cultural Qualitative Study Comparing Taiwanese and Dutch Medical Undergraduates

PURPOSE

Current knowledge about the interplay between emotions and professional identity formation is limited and largely based on research in Western settings. This study aimed to broaden understandings of professional identity formation cross-culturally.

METHOD

In fall 2014, the authors purposively sampled 22 clinical students from Taiwan and the Netherlands and asked them to keep audio diaries, narrating emotional experiences during clerkships using three prompts: What happened? What did you feel/think/do? How does this interplay with your development as a doctor? Dutch audio diaries were supplemented with follow-up interviews. The authors analyzed participants' narratives using a critical discourse analysis informed by Figured Worlds theory and Bakhtin's concept of dialogism, according to which people's spoken words create identities in imagined future worlds.

RESULTS

Participants talked vividly, but differently, about their experiences. Dutch participants' emotions related to individual achievement and competence. Taiwanese participants' rich, emotional language reflected on becoming both a good person and a good doctor. These discourses constructed doctors' and patients' autonomy in culturally specific ways. The Dutch construct centered on "hands-on" participation, which developed the identity of a technically skilled doctor, but did not address patients' self-determination. The Taiwanese construct located physicians' autonomy within moral values more than practical proficiency, and gave patients agency to influence doctor-patient relationships.

CONCLUSIONS

Participants' cultural constructs of physician and patient autonomy led them to construct different professional identities within different imagined worlds. The contrasting discourses show how medical students learn about different meanings of becoming doctors in culturally specific contexts.

'How would you call this in English?' : Being reflective about translations in international, cross-cultural qualitative research

INTRODUCTION

Medical education researchers increasingly collaborate in international teams, collecting data in different languages and from different parts of the world, and then disseminating them in English-language journals. Although this requires an ever-present need to translate, it often occurs uncritically. With this paper we aim to enhance researchers' awareness and reflexivity regarding translations in qualitative research.

METHODS

In an international study, we carried out interviews in both Dutch and English. To enable joint data analysis, we translated Dutch data into English, making choices regarding when and how to translate. In an iterative process, we contextualized our experiences, building on the social sciences and general health literature about cross-language/cross-cultural research.

RESULTS

We identified three specific translation challenges: attending to grammar or syntax differences, grappling with metaphor, and capturing semantic or sociolinguistic nuances. Literature findings informed our decisions regarding the validity of translations, translating in different stages of the research process, coding in different languages, and providing 'ugly' translations in published research reports.

DISCUSSION

The lessons learnt were threefold. First, most researchers, including ourselves, do not consciously attend to translations taking place in international qualitative research. Second, translation challenges arise not only from differences in language, but also from cultural or societal differences. Third, by being reflective about translations, we found meaningful differences, even between settings with many cultural and societal similarities. This conscious process of negotiating translations was enriching. We recommend researchers to be more conscious and transparent about their translation strategies, to enhance the trustworthiness and quality of their work.

Patterns in clinical students' self-regulated learning behavior: a Q-methodology study

Students feel insufficiently supported in clinical environments to engage in active learning and achieve a high level of self-regulation. As a result clinical learning is highly demanding for students. Because of large differences between students, supervisors may not know how to support them in their learning process. We explored patterns in undergraduate students' self-regulated learning behavior in the clinical environment, to improve tailored supervision, using Q-methodology. Q-methodology uses features of both qualitative and quantitative methods for the systematic investigation of subjective issues by having participants sort statements along a continuum to represent their opinion. We enrolled 74 students between December 2014 and April 2015 and had them characterize their learning behavior by sorting 52 statements about self-regulated learning behavior and explaining their response. The statements used for the sorting were extracted from a previous study. The data was analyzed using by-person factor analysis to identify clusters of individuals with similar sorts of the statements. The resulting factors and qualitative data were used to interpret and describe the patterns that emerged. Five resulting patterns were identified in students' self-regulated learning behavior in the clinical environment, which we labelled: Engaged, Critically opportunistic, Uncertain, Restrained and Effortful. The five patterns varied mostly regarding goals, metacognition, communication, effort, and dependence on external regulation for learning. These discrete patterns in students' self-regulated learning behavior in the clinical environment are part of a complex interaction between student and learning context. The results suggest that developing self-regulated learning behavior might best be supported regarding individual students' needs.

