Widening how we see the impact of culture on learning, practice and identity development in clinical environments.

As part of this State of the Science series on Self, Society and Situation, we focus on how we might see the situation of the workplace as a learning environment in the future. Research to date into how health professionals learn while working in clinical workplace environments has mostly focused on the supervisor-trainee relationship or on the interaction between the affordances of a workplace and the receptiveness of trainees. However, the wider environment has not received as much focus-though frequently mentioned, it is seldom investigated. We suggest there is a need to embrace the wider institution factors, recognise and acknowledge an organisation's values and culture as they impact on clinical learning in order to work with these, not around them or ignore them, to make what may be tacit visible through reflection and observation and to embrace a range of perspectives on culture.

Improving the prescribing practice of junior doctors through interprofessional collaboration and evidence-based education.

The last decade (2010-2019) has seen calls to action to improve the prescribing practice of junior doctors. An in-depth investigation into the causes of prescribing errors by foundation trainees in relation to their medical education (the EQUIP study) in the UK reported a prescription error rate of 8.9% for all prescribed medicines, and although that is a UK study, there are similarities with New Zealand prevocational training programmes. The EQUIP study revealed that existing teaching strategies are not working. To believe a single intervention will prevent most prescribing errors is simplistic, and for improvement to occur, new prescribers need to learn from their mistakes. Traditionally, the education of junior doctors has focused on their competence and professional registration requirements. Working in healthcare is collective and multidisciplinary, and errors occur through human and system factors.

Becoming clinical supervisors: identity learnings from a registrar faculty development program.

This article shares our experiences and surprises as we developed, implemented and evaluated a 12-week faculty development program for registrars as clinical supervisors over three cohorts. The program has consistently been rated highly by participants. Yet, following a comprehensive curriculum review, we were surprised that our goal of encouraging identity development in clinical supervisors seemed to be unmet. Whilst our evaluation suggests that the program made important contributions to the registrars' knowledge, application and readiness as clinical supervisors, challenges linked to developing a supervisor identity and managing the dual identity of supervisor and clinician remain. In this article we describe our program and argue for the importance of designing faculty development programs to support professional identity formation. We present the findings from our program evaluation and discuss the surprising outcomes and ongoing challenges of developing a cohesive clinical educator identity. Informed by recent evidence and workplace learning theory we critically appraise our program, explain the mechanisms for the unintended outcomes and offer suggestions for improving curricular and pedagogic practices of embedded faculty development programs. A key recommendation is to not only consider identity formation of clinical supervisors from an individualist perspective but also from a social perspective.

Finding your feet: student participation during initiation of international clinical placements : Student participation during initiation.

INTRODUCTION: International placements challenge students to find the right level of participation, as local practices, language and time pressure may affect their engagement in patient-related tasks or team activities. This study sought to unpack the initiation process during international clinical placements with the ultimate aim to achieve active student participation. METHODS: Following a constructivist grounded theory approach, we conducted two individual interviews with 15 undergraduate healthcare students (before departure and whilst on placement). To identify emerging themes, we applied an iterative process of data collection and constant comparative analysis. Several team discussions informed further analysis, allowing us to reach a more conceptual level of theory. RESULTS: From our findings we constructed a four-phase model of healthcare students' initiation of international clinical placements, which brings into focus how the phases of 'orientation', 'adjustment' and 'contribution to patient care' build up towards a 'sense of belonging'. We identified several factors that induced active student participation in practice, such as a favourable workplace setting, opportunities for learning and a local support network. DISCUSSION: Active student participation is aimed at different goals, depending on the four phases of initiation that eventually lead to a sense of belonging and support workplace learning.

Beyond competencies - describing work ready plus graduates for the New Zealand medical imaging workforce.

INTRODUCTION: Medical imaging is a profession where technology and practice is moving forward at a fast pace, while also being situated within rapidly evolving models of healthcare delivery. This requires capabilities in our graduates beyond the competencies to undertake the role. This study used an existing Professional Capability Framework as the foundation for the development of a survey tool to identify those capabilities most valued by the health services that provide placement opportunities for students. METHODS: A prospective survey, conducted online, was used to gather the data from senior medical imaging staff who work regularly with students and new graduates. RESULTS: The results identified the top capabilities within each of three domains of personal, interpersonal, and cognitive capabilities. The results from the personal domain show that remaining calm under pressure or when things take an unexpected turn; understanding personal strengths and limitations; being willing to face and learn from errors; wanting to do as good a job as possible and having energy, passion and enthusiasm for the profession and role are most valued by the profession. We have identified links between the most desired interpersonal capabilities and attributes of well-functioning interprofessional teams and the cognitive capabilities align to those required for critical thinking and clinical reasoning. CONCLUSIONS: These results have allowed the curriculum development team to review the graduate profile of medical imaging technology graduates. The curriculum development team has begun a process to incorporate learning strategies that will encourage the development of these capabilities in our graduates.

