Despite the imperative for future doctors to develop adequate competence in caring for the growing demographic of elderly patients with complex health care problems, nursing homes and other geriatric care facilities continue to be underused as learning environments for the education of future doctors.1–3 As early as the 1990s, several authors advocated, both in this and another leading medical journal, employing the nursing home as a site for teaching the medical interview and physical diagnosis4,5; however, more than two decades later, a former editor of this journal must still wonder why students and residents do not learn and work in nursing homes throughout the United States.3
In general, medical schools and residency programs are placing increasing emphasis on geriatrics training.1 Recently, several authors have described initiatives to improve the quality of care provided to elderly people within internal medicine and family medicine residency programs.6 Another set of authors has detailed efforts to advance geriatrics education in medical schools and training programs by offering a faculty development program to nongeriatricians.7 Diachun and colleagues8 have written about the use of patient or caregiver feedback as a tool to cover for the lack of geriatricians supervising students or residents in the performance of comprehensive geriatric assessments, and Moran and colleagues9 have described a program to teach residents to apply geriatric knowledge and skills within a general internal medicine context. These initiatives are helpful; nevertheless, other research has shown that specific rotations in geriatric medicine are more effective in preparing students to care for the elderly compared with nonspecific clerkships.2 Further, additional research indicates that longitudinal rotations or internships in a long-term care facility increase internal medicine residents’ knowledge of and attitudes toward geriatrics.10 However, almost no research provides evidence of, specifically, the pros and cons of the nursing home as learning environment. Recommendations to include nursing homes as core sites in medical education are based mostly on personal views or perceptions rather than on sound evidence.3,11,12
In the context of early clinical experience, we recently demonstrated that nursing home placements are highly suitable to enhancing medical students’ personal and professional development because of the many opportunities they offer for active participation in patient care, the modeling of patient-centered behavior, and team spirit.13–15 Within the context of graduate medical education, Stok-Koch and colleagues16 carried out an exploratory study among elderly care residents and their supervisors; their results showed that social integration and a good atmosphere are the most salient factors influencing workplace learning in the nursing home. To our knowledge, no prior publications elucidate specifically how and what students or residents learn in the context of a nursing home. Therefore, we deliberately chose to focus solely on residents’ concrete experiences of the nursing home as a learning environment. We were most interested in the factors in this unique sociocultural environment that hampered or facilitated learning, rather than in self-reported learning outcomes themselves.
In this study we aimed to answer the following questions:
1. Which factors characterize the nursing home as a learning environment?
2. What stimulates or hampers learning in the nursing home?
We carried out this study at the Radboud University Nijmegen Medical Centre (Nijmegen, the Netherlands), which offers two separate specialist training programs set partly in nursing homes: one in elderly care medicine and one in family medicine. The first year and the final six months of the three-year residency program in elderly care medicine take place in a long-term care facility (i.e., skilled nursing facility); the remainder of the program includes internships in different settings, such as general, rehabilitation, or psychiatric hospitals.17 The family medicine curriculum has a comparable structure; that is, trainees are in general practice during their first and third years and have different internships in the second year of the program. One of these second-year internships is a mandatory three-month internship in a long-term care facility.
As learning in medical practice necessarily takes place in interactions with patients, doctors, and other health care providers on the wards, we approached the nursing home as a learning environment from a predominantly sociocultural perspective. In other words, we conceptualized meaning and identity as negotiated and constructed through interactions with other individuals and artifacts (tools or organizational arrangements—e.g., electronic devices, patient charts, or ward rounds) while participating in communities of practice.18,19 In doing so, we emphasized the importance of both context (learning is situated) and process (learning is dynamic).20 We aimed to look at residents’ experiences within their sociocultural environments (in this case, the nursing home), which means we were collecting data about context and process as perceived by residents.