How clinical medical students perceive others to influence their self-regulated learning

OBJECTIVES

Undergraduate medical students are prone to struggle with learning in clinical environments. One of the reasons may be that they are expected to self-regulate their learning, which often turns out to be difficult. Students' self-regulated learning is an interactive process between person and context, making a supportive context imperative. From a socio-cultural perspective, learning takes place in social practice, and therefore teachers and other hospital staff present are vital for students' self-regulated learning in a given context. Therefore, in this study we were interested in how others in a clinical environment influence clinical students' self-regulated learning.

METHODS

We conducted a qualitative study borrowing methods from grounded theory methodology, using semi-structured interviews facilitated by the visual Pictor technique. Fourteen medical students were purposively sampled based on age, gender, experience and current clerkship to ensure maximum variety in the data. The interviews were transcribed verbatim and were, together with the Pictor charts, analysed iteratively, using constant comparison and open, axial and interpretive coding.

RESULTS

Others could influence students' self-regulated learning through role clarification, goal setting, learning opportunities, self-reflection and coping with emotions. We found large differences in students' self-regulated learning and their perceptions of the roles of peers, supervisors and other hospital staff. Novice students require others, mainly residents and peers, to actively help them to navigate and understand their new learning environment. Experienced students who feel settled in a clinical environment are less susceptible to the influence of others and are better able to use others to their advantage.

CONCLUSIONS

Undergraduate medical students' self-regulated learning requires context-specific support. This is especially important for more novice students learning in a clinical environment. Their learning is influenced most heavily by peers and residents. Supporting novice students' self-regulated learning may be improved by better equipping residents and peers for this role.

Becoming a Doctor in Different Cultures: Toward a Cross-Cultural Approach to Supporting Professional Identity Formation in Medicine

Becoming a doctor is fundamentally about developing a new, professional identity as a physician, which in and of itself may evoke many emotions. Additionally, medical trainees are increasingly moving from one cultural context to another and are challenged with navigating the resulting shifts in their professional identify. In this Article, the authors aim to address medical professional identity formation from a polyvocal, multidisciplinary, cross-cultural perspective. They delineate the cultural approaches to medical professionalism, reflect on professional identity formation in different cultures and on different theories of identity development, and advocate for a context-specific approach to professional identity formation. In doing so, the authors aim to broaden the developing professional identity formation discourse to include non-Western approaches and notions.

Dealing with emotions: medical undergraduates' preferences in sharing their experiences

CONTEXT

Patient care evokes emotional responses such as uncertainty, grief and pride in medical students. There is a need for opportunities to share and express such emotions because they influence students' professional development and well-being. There is a trend towards introducing mentor programmes into medical curricula. It remains unknown whether students are willing and able to share their emotional experiences within this formal setting. We set out to explore how medical students share their emotional experiences and why.

METHODS

We used thematic analysis, including purposeful sampling, parallel processes of data collection and constant comparative analysis, maintaining an audit trail for validation purposes. The study had a constructivist, interactional design and used Goffman's dramaturgical theory as an interpretive framework. Nineteen students participated in individual, semi-structured interviews.

RESULTS

Participants' narratives revealed a preference for sharing emotional experiences away from people who might expect them to uphold formal behaviour. They deliberately decided with whom to share their emotional experiences. Participants had a preference to talk to fellow students working in the same department, or family and friends outside medical school.

CONCLUSIONS

Participants found it difficult to uphold behaviours that they thought patients, preceptors or the organisation expected of them as future doctors. In adjusting their behaviour to meet those expectations, they became attuned to how to best present themselves based on the people present. This influenced how they chose which emotional experiences to share with whom.

The impact of chemosensory and food-related changes in patients with advanced oesophagogastric cancer treated with capecitabine and oxaliplatin: a qualitative study

Purpose

Chemosensory changes are frequently observed side effects of cytotoxic treatment and have an impact on daily life by altering food-related behaviour and daily practices. For oesophagogastric cancer patients, these changes can be particularly important as they may have specific needs with regard to eating, due to obstruction of the upper intestinal tract. The purpose of this study was to gain insight into the impact of chemosensory and food-related changes in oesophagogastric cancer patients undergoing chemotherapy and how this may influence the practical and social aspects of food-related behaviour of patients and their relatives.

Methods

We used a qualitative interview approach with a cross-sectional design using semi-structured interviews. Template analysis was used to analyse patients’ experiences with and the impact of chemosensory changes on daily life. Thirteen advanced oesophagogastric cancer patients treated with capecitabine and oxaliplatin were included by convenience sampling, recruited from one academic hospital, and interviewed at home or in the hospital.

