Stalmeijer, Renée E. PhD; Dolmans, Diana H.J.M. PhD; Snellen-Balendong, Hetty A.M. MD; van Santen-Hoeufft, Marijke MD; Wolfhagen, Ineke H.A.P. PhD; Scherpbier, Albert J.J.A. MD, PhD
Clinical teaching has received much attention in the medical education literature over the last three decades. A lot of effort has been put into training and giving feedback to clinical teachers to help them optimize their teaching1 and into mapping the clinical learning environment to identify those elements that can either make or break the learning experience of students during clerkships.2,3 However, Graffam and colleagues4 detected a lack of instructional models that speak directly to the teaching behaviors of clinical teachers. To remedy this lack, we recently developed a three-step clinical teaching model5 based on principles of cognitive apprenticeship (CA).6 CA was designed as a model to foster situated learning7 by accounting for the setting in which students should apply their knowledge and skills and using several teaching methods: modeling, coaching, scaffolding, articulation, reflection, and exploration. The key feature of CA is to make the expert’s internal (tacit) cognitive processes explicit to better enable students to observe, enact, and practice these with the help of their teacher.
Step 1 of the model (Figure 1) encompasses creating a safe learning environment and modeling and aims to facilitate student learning. Clinical teachers have a responsibility to provide a safe learning environment8,9 in which students feel free to ask questions and seek guidance. Simultaneously, the clinical teacher is expected to be a good role model, demonstrate relevant skills, and reason out loud.10 Step 2 revolves around meaningful learning interactions and co-facilitation between student and teacher. Interaction is prerequisite to enable teachers to provide guidance appropriate for the student’s level and to use feedback and observation in coaching the student.11,12 In Step 3 the clinical teacher seeks to stimulate the student to engage in self-directed learning by focusing on the articulation of knowledge and encouraging students to reflect on their performance.13 The aim is also to engage students in practice by asking them to use exploration, that is, formulating and working toward specific learning objectives.14,15
Although earlier studies have demonstrated CA as a valid concept for undergraduate clinical teaching,5,16 it is unclear how this theoretical model fits with the teaching practice of experienced clinical teachers when supervising students during workplace learning or how, in their perception, CA is influenced by the teaching environment and characteristics of clinical teachers and students. Research has typically focused on either clinical teaching or the clinical learning environment, but few studies have addressed their interactions. Therefore, we examined the following research questions:
1. How does the clinical teaching model based on principles of CA fit with clinical teaching practice as perceived by experienced clinical teachers?
2. Which factors (on the environment, teacher, and student levels) influence the use of the model during clerkship teaching as perceived by the clinical teachers?
We conducted the study among hospital-based clinical teachers of students in years 4 to 6 of a six-year undergraduate medical program at Maastricht University Medical School. Years 4 to 6 are devoted to clerkships in the academic hospital and affiliated regional hospitals. Rotations differ in duration depending on the type of rotation and the discipline, and the sequence of rotations differs among students. During rotations, students spend time in the wards, the outpatient clinics, and the accident and emergency department. Clerkships in years 4 and 5 last between 4 and 10 weeks (“regular clerkship”), whereas students in year 6 undertake an 18-week “senior clerkship” in a discipline of their choice.
The research team consisted of three educationalists/educational psychologists (R.E.S., D.H.M.J.D., I.H.A.P.W.) and three medical doctors with ample experience in medical education either in curriculum development (H.A.M.S.B., A.J.J.A.S.) or in supervising students during clerkships (M.v.S.H.).
Sampling and participants
In January 2010, key informants from the academic hospital and three regional hospitals contributed to the purposive sampling of participants. We enlisted key informants because of their involvement with the organization of clerkships at the hospital level. On the basis of principles of purposive sampling,17 we asked the key informants to suggest participants who had several years of experience supervising students during both regular and senior clerkships. Additionally, we requested that they focus on departments that offer both regular clerkships (years 4 and 5) and senior clerkships (year 6) (internal medicine, surgery, pediatrics, obstetrics–gynecology, and neurology) because the regular clerkships in disciplines such as dermatology, ophthalmology, and otolaryngology give students only limited time in the clinical setting.