We chose a focus group design, allowing for interactive discussions in which participants often query and have to explain themselves to one other, thus engaging in a collaborative sense-making process.21,22 Moreover, focus groups offer great opportunities for observing the extent of consensus and disagreement among participants.22 We approached residents in their training groups, units within which residents come together once a week for reflection and teaching sessions. We considered these naturally occurring groups the best suitable venue for gaining more insight into the learning processes taking place in nursing homes. Because members of training groups are familiar with discussing educational issues with one another, we supposed this approach would offer a relatively safe environment to share experiences, thereby leading to maximal depth of disclosure.23
From December 2011 through February 2012, we held five focus group interviews. Each group included 4 to 10 participants, and each session lasted about one hour. Of the five groups, four comprised first- or third-year elderly care residents, and one group comprised second-year family medicine residents during their long-term care internship.
A skilled moderator (E.H.) facilitated the discussion; the assistant moderator (F.M.) took notes. The first author (F.M.) audio-taped the sessions and then transcribed them verbatim. We used the following prompts to keep the discussions (held in Dutch) going:
* What was the most instructive experience you had in the nursing home, and what did you learn from it and why?
* What do you consider the main learning opportunities in the nursing home?
* What stimulates your learning in the nursing home, and what hampers the learning process? and
* What makes the nursing home unique as a learning environment?
Because qualitative research is based on experience and on the construction of meaning, we deliberately chose to have both an experienced elderly care physician (E.H.) and an elderly care resident (F.M.) run the groups. Their hands-on experience within the nursing home made it possible to pose in-depth questions and to ask for maximum clarification during the interviews.
Data analysis was an iterative process following a grounded theory approach.24 Directly after each focus group session, the moderator (E.H.) and assistant moderator (F.M.) conducted a first debriefing, sharing their initial thoughts and observations, and summarizing and reflecting on the session. We (E.H. and F.M.) used these reflections as entries for our research logs, which served as a first step in our process of making sense out of the data. Each of us then, independently, carried out a preliminary analysis of the session, allowing the evolving conceptual framework to inform the subsequent focus group discussions.
The two of us (F.M., E.H.) independently coded four interviews. We discussed differences and adapted codes until we reached full agreement about content and inclusion criteria.25 We renamed and rearranged codes into broader themes and eventually assigned these themes to more abstract categories. During this process, we constructed figures and diagrams to reach a better understanding of the meaning of the text. The use of the qualitative research software ATLAS.ti (ATLAS.ti GmbH, Berlin, Germany) supported our analysis. We believed we reached saturation after four interviews, and the analysis of a fifth focus group interview, conducted by F.M., confirmed that, indeed, further interviews would not produce further themes. To triangulate our findings, E.H. discussed the ultimate framework with two teams of elderly care physicians who approved it to be recognizable and trustworthy.
Under Dutch law, educational research is exempt from formal ethics approval. We discussed the aims and design of the study with the head of the Department of Elderly Care Medicine in order to take all necessary precautions to ensure our participants’ well-being. F.M. informed all trainees in both the elder care and family medicine programs and asked them to participate in a group discussion about their learning in the nursing home. Thus, residents knew we would ask them to discuss their experiences and that we aimed to use our findings to further improve the nursing home as a learning environment. We emphasized that participation was fully voluntarily, that confidentiality was granted, and that participants could withdraw from the study at any time without consequences. We assured the participants that results would be presented only anonymously and at the group level, guaranteeing that participation would not have any effect on residents’ positions or evaluations. At the start of each session, E.H. again explained the procedure and obtained written informed consent. As the interviews were scheduled during lunchtime, we offered a free lunch.
All elderly care residents in the first and third year of the program (N = 36) participated in the study. At the time of the study, only six family care residents were enrolled in a nursing home placement. Two of them were not able to participate because of time constraints. Response rate thus was almost 100% (95%; 40/42). We have summarized the information on the demographics of the participants in Table 1. The participants in our study were all assigned to different nursing homes located within a large educational area.
Our data set consists of almost five hours of group-discussion-generated data, to which we assigned more than 150 different codes during our first round of open coding. Later in the analysis, we rearranged this huge number of codes into 23 themes, which eventually led us to identify five broader categories: organization, medical opportunities, communication, teamwork, and supervision. Table 2 displays these themes, categories, and the related codes. We found we could divide each of the five categories into two subcategories: dealing with less (i.e., fewer resources) and learning more. There appeared to be one underlying construct: “dealing with less” was closely interrelated to “learning more.”
