Orienting Students to Learning in Clinical (or other workplace) settings

At the outset

Before they commence studies in medicine, there are some basic educational abilities that students should possess. They probably already are very skilled at the routines of swatting for examinations that focus on knowledge or content, and encourage students reproduce that content in test conditions. The systems of assessment that educators set up reward certain behaviours in students and not others. Content-focussed knowledge tests will reward the study of declarative knowledge (facts, definitions, routine application awareness); other formats such as the essay will reward understanding, awareness of context, and reasoning. These different assessment regimes require for success different behaviours on the part of the student. The first to let students become aware of is what they already assume that learning is, and how they approach learning (see students’ approaches to learning).

The next ability all students should develop is the ability to “reflect” on their learning. Reflective practice is part of professional practice; the extension of application to learning is natural and will carry forward into students’ future careers in medicine which is a profession that is characterised by the idea of lifelong learning. There are specific ways to approach developing students’ reflective practice – initially as learners but, as a transferable ability, later as professionals. The 4Rs model is one such example (Ryan and Ryan 2012):

Report and Respond

Report what happened or what the issue or incident involved. Why is it relevant? Respond to the incident or issue by making observations, expressing your opinion, or asking questions.

Relate

Relate or make a connection between the incident or issue and your own skills, professional experience, or discipline knowledge. Have I seen this before? Were the conditions the same or different? Do I have the skills and knowledge to deal with this? Explain.

Reason

Highlight in detail significant factors underlying the incident or issue. Explain and show why they are important to an understanding of the incident or issue. Refer to relevant theory and literature to support your reasoning. Consider different perspectives. How would a knowledgeable person perceive/handle this? What are the ethics involved?

Reconstruct

Reframe or reconstruct future practice or professional understanding. How would I deal with this next time? What might work and why? Are there different options? What might happen if...? Are my ideas supported by theory? Can I make changes to benefit others?

Students need to value lifelong learning. Lifelong learning is as much a disposition as it is a set of practices. Lifelong learning is closely tied to the idea of self-directed learning. Lifelong learning focuses on practices and dispositions enacted and lived across the life course, but self-directed learning is the crucial underpinning ability that makes it possible to continue to learn throughout the life course (Candy 1991). Students need to develop self-directed learning abilities as part of their preparation for learning in higher education generally and in medicine specifically. The epistemological beliefs (Bath and Smith 2009) and their meta-cognitive strategies (Schneider and Preckel, 2017) are essential to self-directed and lifelong learning.

In the workplace or clinical setting

Students who are in workplace or clinical settings to learn, may not be fully aware of the approach they should, or can, take to pursue their own learning goals. There are different aspects that you should make students aware of as part of their preparation for learning.

First, they need to understand their role, and your role, in their learning. In workplace learning students must be prepared to take on a more self-directed approach to extracting valuable learning from their experiences in the setting. This can be a difficult transition for students if they have become accustomed to educators who have tended to adopt a transmissive or didactic approach to their teaching which renders the students relatively passive in their role. Similarly, workplace or clinical educators should recognise that the workplace or clinical setting itself is a very different environment for the educator, compared with classroom teaching. The clinical or workplace educator must help the student to recognise and extract learning from the experiences they have in the clinical or workplace setting. This can mean a challenging transition for clinical or workplace educators who have had previous experiences with more didactic and transmissive teaching approaches. Both students and educators in workplace or clinical settings need to work together to maximise the learning gains that arise, with great variability, in those settings. Thus, explicitly discussing the roles the parties will be taking, or expected to take, in the clinical or workplace setting is an important part of induction.

Workplace and clinical settings vary enormously from time to time and between settings, in the degree to which they provide opportunities for student learning. This is quite normal but needs to be taken into account in preparing students to understand that there will be occasions on which, or settings in which, they will have a great many opportunities to learn, and others in which learning opportunities are rarer or harder to access.

We need to acknowledge that students vary as individuals in relevant ways. For instance, some are forthcoming and look for, and look out for, learning opportunities. Others are more reticent, and less likely to assert themselves in pursuit of their own learning.

The clinical workplace will variously expose students to a range of experiences that have educational value and which the students should be prepared to recognise during their time in the setting. Students may be more or less actively involved in the work, depending on how advanced the student, and how active a role they can legitimately take. Sometimes students will be only able to observe the work that goes on in the setting, at other times they will be able to do the work (probably under supervision). The sorts of things that occur in clinical settings, from which students could learn a great deal, include history-taking, digital and manual medical record-keeping, diagnostic reasoning, interprofessional communication, patient communication, patient family communication, and a range of diagnostic tests, measures, and techniques, and clinical procedures and interventions. Helping the students to understand what roles they can expect to take across the range of experiences they can expect to observe or have, is a key part of induction.

Student need to learn to adopt and adapt metacognitive strategies and reflective practice to interrogate the experiences they have in the workplace or clinical setting, in order to extract from these the maximum learning. In order to do this, students need to be aware of the learning outcomes that they are expected to be achieving thought their workplace or clinical experiences. Thus, induction, and periodic reinforcement of those learning outcomes are crucial signposting for students to guide this interrogation in the search for learning.

References

Bath, D. M., & Smith, C. D. (2009). The relationship between epistemological beliefs and the propensity for lifelong learning. Studies in Continuing Education, 31(2). https://doi.org/10.1080/01580370902927758

Candy, P. (1991). Self-direction for lifelong learning: A comprehensive guide to theory and practice. Jossey-Bass.

Ryan, M., & Ryan, M. (2012). Developing a systematic, cross-faculty approach to teaching and assessing reflection in higher education (Final report 2012). November, 29.

Schneider, M., & Preckel, F. (2017). Variables associated with achievement in higher education: A systematic review of meta-analyses. Psychological Bulletin, 143(6), 565–600. https://doi.org/10.1037/bul0000098