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Systems-Oriented Workplace Learning Experiences for Early Learners: Three Models

O’Brien, Bridget C. PhD; Bachhuber, Melissa R. MD; Teherani, Arianne PhD; Iker, Theresa M.; Batt, Joanne; O’Sullivan, Patricia S. EdD

doi: 10.1097/ACM.0000000000001243
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Purpose Early workplace learning experiences may be effective for learning systems-based practice. This study explores systems-oriented workplace learning experiences (SOWLEs) for early learners to suggest a framework for their development.

Method The authors used a two-phase qualitative case study design. In Phase 1 (spring 2014), they prepared case write-ups based on transcribed interviews from 10 SOWLE leaders at the authors’ institution and, through comparative analysis of cases, identified three SOWLE models. In Phase 2 (summer 2014), studying seven 8-week SOWLE pilots, the authors used interview and observational data collected from the seven participating medical students, two pharmacy students, and site leaders to construct case write-ups of each pilot and to verify and elaborate the models.

Results In Model 1, students performed specific patient care activities that addressed a system gap. Some site leaders helped students connect the activities to larger systems problems and potential improvements. In Model 2, students participated in predetermined systems improvement (SI) projects, gaining experience in the improvement process. Site leaders had experience in SI and often had significant roles in the projects. In Model 3, students worked with key stakeholders to develop a project and conduct a small test of change. They experienced most elements of an improvement cycle. Site leaders often had experience with SI and knew how to guide and support students’ learning.

Conclusions Each model could offer systems-oriented learning opportunities provided that key elements are in place including site leaders facile in SI concepts and able to guide students in SOWLE activities.

B.C. O’Brien is associate professor, Department of Medicine, and research faculty member, Office of Research and Development in Medical Education, University of California, San Francisco, School of Medicine, San Francisco, California.

M.R. Bachhuber is associate clinical professor, Department of Medicine, University of California, San Francisco, and deputy associate chief of staff for education, San Francisco VA Medical Center, San Francisco, California.

A. Teherani is professor, Department of Medicine, and research faculty member, Office of Research and Development in Medical Education, University of California, San Francisco, School of Medicine, San Francisco, California.

T.M. Iker was research assistant, Office of Research and Development in Medical Education, University of California, San Francisco, School of Medicine, San Francisco, California, at the time this work was completed.

J. Batt is clinical research coordinator, Department of Nephrology, University of California, San Francisco, San Francisco, California.

P.S. O’Sullivan is professor, Department of Medicine and Surgery, and director, Office of Research and Development in Medical Education, University of California, San Francisco, School of Medicine, San Francisco, California.

Funding/Support: This work was funded by an educational innovations grant from the UCSF Academy of Medical Educators and the UCSF Office of Medical Education.

Other disclosures: None reported.

Ethical approval: All participating students were informed of this study and agreed to participate. This study was reviewed by the UCSF human research protection program committee on human research and granted exempt status on April 23, 2014 (IRB# 13-12623).

Previous presentations: Versions of this work have been presented as a brief oral presentation at the UCSF Educational Showcase on March 30, 2015 in San Francisco, California; in a symposium at the American Educational Research Association annual meeting on April 16, 2015 in Chicago, Illinois; and as a poster at the Association of American Medical Colleges’ Western Group on Educational Affairs annual meeting on April 23, 2015 in San Diego, California.

Supplemental digital content for this article is available at http://links.lww.com/ACADMED/A363.

Correspondence should be addressed to Bridget C. O’Brien, UCSF Office of Medical Education, Box 0710, 533 Parnassus Ave., Suite U-80, San Francisco, CA 94143; e-mail: bridget.obrien@ucsf.edu.

To provide optimal care to patients in today’s complex health care system, physicians must be capable of working with others to critically examine, redesign, and improve the systems in which they deliver care.1 The growing importance of competence in systems-based practice (SBP), defined as “awareness of and responsiveness to the larger context and system of health care, as well as the ability to call effectively on other resources in the system to provide optimal health care,”2 suggests that medical students should learn SBP early in their education and refine it throughout their careers.3