Prospective participants received a letter or e-mail from the researchers or a key informant explaining the goals of the research and requesting that they participate in an interview. Twenty-two prospective participants agreed to participate by sending an e-mail to the principal investigator. R.E.S. telephoned those who agreed to participate and set a date and time for the interview. On the basis of an iterative data collection and analysis process, we started with 6 interviews and kept adding 3 more at a time after a first round of transcript analysis. After the 15th interview, no new themes or ideas were generated by the participants.18 Saturation was therefore considered to have been met after 17 interviews. The participants were 3 female and 14 male doctors, from 5 different disciplines (6 from internal medicine, 4 from surgery, 3 from pediatrics, 3 from obstetrics–gynecology, and 1 from neurology), who had 4 to 28 years (mean = 13.4 years) of experience in their field. All had ample experience in supervising and assessing students and had attended at least one faculty development course on workplace-based assessment and feedback skills, which is mandated by the Dutch College for Medical Specialists.
In the period of February to March 2010, R.E.S. conducted semistructured interviews using a visual depiction of the model (Figure 1) and a semistructured interview guide based on the literature describing factors that had been shown to influence clinical teaching.3 We discussed the guide within the research team and focused on speaking to the physicians’ perceptions of clinical teaching. The approach to the current research was a pragmatic one,19 and the principal aim was to investigate whether the model was compatible with the practical experiences of clinical teachers. Interviews took place at a location of the participants’ choice. R.E.S. used the interview guide as a starting point for the interview but also pursued interesting new information that emerged during the interview. This new information was then included in the subsequent interviews. In addition, R.E.S. asked the participants to comment on the teaching model (Figure 1).
At the time of the study, formal approval of medical education research was not within the purview of the ethics committee of the academic hospital, and the now-established ethical review board of the Netherlands Association for Medical Education was not yet formally installed. On the basis of known ethical guidelines for research (Declaration of Helsinki),20 we adhered to the following guidelines: The goals and procedures of the study were fully explained to the participants, who were invited to ask questions. We explained that participation was voluntary and that they were free to withdraw at any time. All participants signed an informed consent form detailing the goals and the expected outcomes of the study. The participants received no remuneration. We anonymized the transcripts and only discussed them within the research team, where we maintained strict confidentiality.
We audio-taped all interviews, transcribed them verbatim, and submitted them to the participants for approval. Data analysis occurred alongside data collection in an iterative fashion. R.E.S. and H.A.M.S.B. coded the transcripts independently, searching for relevant concepts that recurred within and between transcripts. R.E.S. and H.A.M.S.B. discussed and compared their independent coding to develop a single codebook for use in the rest of the analyses. R.E.S. then continued the analysis, identifying recurring themes within and between transcripts. The research team discussed the resulting themes until we reached consensus. The analysis was supported by Atlas-ti 6.0 software (ATLAS.ti, GmbH, Berlin, Germany).
Several themes resulted from the analysis: short versus long clerkship rotations, the continuing importance of modeling and safe learning environment, role division and role hierarchy while teaching, experience as a physician and as a teacher, motivation/enthusiasm for teaching, level of experience and motivation of the student, and proactive behavior of the student. We have organized these themes according to the two research questions. Furthermore, for the second research question, we have organized the themes on the environmental, teacher, and student levels.
How well does the theoretical model match the practice of experienced clinical teachers?
All participants acknowledged that they had experience with the various teaching methods and three steps represented within the model. They commented that the model offered a structured picture of their teaching practice and that, in practice, the clinical teaching experience was not always such a linear process as suggested by Figure 1. Two themes featured prominently in the teachers’ descriptions of their teaching activities: differences between the regular (6–10 weeks) and senior (18 weeks) clerkships, and the ongoing importance of modeling and a safe learning environment.