Results

There was a large variation in the impact of chemosensory changes in oesophagogastric cancer (OGC) patients, though daily life was impacted substantially when chemosensory and/or food-related changes were experienced. Three main themes emerged from the interviews: altered food preferences, practical constraints in daily life, and impact on social functioning.

Conclusion

Chemosensory and food-related changes significantly influenced food preferences and had practical and social consequences in daily life of patients and their relatives. Specific nutritional care for these patients should be directed towards enhancing food enjoyment and should take the specific needs, related to the location of the tumour, into account.

Professional identity at stake: a phenomenological analysis of spiritual counselors' experiences working with a structured model to provide care to palliative cancer patients

Background

Good palliative care requires excellent interprofessional collaboration; however, working in interprofessional teams may be challenging and difficult.

Aim

The aim of the study is to understand the lived experience of spiritual counselors working with a new structured method in offering spiritual care to palliative patients in relation to a multidisciplinary health care team.

Design

Interpretive phenomenological analysis of in-depth interviews, was done using template analysis to structure the data. We included nine spiritual counselors who are trained in using the new structured method to provide spiritual care for advanced cancer patients.

Results

Although the spiritual counselors were experiencing struggles with structure and iPad, they were immediately willing to work with the new structured method as they expected the visibility and professionalization of their profession to improve. In this process, they experienced a need to adapt to a certain role while working with the new method and described how the identities of the profession were challenged.

Conclusions

There is a need to concretize, professionalize, and substantiate the work of spiritual counselors in a health care setting, to enhance visibility for patients and improve interprofessional collaboration with other health care workers. However, introducing new methods to spiritual counselors is not easy, as this may challenge or jeopardize their current professional identities. Therefore, we recommend to engage spiritual counselors early in processes of change to ensure that the core of who they are as professionals remains reflected in their work.

Exploring the factors influencing clinical students' self-regulated learning

OBJECTIVES

The importance of self-regulated learning (SRL) has been broadly recognised by medical education institutions and regulatory bodies. Supporting the development of SRL skills has proven difficult because self-regulation is a complex interactive process and we know relatively little about the factors influencing this process in real practice settings. The aim of our study was therefore to identify factors that support or hamper medical students' SRL in a clinical context.

METHODS

We conducted a constructivist grounded theory study using semi-structured interviews with 17 medical students from two universities enrolled in clerkships. Participants were purposively sampled to ensure variety in age, gender, experience and current clerkship. The Day Reconstruction Method was used to help participants remember their activities of the previous day. The interviews were transcribed verbatim and analysed iteratively using constant comparison and open, axial and interpretive coding.

RESULTS

Self-regulated learning by students in the clinical environment was influenced by the specific goals perceived by students, the autonomy they experienced, the learning opportunities they were given or created themselves, and the anticipated outcomes of an activity. All of these factors were affected by personal, contextual and social attributes.

CONCLUSIONS

Self-regulated learning of medical students in the clinical environment is different for every individual. The factors influencing this process are affected by personal, social and contextual attributes. Some of these are similar to those known from previous research in classroom settings, but others are unique to the clinical environment and include the facilities available, the role of patients, and social relationships pertaining to peers and other hospital staff. To better support students' SRL, we believe it is important to increase students' metacognitive awareness and to offer students more tailored learning opportunities.

Learning to care for older patients: hospitals and nursing homes as learning environments

CONTEXT

A significant challenge facing health care is the ageing of the population, which calls for a major response in medical education. Most clinical learning takes place within hospitals, but nursing homes may also represent suitable learning environments in which students can gain competencies in geriatric medicine.

OBJECTIVES

This study explores what students perceive as the main learning outcomes of a geriatric medicine clerkship in a hospital or a nursing home, and explicitly addresses factors that may stimulate or hamper the learning process.

METHODS

This qualitative study falls within a constructivist paradigm: it draws on socio-cultural learning theory and is guided by the principles of constructivist grounded theory. There were two phases of data collection. Firstly, a maximum variation sample of 68 students completed a worksheet, giving brief written answers on questions regarding their geriatric medicine clerkships. Secondly, focus group discussions were conducted with 19 purposively sampled students. We used template analysis, iteratively cycling between data collection and analysis, using a constant comparative process.

RESULTS

Students described a broad range of learning outcomes and formative experiences that were largely distinct from their learning in previous clerkships with regard to specific geriatric knowledge, deliberate decision making, end-of-life care, interprofessional collaboration and communication. According to students, the nursing home differed from the hospital in three aspects: interprofessional collaboration was more prominent; the lower resources available in nursing homes stimulated students to be creative, and students reported having greater autonomy in nursing homes compared with the more extensive educational guidance provided in hospitals.