Family medicine residents and elderly care residents from different backgrounds differed in their perceptions and specific learning needs.
Dealing with less.
Residents described the nursing home as an unstructured learning environment. They mentioned a lack of standard procedures, prescheduled activities, and instructions about how to carry out particular tasks. Residents needed to develop a daily routine on their own.
I had to initiate rounds myself, two times a week. (Family medicine resident)
Residents could not depend on the presence of adequately skilled nursing staff during rounds or in multidisciplinary meetings. They also reported a lack of support staff, resulting in spending a lot of time completing inappropriate, often administrative, tasks.
Residents perceived a lot of freedom and stated that organizing their own work was a valuable experience.
You have to structure your day by yourself and you are learning a lot by doing that. (Family medicine resident)
Other personnel at the nursing homes perceived the residents as readily accessible and asked them to complete nonmedical tasks. This accessibility required the residents to learn how to define and restrict their tasks and responsibilities, which they considered instructive. One family medicine resident, approached to provide computer support, felt as if others considered her to be a “handyman.” She commented,
You need to set clear limits, getting to know what you think is important to do or not. (Family medicine resident)
Dealing with less.
One of the central features of working in the nursing home was the paucity of advanced diagnostic tools and medical procedures (e.g., blood testing and radiology). Residents considered this lack an obstacle for the learning and preservation of skills in the medico-technical domain. Residents were afraid they would lose skills in interpreting laboratory results or electrocardiograms, or that they would lose confidence in administering intravenous fluids or medications.
Sometimes you are not able to practice things just because they just are not there. Like having electrocardiograms available, providing you with the opportunity to keep up your interpretation skills. (Elderly care resident, Year 1)
For some residents, the limited technical or procedural possibilities reduced the attractiveness of working in a nursing home, hampering the development of a medical doctor identity. Trainees also described a lack of learning materials such as recent scientific publications or medical protocols.
I would like to have those technical opportunities … to feel a bit more like a doctor. (Elderly care resident, Year 1)
Residents described a large variety of medical conditions or patients’ signs and symptoms prevalent in the nursing home. They were able to learn about chronic disease, end-of-life care, rehabilitation, and psychogeriatric diseases. Having limited access to advanced diagnostic or medical procedures resulted in a huge increase in clinical expertise, in the development of clinical skills, and in residents’ confidence in the value of the medical interview and physical examination.
You really develop clinical expertise, reaching a diagnosis, without all those additional resources. (Elderly care resident, Year 1)
Trainees needed to think carefully about the different treatment options. This necessary consideration resulted in more deliberate decision making; residents learned to take into account perceived benefits and side effects, as well as financial aspects. This contrasted with the hospital, where treatment options are much more standardized.
The choices are made much more deliberately.… In the hospital you simply follow a protocol, without actually thinking about it. (Elderly care resident, Year 3)
Dealing with less.
Patients often were restricted in their ability to communicate because of medical or cognitive problems.
You are caring for frail elderly. Sometimes they are not able to communicate, for example due to aphasia or cognitive problems. So then you are confronted with specific barriers. (Elderly care resident, Year 3)
Residents, however, realized that patients’ obstacles to communication encouraged them to advance their own skills instead. The third-year, elderly care resident above noted, “I think this demands even more of your communication skills.” Further, residents described engaging in more frequent and more intense conversations. They described being more involved in the care of not only patients but also families than they would have been in hospitals.
What I really have learned to value are family meetings. I thought that, as a family doctor, you know, as a family doctor you only see individual patients. I never thought about, and neither did my supervisor, inviting the family to talk about the care for a patient. These are things I would like to do, next year, in a new family medicine placement, I plan do this more often. (Family medicine resident)
Dealing with less.
The level of education of the personnel in nursing homes in the Netherlands is quite low (nurses—many of them nursing assistants—in these Dutch facilities generally have only two or three years of vocational training). This discrepancy in education affected how residents and nurses communicated with each other.