Although all participants agreed that the teaching methods of the model were useful for all clerkships, participants reported that shorter clerkships were often limited to Steps 1 and 2 of the model. The main reason participants cited for not reaching Step 3 (articulation and exploration) was time constraints on the part of the student (limited time in the department) and the physician (not enough time to truly focus on observing and coaching the student). The participants did note, however, that Step 1 was crucial for students in shorter clerkships to find their bearings in the department and the discipline. One participant articulated the importance of
creating a safe learning environment, in fact that is what we do during a student’s first two weeks in the department. Go and sit somewhere in the department and observe what is going on, shadow your resident. So make few demands, give them time to settle in. When they want more, they can do more, but there is no pressure. And then gradually towards more responsibility and so a little more coaching, where we give more feedback or observe them and do a mini-CEX [clinical evaluation exercise] or something. (Participant #4)
Another agreed, stating:
Well, yes, I think that [modeling and creating a safe learning environment] is the foundation. I mean, you set a good example and you have to ensure that people feel safe, let’s say with regard to making mistakes or doing good things. That is sort of the basis, for if that is missing, things are bound to go wrong. In that case, people keep running into difficulties and are afraid to speak up or afraid to take action. (Participant #8)
All participants agreed that all steps of the model occurred during the longer clerkships, when students spend more time in the department and become “part of the team,” which enables clinical teachers to get to know them better, monitor their learning curve, and adapt teaching activities to the level of the student:
… with senior students … I also have a plan in mind, like, well, I want them to have seen this, and this, and that by the end of the clerkship, and [to know] what is a sick child and how do you treat them, how do you approach them, and that they get the theoretical background. I monitor this too, so then I also elaborate on content and I have them perform some skills, which I just do not get around to with the other [regular clerkship] students. So with a senior student my aim is that at the end of the clerkship, that they can do a part of an inguinal hernia in a child, yes “perform” sounds rather strong somehow. (Participant #7)
Which factors influence the use of the model in undergraduate clinical teaching practice as perceived by the clinical teachers?
Most participants mentioned the influence of environmental elements, such as “time constraints” and “lack of facilities where students can see their own patients,” as inhibiting factors to administering all three steps. Also influencing the way in which the steps were applied was the division of teaching roles within the department. The main responsibility for teaching lies with the specialists and the residents, whose teaching covered all three steps. Most of the teaching during shorter clerkships was done by residents and focused mainly on Steps 1 and 2, although a specialist conducted the final assessment in these clerkships. Occasionally, this gave rise to suboptimal learning situations, as when residents are too preoccupied with their own learning to pay attention to the student’s learning process:
When a student is unlucky, he or she will have a resident who has only one minute on the fly, so to speak. So all this resident can do is try to stay alive, because “at 5 PM the supervisor will arrive and start asking all sorts of hard questions, and am I going to survive that?” So the resident is not interested in the student at all. (Participant #13)
During longer clerkships students were supervised by specialists. This was partly because senior clerkship students were looked on as “semiresidents” and occasionally given tasks that could also be undertaken by a resident. Besides specialists and residents, specialized nursing staff and midwives were also involved in Steps 1 to 3. Participants described nurses as mostly taking part in Step 1 of the model, as they contributed to the learning climate and could help students in their socialization within the department:
Well, it may not actually be a formal role … [but] it is the nurses who will often say, like, … “hey, the papers are there and no, you had better call so-and-so or you had better do this.”… So it is not so much that they have a very specific, well-defined task, it is more in day-to-day practice that they have a guiding role in getting students settled. (Participant #10)
Despite nurses not having a formal role in teaching, certain skills (e.g., caring for patients, giving intravenous injections) were more often than not taught by nurses, especially experienced and specialized nurses (e.g., in the brain care unit, intensive care unit, neonatal intensive care unit). During the obstetrics–gynecology clerkships, midwives also contributed to all three steps in the delivery rooms.
Clinical teacher level
There was no agreement among the participants with regard to the question of whether or not clinical teaching was a special skill. There was general agreement, however, that whether individuals got involved in clinical teaching depended very much on personal characteristics. Two themes that emerged on this topic were “experience as a physician and as a teacher” and “motivation to teach/enthusiasm for teaching.”
The majority of the participants explained that they had actively taught students ever since their own residency. They remembered being so overwhelmed at first by their own learning that they found it all but impossible to move beyond Step 1 in their teaching. As their clinical expertise grew, they gradually became able to pay more attention to the learning of students and move to Steps 2 and 3 (coaching and exploration):
I’m calmer now, I am obviously more efficient in doing consultations and I feel that I see the patient’s problem more quickly. So, often I have energy left to observe students. Whereas at first I was unable to do that because I had to listen to the patient, but now I usually know—well, let me put it this way, I listen to the patient with my left ear, and my right eye and ear are available to observe the student. (Participant #7)
A frequent topic in relation to the division of teaching roles within the department was that some physicians were simply more motivated to teach than others. Physicians who liked teaching deliberately scheduled time for teaching and found ways to cover all three steps of the model. They were motivated by seeing students grow and liked to look for ways to pass on the knowledge and skills of their own discipline.
The participants agreed that students could have a significant effect on teaching and the extent to which teachers applied or did not apply the three steps. The main contributing characteristics that participants identified were students’ levels of experience and motivation and students being proactive.