Clinical learning environments: place, artefacts and rhythm.

CONTEXT: Health care practitioners learn through experience in clinical environments in which supervision is a key component, but how that learning occurs outside the supervision relationship remains largely unknown. This study explores the environmental factors that inform and support workplace learning within a clinical environment. METHODS: An observational study drawing on ethnographic methods was undertaken in a general medicine ward. Observers paid attention to interactions among staff members that involved potential teaching and learning moments that occurred and were visible in the course of routine work. General purpose thematic analysis of field notes was undertaken. RESULTS: A total of 376 observations were undertaken and documented. The findings suggest that place (location of interaction), rhythm (regularity of activities occurring in the ward) and artefacts (objects and equipment) were strong influences on the interactions and exchanges that occurred. Each of these themes had inherent tensions that could promote or inhibit engagement and therefore learning opportunities. Although many learning opportunities were available, not all were taken up or recognised by the participants. CONCLUSIONS: We describe and make explicit how the natural environment of a medical ward and flow of work through patient care contribute to the learning architecture, and how this creates or inhibits opportunities for learning. Awareness of learning opportunities was often tacit and not explicit for either supervisor or learner. We identify strategies through which tensions inherent within space, artefacts and the rhythms of work can be resolved and learning opportunities maximised.

Becoming a practitioner: workplace learning during the junior doctor's first year.

BACKGROUND: Newly qualified doctors (interns) report that they learn a great deal in the first year of practice, but exactly what is learnt is not well understood. AIMS: To document the reflections and perceptions of first year junior doctors in order to reveal and chronicle their informal and often tacit learning in the workplace within a practice methodology framework. METHODS: New Zealand interns, from three sites, participated in group interviews modelled on a conversation and joint enquiry style. RESULTS: We found that learning in the first year after graduation falls into three broad themes: (1) concrete tasks, (2) project management and (3) identity formation. Identity formation appeared the most challenging and included getting used to being seen by others as a doctor. CONCLUSION: All themes have implications for curriculum development and clinical supervision in both undergraduate programmes and during internship. The third theme (identify formation) is the most complex. We draw on a model from management literature, to describe intern education as a process of becoming: as an unfolding and as a transformation of the self over time. We argue that reconfiguring internship as a period of identity formation, and as a self-determined, active process of 'becoming a doctor' provides a wider perspective than enculturation or socialisation theories to understand this significant transition.

Interprofessional learning in medical education in New Zealand.

This article considers interprofessional learning initiatives in the context of undergraduate and postgraduate education and the continuing professional development of doctors and other health professionals. The evidence for and challenges to delivering interprofessional education are discussed along with current interprofessional education initiatives in Aotearoa/New Zealand and Australia. Many opportunities exist for health professionals to work together more effectively. We all want the best outcomes for our patients and good working relationships, but often we work and learn in professional silos. This paper explores the policy drivers for interprofessional learning (IPL), provides evidence for what works, identifies some of the challenges and shares examples of how health professionals in New Zealand are implementing IPL initiatives: aimed at improving health outcomes and facilitating well-functioning workplaces for all members of the health care team.

Programmatic research in medical education: a national collaboration.

AIM: We aimed to identify areas that are a high priority for medical education research in New Zealand and that would benefit from a coordinated collaborative approach as an initial step in developing a coordinated research strategy. METHODS: A modified Delphi technique was used to reach consensus, among medical education researchers in New Zealand, on the optimal areas of activity. RESULTS: The programme of research fits under an overarching theme of "Growing a professional workforce". Seven key areas of activity have been identified: engaging in community and clinical learning environments; improving recruitment and retention; improving phases of transition; assessing professional behaviours; promoting quality feedback; engaging clinical teachers and educational and clinical leadership. CONCLUSION This programme of medical education research projects is in the national interest, assists in theory building, helps develop research groups with similar interests, helps avoid duplications, ensures efficient use of funding opportunities, and makes effective use of existing expertise.

The good apprentice in medical education.

This paper targets both current apprentices and their supervisors drawing on current research to answer the following questions. What is apprenticeship and what are the key elements? What is a good apprentice and what can an intern or registrar do to assist their own learning and development? It takes a pragmatic approach and seeks to assist apprentices and their supervisors by attending closely to what is practicable, realistic, expedient and convenient; articulating this and laying it out as clearly as possible.

Maximising learning through effective supervision.

This article targets supervisors and their important role in maximising learning of novice practitioners. The article draws on current research to highlight the importance of clinical supervision and the roles and tasks of the supervisor. Some of the challenges of supervision and how the supervisor can be supported are also discussed. The article has a pragmatic and practical focus to assist the supervisor in one of the most important, challenging but rewarding educational roles.