People employed in the nursing home generally are lowly qualified. You are one of the highest educated in the nursing home, so you need to find other ways of communicating and working together. (Elderly care resident, Year 1)
Within the multidisciplinary team, residents frequently needed to discuss their treatment plans and reach an agreement with other health care professionals, which they considered to contribute highly to their learning process. The need to adjust to different levels of education and other ways of thinking offered great learning potential.
You should think carefully about what you are saying and you should check, without being disrespectful, if they understand what has been said. (Elderly care resident, Year 1)
In nursing homes a medical problem is often presented inadequately. You learn to ask in more detail, and to search for the underlying question. (Elderly care resident, Year 3)
Compared with in the hospital, residents in the nursing homes did not have many other doctors around. Working as a member of a multidisciplinary team, instead of communicating with predominantly other physicians, turned out to be very instructive.
Paying more attention to the social aspects of the care for patients, not only the medical stuff. (Elderly care resident, Year 3)
And also when you engage in a conversation with patients or families together with a nurse, then you can also learn from each other. You may complement each other and … yes, if I then, the next time, should have the conversation on my own, because the nurses don’t have time for it, then … yes, … I know more about how they engage in such conversations. And then I will just use that, so, … yes, I think that actually is most instructive. (Elderly care resident, Year 3)
Within a nursing home you can also learn from other health care workers, the psychologist, the occupational therapist and the physiotherapist, who are all there. That’s unique, you won’t meet those disciplines that often in a hospital. You can also, with the social worker, talk about the many legal issues, and you see the psychological or psychiatric diseases.… Thus as a learning climate for a medical doctor, a learning environment, there is a lot to get out of it. (Elderly care resident, Year 3)
Dealing with less.
Trainees reported a lack of standardized supervision agreements. Feeling a strong urge to function as independently as possible, residents asked for supervision only when they faced difficult or unusual situations. As a consequence, care on the wards in the nursing home was not always supervised, leading to residents’ uncertainties about their actual level of competence.
I’m not aware of what I don’t know. And I am afraid I won’t learn that in the nursing home as well. (Elderly care resident, Year 1)
In particular, when patients’ conditions remained more or less stable for a long time and did not require additional, out-of-hours medical care, residents expressed concerns about medical errors remaining undetected for a long period. The relatively low educational level of the nursing staff further added to this feeling.
They [the nurses] will be less inclined to ask critically: “Why do you do that?” (Elderly care resident, Year 1)
Although formal supervisory agreements were limited, residents described a lot of opportunities for informal interaction with other colleagues.
I don’t share a room with my supervisor, but with one of the other physicians, and then conversations arise naturally. That works fine. You realize that everybody sees things differently. That’s of great value. (Elderly care resident, Year 1)
Trainees described the nursing home as a safe learning environment. The open atmosphere and the absence of hierarchy made it easy for them to ask for help. The lack of formal agreements offered opportunities for shaping supervision according to one’s preferences. Being trusted to work quite independently resulted in a gain of confidence.
That you are allowed to do many things on your own, realizing “Yes, I can do that!” (Family medicine resident)
Consensus and disagreement
The topics that family medicine residents brought up differed from those that elderly care residents raised. Family medicine residents commented mostly on the lack of structure, which apparently was in great contrast with the working environments (i.e., primarily hospitals and family practices) they had previously experienced. We also observed differences in the concerns of younger and native residents compared with older, immigrant residents. Within focus group 2, for example, which was composed of both young native Dutch residents and older, more often immigrant residents, discussions arose around how the residents value the particular characteristics of the nursing home. The young, native Dutch residents highly favored the freedom they encountered in nursing homes, whereas the older, more often immigrant residents seemed to struggle with the lack of structure. The latter also noted, specifically, that they struggled with the paucity of learning materials and structured teaching moments or supervision agreements. Their younger, Dutch colleagues preferred the informal possibilities for sharing knowledge and experiences.