CONCLUSIONS

In both hospitals and nursing homes, students not only learn to care for older patients, but also describe various broader learning outcomes necessary to become good doctors. The results of our study, in particular the specific benefits and challenges associated with learning in the nursing home, may further inform the implementation of geriatric medicine clerkships in hospitals and nursing homes.

Emotions and identity in the figured world of becoming a doctor

CONTEXT

There is little room in clerkship curricula for students to express emotions, particularly those associated with the development of a caring identity. Yet it is recognised that competence, alone, does not make a good doctor. We therefore set out to explore the relationship between emotions and identity in clerkship education. Our exploration was conceptually oriented towards Figured Worlds theory, which is linked to Bakhtin's theory of dialogism.

METHODS

Nine female and one male member of a mixed student cohort kept audio-diaries and participated in both semi-structured and cognitive individual interviews. The researchers identified 43 emotionally salient utterances in the dataset and subjected them to critical discourse analysis. They applied Figured Worlds constructs to within-case and cross-case analyses, supporting one another's reflexivity and openness to different interpretations, and constantly comparing their evolving interpretation against the complete set of transcripts.

RESULTS

Students' emotions were closely related to their identity development in the world of medicine. Patients were disempowered by their illnesses. Doctors were powerful because they could treat those illnesses. Students expressed positive emotions when they were granted positions in the world of medicine and were able to identify with the figures of doctors or other health professionals. They identified with doctors who behaved in caring and professionally appropriate ways towards patients and supportively towards students. Students expressed negative emotions when they were unable to develop their identities.

CONCLUSIONS

Critical discourse analysis has uncovered a link between students' emotions and their identity development in the powerful world of becoming and being a doctor. At present, identity development, emotions and power are mostly tacit in undergraduate clinical curricula. We speculate that helping students to express emotions and exercise power in the most effective ways might help them to develop caring identities.

Beyond limitations: Improving how we handle uncertainty in health professions education research

The researchers' assumptions invariably influence research outcomes. This is true for both qualitative and quantitative studies. Assumptions or choices regarding underlying theories, causal relations, study setting and population, sampling strategies, participant non-response, data collection, data analysis, and researchers' perceptions and interpretations of results are among factors that can induce uncertainty in research findings. Researchers tend to treat these factors as potential study limitations, but how they may impact research findings is rarely explicated and, therefore, mostly unknown. In this article, we approach uncertainty as unavoidable in research and argue that communicating about uncertainty can inform researchers, policy makers and practitioners about the validity and applicability of the study findings for their interests and contexts. We illustrate approaches to address, interpret, and explicate uncertainty in medical education research in both qualitative and quantitative paradigms. Across research paradigms, we call on researchers to consider the uncertainty in their research findings, employ appropriate methods to explore its extent and effects in their work, and communicate it explicitly in their research papers. This will help to advance our understanding of the nature and implications of the emerging knowledge in our field.

Medical students' emotional development in early clinical experience: a model

Dealing with emotions is a critical feature of professional behaviour. There are no comprehensive theoretical models, however, explaining how medical students learn about emotions. We aimed to explore factors affecting their emotions and how they learn to deal with emotions in themselves and others. During a first-year nursing attachment in hospitals and nursing homes, students wrote daily about their most impressive experiences, explicitly reporting what they felt, thought, and did. In a subsequent interview, they discussed those experiences in greater detail. Following a grounded theory approach, we conducted a constant comparative analysis, collecting and then interpreting data, and allowing the interpretation to inform subsequent data collection. Impressive experiences set up tensions, which gave rise to strong emotions. We identified four 'axes' along which tensions were experienced: 'idealism versus reality', 'critical distance versus adaptation', 'involvement versus detachment' and 'feeling versus displaying'. We found many factors, which influenced how respondents relieved those tensions. Their personal attributes and social relationships both inside and outside the medical community were important ones. Respondents' positions along the different dimensions, as determined by the balance between attributes and tensions, shaped their learning outcomes. Medical students' emotional development occurs through active participation in medical practice and having impressive experiences within relationships with patients and others on wards. Tensions along four dimensions give rise to strong emotions. Gaining insight into the many conditions that influence students' learning about emotions might support educators and supervisors in fostering medical students' emotional and professional development.