General practice rotations for post graduate year 1 and 2 house officers--how feasible?

AIMS: To study the needs and support requirements of general practitioners facilitating general practice rotations for post graduate year (PGY)1/PGY2 house officers at their surgeries. METHOD: This was a telephone survey of general practitioners (GPs) from different practices in Canterbury Province, New Zealand. A semi-structured interview format was used as this allowed questions and responses to be clarified and provided the opportunity for respondents to make additional comments. RESULTS: Twenty GPs from 20 different practices were interviewed in the study. There was a 100% positive response to the concept of a house officer (HO) rotation in general practice. Perceived benefits included the opportunity for house officers to improve their understanding of primary healthcare and general practice, gain clinical skills less available in the hospital setting, as a way to promote general practice and to enhance communication at the primary-secondary interface. Fifteen (75%) thought that this rotation would be better suited to PGY2 or more experienced PGY1 graduates. Eighteen (90%) of GPs reported that costs to their practice must be covered for HO rotations. Seventeen (85%) of GPs reported that their practices did not currently have adequate consulting space to accommodate a HO. CONCLUSIONS: GPs support HO rotations in general practice with perceived benefits for both HOs and general practice. PGY2 house officers were thought more suitable for GP rotations. Potential barriers to GP rotations include possible financial costs and capacity issues at the practice.

Maximising the clinical learning of junior doctors: applying educational theory to practice.

Effective learning in the workplace emphasises the importance of participation in the social context and activities of that workplace. A model has previously been developed that sets out the elements of positive and participatory learning environments. The introduction of an attachment in the Emergency Department for newly graduated doctors provided an opportunity to (1) identify and implement the relevant elements from the theoretical model; (2) develop an evaluation plan in order to guide and monitor the intervention. The lessons learned from converting a theoretical model into practice and the use of quality management processes for implementation, monitoring, and evaluation are discussed.

The development of a national bicultural and interprofessional programme in clinical teaching and supervision in New Zealand.

Throughout the world, particularly in colonized countries, the health status of indigenous people and the unequal representation of indigenous people within the health workforce is of concern. In 2002, as part of a national health workforce development strategy, a qualification was developed to provide Maori (Indigenous New Zealander) health professionals with the skills and confidence to teach and supervise students on clinical placements in Maori health environments. This project required close collaboration between two education providers, one a Maori private education provider and the other a traditional government-funded tertiary institution; and for both organizations to work cooperatively with Maori communities and Maori health providers. The Christchurch College of Education (CCE) and Mauri Ora Associates are jointly involved in the administration, design and delivery of the programme, recruitment of guest lecturers, and ongoing curriculum updates. The content for the programme is mainstream, international and interprofessional but the pedagogy is Maori, with Maori customs, values and traditions upheld and practised. A national Maori health workforce development organization contracts independently with both organizations and provides an oversight and quality monitoring role. Together, the three organizations work with other Maori health professional groups and Maori elders to deliver the qualification. This paper describes how this course was designed, how it is delivered within a Maori paradigm, and how the outcomes are achieved. It also describes the cooperation between Maori and Pakeha (white New Zealanders) across health, community and educational organizations that was required to sustain this programme over five years and identifies some themes that may be applied in a global context. In sharing our experiences, we hope to inspire others to consider ways they can meet the needs of indigenous learners within their mainstream programmes.

Radiology knowledge in new medical graduates in New Zealand.

AIMS: To establish the level of knowledge of new medical graduates in New Zealand about common radiological investigations and to assess their ability to request most appropriate, cost-effective radiological investigations for common clinical scenarios. METHODS: A test was developed and administered in Waikato, Christchurch, Rotorua, Auckland, and Dunedin hospitals during the first month of new house officer year (November 2002). RESULTS: Sixty-two first year house officers participated; 59 were New Zealand medical graduates (Auckland: 24 and Otago: 35) and 3 were from overseas institutions. The mean score for questions that assessed about risks involved in common investigations, including radiation, was 47% (95% CI: 45%-49%). The mean score for selecting the appropriate clinical investigations was 53% (95% CI 52%-54%). Most significantly, only 42% (95% CI 38%-46%) of the respondents thought they had adequate radiology teaching to work as house officers. The following percentage of the respondents never observed the respective examination during their medical school training: barium enema 72% (95% CI: 60%-82%); IVU 75% (95% CI: 63%-87%); US scan 25% (95% CI: 16%-37%); CT scan 20% (95% CI: 11%-32%); angiogram 16% (95% CI: 9%-28%); MRI 42% (95% CI: 30%-54%). The mean score for the practical knowledge about common investigations was 50 (95% CI: 48%-52%). CONCLUSIONS: Medical students report that they have limited exposure to radiology teaching during their medical school training. The test results suggest that medical school training enabled them to commence their probationary year with a 'just safe' level of radiology knowledge and skill.