Some specific components of SBP include knowledge of the systems in which health care is delivered, ability to connect individual practices with the larger systems in which they occur, and ability to identify problems and to design and evaluate potential solutions to these problems.2,4 To achieve proficiency in SBP, learners must develop systems thinking skills5 and learn to work collaboratively with others on systems improvement (SI) efforts. Some components of SBP (e.g., systems thinking, tools and language used for improvement) may require a different set of curricular experiences and pedagogical strategies from those aimed at developing clinical reasoning and patient–physician interaction skills.1,3,4

To date, educators have largely designed SBP education for residents and senior medical students, often emphasizing patient safety and SI concepts and projects.6 The few examples of SBP curricula for early (preclerkship) learners tend to occur in classroom or nonclinical settings, focus on principles of quality improvement or patient safety—using lectures, small-group discussions, or online modules—and rarely provide opportunities for ongoing participation in authentic SBP activities in the workplace.7 Because systems-oriented habits of mind are usually not being developed early on, students’ appreciation for SBP as part of physicians’ work is probably less than it should be.3,8,9

Over the last decade, educators have been encouraged to incorporate more time for authentic clinical experiences into the first two years of the curriculum. Engaging students in SI efforts in real clinical settings is a way to provide authentic early experiences (AEEs) that may add value to the clinical setting.1 Systems-oriented AEEs include learning opportunities related to the delivery of clinical care, patients’ experiences of care, the roles and responsibilities of various health professionals, and the language of practice, all fostered through immersion in “real life” settings in which health care services are delivered and in which preclerkship students can engage in activities associated with their profession.10–12 AEEs are widely recognized by students and educators as beneficial and enjoyable when properly designed13,14 (see List 1 for key components) and are generally associated with positive learning outcomes for clinical knowledge, clinical and communication skills, and professional identity formation.14 Additionally, AEEs may be appropriate for developing skills in SBP.15

A handful of articles have described AEEs that promote SBP.15,16 Both Sheu et al15 and Chen et al16 identified ways in which first- and second-year medical students learned elements of SBP through active engagement in student-run clinics; Ogrinc et al17 described their Health Leadership Practicum Elective, in which second-year students participated in SI projects at a local site with guidance from a faculty coach at the site. However, these experiences were all elective ones accessed by a small proportion of students. Gould et al18 reported positive outcomes (knowledge and self-efficacy) from an experiential continuous SI curriculum for all second-year medical students, but also noted skepticism among students about the value of the SI activities; student feedback suggested shortcomings in achieving a fully integrated, authentic SBP experience. To develop robust AEEs in SBP for all early learners, educators need information about potential models, activities, pedagogical strategies, and outcomes.

Our study aimed (1) to critically analyze the purpose, types of activities, pedagogical strategies, and outcomes associated with existing systems-oriented workplace learning experiences (SOWLEs) and then develop models for SOWLEs; and (2) to use the findings from our analysis described in the first aim to further refine a framework for SOWLEs that educators can use to guide development and evaluation of SOWLEs for early learners.

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Method

Study design

We used a two-phase case study design from a constructivist approach.18 Phase 1 (January–April 2014) consisted of integrated SOWLEs (i.e., SOWLEs offered as electives that students could participate in as part of their preceptorship sessions). As part of the preceptorship experience, some students spent five to six half-day sessions over four months in a clinical setting participating in SI efforts. In Phase 1, we conducted interviews with leaders of those SOWLE electives to identify similarities and differences in structure, content, pedagogy, and outcomes across experiences (cases). We identified patterns that suggested models of SOWLEs. Phase 2 (July and August 2014) consisted of seven pilot SOWLEs. Students spent eight weeks of immersion at a clinical site, 30 to 40 hours per week. In Phase 2, we sought elaboration and verification of these models through case studies of the seven pilot SOWLEs,19,20 which were at a variety of sites.

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Participants, setting, and curriculum

In Phase 1, we asked curricular leaders in our medical school to suggest examples of workplace-based experiences that matched the goals of SOWLEs (i.e., to provide experiences that engage early learners in workplace-based SBP activities on multiple occasions over several months). We then e-mailed each of the leaders of these experiences, inviting them to participate in interviews. We interviewed the 10 leaders who replied, who were from diverse settings (e.g., inpatient and outpatient; university health system; and community based, county, and Veterans Affairs systems) and diverse disciplines (e.g., primary care, specialty care).

In Phase 2, our institution supported seven SOWLE pilots in different disciplines hosted in three health care systems (university, county, and veterans), each with an identified site leader. Seven medical and two pharmacy students participated for eight weeks during the summer between their first and second years. All students participating in the pilots were informed of our study and agreed to participate.