We found a striking consensus regarding communication and teamwork. Most residents appreciated the huge learning opportunities arising from the need to communicate with patients, families, and other caregivers about often-difficult or sensitive topics. They emphasized the benefits of frequently having to tune in to different levels of understanding.
Summary of main findings
Residents characterized working and learning in a nursing home as “dealing with less.” Specifically, residents had to deal with a loosely structured organization and a nursing staff not as well trained as in other contexts (e.g., the hospital). They described a paucity of advanced diagnostic or treatment options. Patients were restricted in their ways and levels of communication. Formal supervision was minimal, sometimes causing the residents to feel uncertain.
Interestingly, this process of dealing with less led to learning more. Contending with fewer resources and formal parameters stimulated the development of communication and management skills. The absence of advanced diagnostic technologies resulted in the development of clinical skills, expertise, and confidence in the physical exam. The need to think carefully about treatment options led to more deliberate decision making. Being around so many different types of health care professionals (e.g., occupational therapists, mental health workers) offered large learning opportunities, and working quite independently in a complex environment led residents to develop a strong sense of confidence.
Relation to other publications
Although, to our knowledge, no prior published research directly addresses the nursing home as a learning environment, our findings do resonate with the pivotal role of participation in everyday activities described for workplace learning in medical education in general.26–28 In addition, our study provides a deeper understanding of one of the most important features of workplace learning—namely, informal learning.29,30 Our study offers many examples of how residents are learning to become members of communities of practice both by interacting with others and by learning to deal with specific arrangements or circumstances. Working together with other health care professionals stimulates the development of communication and collaboration skills. On the one hand, residents need to recognize and adapt to the lower educational attainment of some of their colleagues on the interprofessional team, but on the other hand, residents acknowledge the learning opportunities that arise from getting to know each others’ roles and competencies. Because of the lack of structure or formal teaching arrangements, residents need to find their own ways of carrying out tasks and fulfilling responsibilities in a complex social environment. Being placed in a situation in which dealing with less is a central feature prompts residents to make use of the resulting freedom offered in order to take care of patients properly. Our findings clearly show how both contextual and socioemotional factors add to the learning processes taking place in the nursing home, extending previous empirical reports on the importance of “developmental space” as a prerequisite for “learning by doing.”31
The residents in our study reported a strong urge to work independently, requesting help only in difficult or unexpected situations. In other words, “care-as-usual” in nursing homes remains largely unsupervised, which could affect the safety of the patients involved. The pressure on junior doctors to work independently32,33 and the resulting tensions between trainee learning and patient safety34 have been previously described for clinical care in hospitals; our findings suggest that these tensions may be the same in nursing homes. Medical trainees, whether in a hospital or nursing home, are obliged to secure direct assistance for any situation that their limited expertise precludes them from handling alone, but attendings and supervisors must be available to respond in a timely manner to these requests.35 Research indicates that trainees’ decisions about seeking clinical support are influenced not only by the particular clinical situation but also by the availability and approachability of supervisors.35
Participants in our study explicitly describe the nursing home as a safe learning environment with no hierarchy, making it easy to approach more senior colleagues for help; however, the direct availability of senior staff may be limited, as elderly care physicians often attend the patients at different, geographically dispersed nursing homes. In addition, Kennedy and colleagues32 used Lave and Wenger’s36 legitimate peripheral participation framework and the migration theory as described by Amalberti and colleagues37 to explain how identity and organization issues may explain the urge for residents in teaching hospitals to function independently. We suppose that the motivation to identify with the community of autonomous doctors32,36 is the same for residents in nursing homes as it is for residents in hospitals. Further, the pressures to increase productivity and to earn positive assessments that cause residents in hospitals to move beyond the boundaries of safe practice27,32 are not likely to differ for residents in a nursing home. However, in the chronic medical care context of the nursing home, defining the boundaries of safe practice might actually be more complex. Patients in nursing homes often reside in such facilities for an extended period of time and do not always experience acute illnesses, making the decision to consult a more senior physician particularly difficult. To support residents and ensure patient safety, it is important that both residents and supervisors understand these processes. To reach this goal, faculty development programs and explicit team discussions may be helpful.32
Strengths and weaknesses
We used the full potential of a grounded theory approach to characterize the nursing home as a learning environment, which we consider a great strength of the study. We conducted the interviews within already-existing resident groups, enhancing disclosure. The moderator was unknown to the participants, which enhanced honesty, but she was easily able to relate to the groups because of her experience as an elderly care physician and clinical supervisor. The assistant moderator, however, was a member of one of the groups herself. As the discussion within this particular group was comparable to the other interviews, we do not think her role has influenced our findings.