The nursing home as a learning environment: dealing with less is learning more

PURPOSE

Despite the imperative to develop adequate competence in caring for the growing demographic of elderly patients with complex health care problems, nursing homes are underused as learning environments for the education of future doctors; thus, the authors aimed to gain more insight into the characteristics of the nursing home as a learning environment.

METHOD

Approaching the nursing home as a learning environment from a predominantly sociocultural perspective, the authors carried out five focus group interviews (December 2011 through February 2012) with 36 family medicine and elderly care medicine residents during their nursing home placements. Data analysis was an iterative process following a grounded theory approach. The software ATLAS.ti supported data analysis.

RESULTS

The authors identified 23 themes in five categories regarding the nursing home as a learning environment: organization, medical opportunities, communication, teamwork, and supervision. Working and learning in a nursing home was characterized by "dealing with less" (i.e., fewer resources), yet the residents reported that dealing with less resulted in "learning more." Family medicine and elderly care residents from different backgrounds differed in their perceptions and specific learning needs.

CONCLUSIONS

To the authors' knowledge, this study is one of the first to identify characteristics of the nursing home as a learning environment. The main challenge in the nursing home is dealing with less, which, according to the residents in the present study, often leads to learning more. To ensure that learning really happens, the authors call for high-quality supervision to support learners in the nursing home environment.

Entering medical practice for the very first time: emotional talk, meaning and identity development

CONTEXT

During early clinical exposure, medical students have many emotive experiences. Through participation in social practice, they learn to give personal meaning to their emotional states. This meaningful social act of participation may lead to a sense of belonging and identity construction.

OBJECTIVES

The aim of this study was to broaden and deepen our understanding of the interplay between those experiences and students' identity development. Our research questions asked how medical students give meaning to early clinical experiences and how that affects their professional identity development.

METHODS

Our method was phenomenology. Within that framework we used a narrative interviewing technique. Interviews with 17 medical students on Year 1 attachments to nurses in hospitals and nursing homes were analysed by listening to audio-recordings and reading transcripts. Nine transcripts, which best exemplified the students' range of experiences, were purposively sampled for deeper analysis. Two researchers carried out a systematic analysis using qualitative research software. Finally, cases representing four paradigms were chosen to exemplify the study findings.

RESULTS

Students experienced their relationships with the people they met during early clinical experiences in very different ways, particularly in terms of feeling and displaying emotions, adjusting, role finding and participation. The interplay among emotions, meaning and identity was complex and four different 'paradigms' of lived experience were apparent: feeling insecure; complying; developing, and participating.

CONCLUSIONS

We found large differences in the way students related to other people and gave meaning to their first experiences as doctors-to-be. They differed in their ability to engage in ward practices, the way they experienced their roles as medical students and future doctors, and how they experienced and expressed their emotions. Medical educators should help students to be sensitive to their emotions, offer space to explore different meanings, and be ready to suggest alternative interpretations that foster the development of desired professional identities.

Early clinical experience: do students learn what we expect?

CONTEXT

Early clinical experience is thought to contribute to the professional development of medical students, but little is known about the kind of learning processes that actually take place. Learning in practice is highly informal and may be difficult to direct by predefined learning outcomes. Learning in medical practice includes a socialisation process in which some learning outcomes may be valued, but others neglected or discouraged.

OBJECTIVES

This study describes students' learning goals (prior to a Year 1 nursing attachment) and learning outcomes (after the attachment) in relation to institutional educational goals, and evaluates associations between learning outcomes, student characteristics and place of attachment.

METHODS

A questionnaire containing open-ended questions about learning goals and learning outcomes was administered to all Year 1 medical students (n = 347) before and directly after a 4-week nursing attachment in either a hospital or a nursing home. Two confirmatory focus group interviews were conducted and data were analysed using qualitative and quantitative content analyses.

RESULTS

Students' learning goals corresponded with educational goals with a main emphasis on communication and empathy. Other learning goals included gaining insight into the organisation of health care and learning to deal with emotions. Self-reported learning outcomes were the same, but students additionally mentioned reflection on professional behaviour and their own future development. Women and younger students mentioned communication and empathy more often than men and older students. Individual learning goals, with the exception of communicating and empathising with patients, did not predict learning outcomes.

CONCLUSIONS

Students' learning goals closely match educational goals, which are adequately met in early nursing attachments in both hospitals and nursing homes. Learning to deal with emotions was under-represented as a learning goal and learning outcome, which may indicate that emotional aspects of medical students' professional development are neglected in the first year of medical education.