The experience began with a weeklong formal curriculum covering basic concepts relevant for workplace learning and SBP. Faculty members with expertise and experience in SBP taught the curriculum. During the remaining seven weeks, students spent the majority of their time working on site-based projects and reconvened one half-day per week for additional formal curriculum and works-in-progress sessions. At the end of the pilot, we contacted all pilot site leaders by e-mail and invited them to participate in interviews. We interviewed the six leaders who replied.

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Procedures and data collection

In Phase 1, we invited 13 SOWLE leaders to each participate in a one-hour interview. We chose to start with SOWLE leaders because they typically designed the experiences and could provide the most details about the purpose, activities, pedagogical strategies, and outcomes. Two of us, a physician (M.R.B.) and/or an educational researcher (B.C.O.), interviewed 10 leaders; the other 3 were not available. In a semistructured format, the interviewers probed for details related to key elements of effective AEEs described in the literature13,14 (see List 1) and about SBP activities4 (see Supplemental Digital Appendix 1 at http://links.lww.com/ACADMED/A363).

In Phase 2 we collected data from site leaders and students participating in the seven SOWLE pilots, including semistructured interviews (using a modified version of the Phase 1 interview guide), notes from weekly works-in-progress sessions, students’ final project summaries and presentations, and students’ written reflections and recommendations on the design of their experience based on a structured set of questions (see Supplemental Digital Appendix 2 at http://links.lww.com/ACADMED/A363). We sought a complete picture of the experience in Phase 2 and thus chose to interview students as well as leaders. Two of us who are trained research assistants (T.M.I., J.B.) also visited each of the seven sites on at least one occasion for about four hours, taking field notes using a semistructured observational template. We also conducted hourlong interviews with all nine students at the end of the pilot and with six out of the seven site leaders. (See Supplemental Digital Appendix 1 at http://links.lww.com/ACADMED/A363.)

The University of California, San Francisco human research protection program committee on human research approved this study as exempt. All participants received an information sheet describing voluntary participation in the study.

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Data analysis

In Phase 1 we used directed qualitative content analysis21 to code our interview data for content related to goals and purposes, clinical and systems-oriented learning content (curriculum), pedagogical strategies (selection of activities, sequencing, scaffolding), and outcomes (students, patient, faculty/staff, system). One of us (B.C.O.) was the primary coder, and the other members of the research team reviewed excerpts for agreement. When coding was complete, the primary coder reviewed the content pertaining to each code and summarized it into case write-ups for each SOWLE. All of us met regularly to discuss similarities and differences among the learning experiences (cases) and to identify potential models of SOWLEs through discussion and consensus.

In Phase 2, we completed case studies of seven SOWLE pilots.19,20 Three of us (B.C.O., T.M.I., and J.B.) created a case write-up—a descriptive summary of each pilot—based on data from interviews, field notes from site visits and works-in-progress sessions, and students’ written reflections. All of us reviewed these case write-ups and, through careful analysis and group discussion of confirming and disconfirming evidence, mapped each SOWLE pilot (case) to one of the three potential models defined in Phase 1. This process resulted in refinement of the models. As a final step, we reviewed the cases within each model for examples of promising practices commonly associated with AEEs. This was not one of our initial aims, but we recognized connections during our analysis and identified this as an important area to explore in the discussion of our findings.

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Results

On the basis of data collected from SOWLEs occurring in outpatient primary care settings (community and university based), specialty clinics (medicine subspecialties, pediatrics, surgical subspecialties), and inpatient wards (general medicine and surgery), we identified and confirmed three models of SOWLEs. We also noted one additional case that represents a potential risk for SOWLEs when sites and/or supervisors lack experience with and commitment to SI. We have organized our model descriptions emphasizing some of the elements presented in List 1: goals and purposes of the experience, supervisors’ roles/pedagogical strategies, and learning and systems outcomes afforded through these activities.

Table 1 provides a concise summary of our findings. The Results section that follows provides additional contextual information that does not appear in the table. Included in the table are descriptions of and information about the models and supporting quotes from interviews with students and supervisors. Table 2 provides a specific example of a SOWLE in each model. This provides a concrete picture of what an experience looks like.