Data analysis was rigorous: Two researchers were involved in the coding process and used discussions to negotiate meaning and arrive at a greater level of understanding. All of the researchers were working as medical doctors in nursing homes. Although this might seem to compromise independent analysis, we think having hands-on experience in a nursing home led to a far more in-depth understanding of the processes at hand.
The main questions concerning the outcomes of any qualitative study are whether the results can be trusted and applied to other settings. The present study was carried out in a single medical school; however, the participants in our study were assigned to a great number of nursing homes within a large educational area. Two groups of residents were in their first year of the residency program, and their work experience within a nursing home ranged from 4 to 36 months; two other groups comprised residents in their third year of the program, and their experience ranged from 16 to 48 months. Further, all of the third-year residents had experienced working in at least two different nursing home facilities. Therefore, we think our study covers a broad range of experiences in many different nursing homes over a longer period of time, increasing generalizability.
Implications for practice and future research
This study has revealed some unique characteristics of the nursing home as a learning environment, which may inform the current debate about providing internships or clinical placements in nursing homes. In the Netherlands, medical care for patients in nursing homes generally entails making an individual treatment plan, including advanced care planning (e.g., decisions about starting or withdrawing treatment in various circumstances). Treatment goals, however, whether related to rehabilitation, chronic medical care, or end-of-life care, are generally different from goals set for hospital care, which, in turn, influences the educational goals of residents. Moreover, one of the main challenges in the nursing home is dealing with less, which—according to the residents in our study—often leads to learning more. This greater learning suggests that the nursing home is a suitable context not only for gaining geriatric knowledge and improving attitudes about geriatric patients but also for the development of complex communication and collaborative skills and other general competencies regarding organization, time management, and boundary setting. Additional research is needed to further explore learning objectives and learning outcomes for clinical placements in the specific context of a nursing home and to explore how learning and practice in the nursing home translate to practice in other clinical contexts.
We recognize that dealing with less might pose a challenge to novice medical practitioners. Part of the uncertainties that may arise in nursing home practice are covered or addressed, at our institution, during the off-the-job learning sessions residents engage in one day each week. The specific curriculum they are following resembles the American Medical Directors Association’s initiative as described by Swagerty and Tarnove.38 But, to address in real time the uncertainties residents face in the nursing home workplace, we need high-quality supervision which would allow residents to learn and practice safely in an unstructured learning environment with limited medical opportunities. Our study suggests that, at least early in the residency program, closer supervision of the daily work of residents may be needed, to ensure both patient safety and the gradual development of residents’ level of competence. As we found large differences between family medicine residents and elderly care residents from different backgrounds, supervisors should try to align their supervision to the particular needs of individual residents. This might be a subject to further study.
Finally, working closely together with other health care professionals may sometimes be difficult or challenging, but at the same time doing so offers great learning potential; in the areas of, in particular, rehabilitation, chronic medical care, and end-of-life-care, collaborative practice and the role of the physician in the decision-making process may be different from what trainees have learned in medical school. In the current study, we have looked at residents’ experiences within the specific sociocultural environment of the nursing home. To further characterize this particular context as a learning environment for both medical and other health care students, future research should also include the experiences and perceptions of other professionals in the nursing home.
To our knowledge, this study was the first to identify characteristics of the nursing home as a learning environment. The main challenge in the nursing home is dealing with less; however, according to the residents in our study, fewer resources and less structure often lead to learning more. To ensure that great learning really happens, we call for high-quality supervision to support learners and their patients in nursing homes.