Students in shorter and longer clerkships not only differ in age but also in knowledge, skills, and experience in learning in the clinical environment. Inexperience in students in shorter clerkships prevented participants from progressing beyond Steps 1 and 2, whereas during the longer clerkships they felt they could tackle Step 3.
Proactive students were generally described as “easier to work with” than their more “passive” colleagues. It was easier to use all three steps with proactive students because they asked for specific coaching or modeling and clearly indicated their learning needs. As a result, they received more attention and were allowed to undertake more activities independently. Participants noted that students who were more passive or insecure were at risk of getting stuck in Step 1, never progressing beyond the role of passive observer:
Students who show an interest and who make the extra effort will be noticed very quickly in a positive way and they will be accepted and that means they will sort of be taken along to share in the exciting things. But it is definitely possible for a student to behave inconspicuously and low profile and to withdraw from quite a few teaching moments or supervision. (Participant #6)
Although the role of the clinical teacher has received ample attention in medical education research, the interactions between the clinical learning environment and the clinical teacher have remained a relatively uncharted area. The aim of the current study was twofold: (1) to examine whether the teaching model based on CA principles reflects the teaching practices of experienced clinical teachers, and (2) to investigate which factors influence how the teaching model is used in practice during clerkships as perceived by the clinical teachers (on environmental, clinical teacher, and student levels).
The results confirm findings from previous research that CA principles fit with teaching activities in clinical practice.16 This adds to the growing evidence that educational principles from situated cognition and situated learning theories are relevant to clinical teaching practice and research.21 Modeling and a safe learning environment were described as prerequisites for an effective teacher–student relationship. These results are corroborated by previous research showing that modeling in particular is the foundation on which teaching in the workplace is built10,22 and that physicians should support student participation.23
Furthermore, our research unveiled several factors that influence clinical teaching during clerkships in the opinion of clinical teachers. First, the configuration of clerkships strongly influences the type and amount of teaching and supervision that can be performed. These findings resonate with the trend to forgo the “merry-go-round” structure of clerkships24 in favor of more longitudinal clerkships,25 which can ensure meaningful and longitudinal mentorship for students. Second, this study points to the influence of the division of teaching roles within a department on the actual teaching methods used. In essence, clinical teaching could be approached as a team effort and not as the sole responsibility of the individual attending.26 Attending physicians, residents, and nurses can complement one another’s individual competencies to create a strong and positive clinical teaching environment. This is not so different from day-to-day practice in hospitals where both patient care and the continuous professional development of team members is a team effort.1 Future research might focus on designing a workable format for teaching as a team to further optimize the clinical learning environment.27 Third, this research underlines previous findings pointing to the fact that physicians find it easier to teach proactive students than passive students2: The more experienced, motivated, and proactive the student, the easier it is for clinical teachers to apply all three steps of the model. This finding supports the call for equipping students with “clerkship survival skills.”28 Teaching students to be assertive, to be effective communicators, to provide feedback, to develop personal learning objectives, and to manage time28,29 could prepare students for the clinical learning environment and help them to make the most of their time there.
The clinical learning environment is a complex setting to study. A limitation of the current study is that participants may have left out some elements that affect clinical teaching because the participants were not aware of them. A more complete, fully rounded picture might be obtained by triangulating the findings of the current study with the results of observational studies and interviews with other members of the department. The qualitative nature of the study provided in-depth results based on the perspectives of experienced clinical teachers from five different hospitals and five different disciplines. However, transferability of these results to other medical schools and other hospital settings needs to be further investigated.
Our theoretical model based on CA theory provides a possible answer to the reported need of instructional models that speak directly to the teaching behaviors of clinical teachers.4 Future endeavors might focus on translating this model to faculty development initiatives.
Acknowledgments: The authors would like to thank all the participants for their time and Mereke Gorsira for her editorial help.
Other disclosures: None.
Ethical approval: At the time of the study, formal approval of medical education research was not within the remit of the ethics committee of the academic hospital. On the basis of known ethical guidelines for research (Declaration of Helsinki), the following guidelines were adhered to: The goals and procedures of the study were fully explained to the participants, who were invited to ask questions. It was explained that participation was voluntary and that they were free to withdraw at any time. All participants signed an informed consent form detailing the goals and the expected outcomes of the study. The participants received no remuneration. The transcripts were anonymized and only discussed within the research team, where strict confidentiality was maintained.
Previous presentations: Parts of this work were presented at the American Educational Research Association (AERA) conference in Vancouver, British Columbia, Canada, April 13 to April 17, 2012.
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