Table 1

Table 1

Table 2

Table 2

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Model 1: Learning through immersion in a system, delivering an intervention

Data for Model 1 came primarily from six Phase 1 sites and one Phase 2 site. In Model 1, the goals and purposes of the experiences allowed students to actively participate in delivery of patient care to address a specific gap or need in the system. Students participated in activities such as health coaching, motivational interviewing, medication reconciliation, or mobilization of hospitalized patients. These experiences included a systems component in that students contributed to an SI intervention, even if not explicitly defined as such. Supervisors facilitated students’ involvement in the workflow, legitimizing students’ presence and participation, providing students context for the intervention, and teaching relevant clinical skills and knowledge.

Regarding learning and systems outcomes, students typically enjoyed the opportunity to interact with patients and felt that they made meaningful contributions to the workplace, especially when performing tasks that others lacked time to perform. In interviews, supervisors acknowledged that by filling a gap in the system, students helped provide a valued service to patients and/or providers and staff. Supervisors recognized that the value of the experience could diminish over time if students performed the same tasks repeatedly over multiple sessions with little opportunity to increase complexity or develop advanced skills. Model 1 included rich opportunities for systems-oriented learning such as understanding how a specific gap evolves in the system, why the system fails to serve some populations of patients, and roles of various health professionals. However, this learning often was informal or unintentional. Additionally, many learning opportunities focused on clinical knowledge and skills.

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Model 2: Learning through immersion in an SI initiative

Data for Model 2 came primarily from two Phase 1 sites and two Phase 2 sites. In Model 2, goals and purposes centered on engaging students in an SI effort already under way at the site, teaching some of the skills associated with SI, and introducing students to a culture that embraces SBP. These experiences addressed SBP explicitly, unlike the more indirect approach in Model 1. In this model, students’ involvement in both clinical and systems activities depended on the improvement effort in which they were involved, the type of clinical work at their site, and students’ interest in combining clinical and systems activities. Common types of systems activities included observation of a specific process in a microsystem (e.g., discharge process, rounds); data collection through observation, interviews, surveys, and chart reviews; data analysis; and application of SI tools (e.g., creation of process maps and fishbone diagrams, attending meetings with SI project team members).

Site supervisors and/or other on-site faculty and staff members were usually well versed in SBP. These individuals taught SBP concepts and skills; facilitated students’ integration into existing SI initiatives; and provided context, clinical knowledge, and skills directly relevant to the SI initiative. Students were highly engaged in SI activities, particularly if they understood the overarching goals for the initiative, could offer insights, and could incorporate some of their own ideas into it.

Model 2 offered many systems and clinical learning outcomes. Systems learning outcomes were more prominent in Model 2 than in Model 1 and included how to analyze a system, specific techniques used in SI, patient/provider/staff experiences in a system, and roles and responsibilities of different participants in the system. Clinical learning outcomes included specific medical language and knowledge and skills relevant to the SI initiative as well as other opportunities provided by supervisors and other faculty and staff at the site. Students’ impact on the system in Model 2 tended to be embedded in a larger effort. Students’ project summaries and interview data—in which students and supervisors described perceived system-level impact—suggest that students contributed important information or data to support problem identification or evaluation of an intervention, performed critical tasks that others did not have time to do, offered insights or ideas for improvement, and ultimately helped ensure the progress or completion of valued SI efforts. However, when students failed to recognize their role in a larger ongoing initiative, they wondered whether they had met expectations and had a positive impact.

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Model 3: Learning by leading/performing an SI initiative

Data for Model 3 came primarily from two Phase 1 sites and three Phase 2 sites. In Model 3, goals and purposes focused on students’ involvement in their sites and partnerships with key stakeholders to design, implement, and evaluate a small-scale, focused improvement project or test of change. In contrast to Models 1 and 2, students in Model 3 had a significant role in a whole improvement cycle, and they felt ownership and investment in the project. Their projects were either embedded within a larger initiative or launched through students’ own initiatives. Although full implementation and evaluation were the goals, students could not necessarily achieve these in two to three months. While students spent most of their time engaged in specific SBP activities, they participated in clinical activities directly related to design, implementation, and evaluation of their projects. Some supervisors incorporated additional clinical experiences at students’ request. The supervisor’s role in Model 3 was largely to form a partnership with the students to guide them and provide the resources needed for their projects. As such, supervisors tended to be less directive in Model 3 than in Models 1 and 2.

On the basis of our observations of students’ works-in-progress sessions and information provided in interviews and written reflections, students in this model learned specific skills related to SBP, SI in general, as well as various components of a plan–do–study–act cycle and how specific processes work in a clinical setting. Students also gained a realistic understanding of SI, including the frustration of setbacks and the excitement of small successes. In contrast to Model 1, in Model 3 the clinical learning outcomes tended to occur informally and implicitly, whereas systems-oriented learning was explicit. Students’ project summaries, along with interview data from faculty and students, showed that impact on the system varied by project. Some projects made important contributions that would be sustained, while in other projects the intended intervention was not implemented or evaluated before the student’s rotation ended. In this sense, students gained a realistic and authentic experience with SI that fostered both positive and negative impressions.

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Additional case: Learning through immersion in a system

We identified one additional experience that was part of the SOWLE pilots in Phase 2 but did not fulfill the stated goals of SOWLEs. We include this case even though it deviates from the others because it may represent challenges germane to future SOWLE sites. In this example, the experiences of one of the students focused primarily on participation in routine patient care activities rather than on SI activities. By assisting with these patient care activities, the student implicitly learned about roles and relationships among health professionals; workflow within and across clinical services; rules, norms, and safety procedures; and communication processes. The student unintentionally incorporated a systems angle into the experience by creating a guidebook that documented many of the systems features he had to learn to function in the workplace.

In this example, the site supervisor and other faculty and staff who worked with the student had limited training and experience with SI, and the microsystem lacked a culture and commitment to SBP. The student was particularly interested in the clinical work performed at the site and eager to participate in as many clinical activities as possible. Correspondingly, SBP was not a learning priority.

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Discussion

SBP and SI are increasingly recognized as essential parts of high-quality, high-value health care delivery. Many faculty and staff members are still learning how to apply the concepts while simultaneously engaging residents, and now students, in SBP activities. To assist and support faculty in this new educational endeavor, our study’s findings allowed us to identify three models of SOWLEs for early learners and to describe promising practices associated with each model. All three models can provide systems-oriented learning experiences for students, but several factors must be addressed to optimize the workplace experience. Below, we discuss four of these factors, which are related to curriculum design and supervisor roles/pedagogical strategies in the AEEs presented in List 1. We also discuss their implications for sites and institutions that are seeking to design and implement quality SOWLEs in any of the three models.

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Selecting authentic activities for students and legitimizing their participation in these activities

A key component of successful AEEs is selecting authentic activities for students and legitimizing their participation in these activities.13,14 Ideally, students’ SOWLEs occur in sites with an established culture of SBP; regular improvement activities; and supervisors, faculty, and staff who are well versed in and committed to systems thinking and improvement. Unlike clinically oriented AEEs, where learning generally aligns with the core activities of the workplace, systems-oriented activities may not be well integrated into routine work. Many sites selected for student placements may be in the process of building a culture of improvement. Acknowledging this and identifying students’ contributions to the process can be a valuable learning opportunity.

In light of these circumstances, our findings suggest that any of the three models could be used for systems-rich learning experiences even in less-than-ideal conditions. The key is for one or more faculty members to carefully consider the opportunities for systems learning in their environment, select the optimal model, and identify specific gaps that will need to be filled. For example, Model 1 (in which students deliver an intervention to improve quality of care or patient experience) may work well in settings where the activities themselves have high authenticity and value and a faculty member can guide students to see the connections to systems learning and improvement. Model 2 (in which students participate in an existing SI intervention) may be well suited to sites where there is support for SI, but capacity to do the work is limited and thus the student can produce valued information to support sites’ efforts (e.g., needs assessments, process maps). Model 3 (in which students conduct a small test of change) can take place at sites where minimal systems work is in place but a faculty expert and champion can provide significant mentoring to the students and facilitate relationship building and partnerships between students and key stakeholders. Faculty efforts to model systems thinking and commitment to improvement help to reassure students that they are doing critical work and not simply performing tasks that no one else has time to do or that are irrelevant to core work of the site (e.g., patient care).

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Promoting learner agency

A second key component of successful AEEs is promoting learner agency.13Agency describes learners’ perceptions of their ability to select, direct, and/or influence activities and circumstances in their environment.22 In the context of SOWLEs, we found that all three models promoted agency that pertains to students’ sense of their own capacity to change or improve a system through participation in an intervention or project. Important concepts for promoting students’ agency include preparing them to engage in the workplace with site-specific training and expectations; encouraging them to share their insights, questions, and suggestions; and providing them access to resources and support. In all three models, students can have opportunities to share insights through including them in project meetings and giving progress reports to key stakeholders. Faculty can also support students’ agency by allowing students latitude and independence in selecting and shaping a project, particularly in Model 3.

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Providing active support and guidance

The third key element to highlight from the literature on AEEs is providing active support and guidance during the workplace experience.12,13 The ability to support students’ learning of SBP and SI requires that they have access to individuals in the workplace who are knowledgeable in SI, skilled at teaching SI, and committed to guiding students’ learning. These individuals must clearly understand the goals and expectations of the medical school, the types of activities appropriate for early learners, and the level of guidance and support those learners will need. For example, site leaders in our study had to determine the appropriate scope of work for early learners, the amount of background and contextual information needed (given students’ limited clinical experience), and how to provide structure for students’ daily activities and assignments while also allowing students enough flexibility and independence to incorporate their own ideas and address their own learning goals. Site leaders also had to identify ways to engage other faculty and staff members in guiding and supporting students because they often had limited amounts of time to spend with students.

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Engaging students in critical reflection and debriefing

A fourth key component of learning involves engaging students in critical reflection and debriefing of their workplace experiences.13 In our study, this occurred in several ways. Site supervisors had daily or weekly check-ins with students. Often, these were informal conversations rather than structured reflections on systems issues. In the Phase 2 pilots, students had weekly works-in-progress sessions that provided rich opportunities away from the workplace to share and debrief experiences with peers and nonsite faculty, learn how to think about their experiences in a systems framework, and receive feedback and encouragement. Students found that these sessions were particularly valuable and that they enhanced the learning experience regardless of the model.

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Limitations and opportunities for further investigation

The three models we identified are based on a limited number of experiences in a single institution. Many of these were pilots, and thus carefully selected to provide robust educational experiences for students. The students who selected into these pilots may have been more motivated and interested in SI than is the typical medical or pharmacy student. Expanding SOWLEs beyond a limited number of pilots and students may result in more variability and potentially more models. Phase 2 sites all had an immersion structure, with students devoting 30 to 40 hours per week to their sites with minimal competing curricular activities. However, these experiences may be good representations of the higher end of the spectrum of what students can learn and contribute.

There are several opportunities for further investigation based on the models identified in our study. Questions about appropriate preparation for participation in each model are important. Students participating in the Phase 2 pilots all received a core curriculum as well as additional training at their sites and the opportunity for debriefing away from the sites. Future work could explore the balance between a general preparatory curriculum for SOWLEs and a customized, site- or model-specific curriculum and between on-site and off-site debriefing. Future work might also examine faculty and staff development needs for each model as well as possibilities for sites to transition from one model to another as faculty and staff gain SI knowledge and skills and as resources, culture regarding SI, and the status of SI initiatives change.

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Conclusion

SOWLEs, as a type of AEE, offer a promising approach for early learners to begin developing competence in SBP. Every workplace differs in culture, activities, workflow, people, relationships, and performance standards and therefore affords different learning opportunities. This variation is a reality of workplace learning experiences that requires both flexibility in the structure of the experience as well as diligent attention to the goals, objectives, and guiding principles of the SOWLEs.

Our study provides a framework and strategies to guide future design and development of SOWLEs. We suggest that some models may be better suited to certain site characteristics than others. We recommend that, at minimum, all sites have an openness to working with early learners and one or two experienced champions of SBP to legitimize students’ roles and activities, serve as role models, and provide guidance and support.

The three models we identified offer sites options for structuring SOWLEs depending on experience and support for SBP at the site, the status of SI initiatives, and the comfort of supervisors and workplace faculty and staff with SI and working with students. By attending to key factors such as framing activities to highlight systems issues, integrating and legitimizing students’ participation, promoting learner agency, and engaging students in constructive reflection and debriefing, faculty site leaders can enhance both the value of the experience for student learning and also its impact on the workplace.

Acknowledgments: The authors wish to thank the University of California, San Francisco (UCSF) Curricular Ambassadors program for supporting and participating in this project and members of the UCSF ESCape community for helpful feedback on this manuscript.

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