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A review of the evidence linking conditions, processes
and outcomes of clinical workplace learning
Review team (alphabetical order)
The team includes a deliberate mix of nationalities and academic perspectives:
• Els Boshuizen – Dutch; cognitive psychology; expertise development
• Tim Dornan – British; workplace clinical learning; secondary/tertiary care
• Rachel Gick – British; librarian
• Rachel Isba – British; trainee/teacher perspective; secondary/tertiary care
• Karen Mann – Canadian; nurse; medical academic leadership perspective;
spans primary and secondary care
• Albert Scherpbier – Dutch; medical academic leadership perspective
• John Spencer – British; primary care; medical academic leadership; journal
editorial perspective
Versions
No
2.0
3.0
3.1
3.2
3.3
4.0
4.1
Date
10/9/06
18/9/06
23/10/06
3/11/06
26/11/06
29/11/06
3/12/06
Note
Prepared for first review group meeting, AMEE, Sep 06
Revised into BEME format
Minor textual revisions
Incorporation of content from Karen Mann’s book chapter
Minimal corrections
Revision after discussion with Karen Mann and Rachel Gick
Minor corrections prior to submission to BEME
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Background to the topic
In previous work, we reviewed published literature and conducted empirical
research into clinical workplace learning.1 The product was a theoretical model of
how medical students learn in clinical workplaces, which we termed “Experience
based learning” (ExBL). Although published in a thesis, the literature review is
not readily accessible to other scholars. It served its purpose but was not
systematic and the evidence was not critically appraised to a high standard of
scholarship. This proposal is to triangulate a more rigorous literature review
against the ExBL model and contribute the review to the medical education
research community. This protocol is not heavily referenced because the
background is thoroughly laid out in the thesis and available on request but not
included here because it is so long. A previous BEME review constituted one
chapter of the thesis.2
ExBL holds that medical students become doctors by participating in practice.
The outcomes of participation are practical learning and what we have
provisionally termed “emotional learning”. Those types of learning reinforce one
another and make it easier for medical students to be supported participants.
Medical students are also helped to be supported participants by human
interactions and curriculum factors. We identified three types of support:
Organisational, pedagogic, and affective support, a classification that has been
validated independently by another researcher (Lyons, personal communication).
Figure 1 shows how ExBL considers the context, processes, and outcomes of
learning.
Figure 1
Human
interactions
Emotional
learning
Doctor
Student
Experience based learning
Supported
participation
Practical
learning
Curriculum
factors
Context
Process
Outcome
One reason for adding the new term experience based learning to the crowded
research lexicon was to get away from a tendency in the literature to consider, for
example, primary and secondary care clinical education as separate entities
rather than a single process conducted in different contexts. A unitary model, we
reasoned, could make teachers and learners clearer about the process they were
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engaged in. ExBL was framed within the discourse of situated learning, which is
the theoretical orientation of this review.3 ExBL provides some definitions that
help frame the review:
Experience: Authentic (real as opposed to simulated) human contact in a social
or clinical context that enhances learning of health, illness, and/or disease, and
the role of the health professional, and helps the learner construct a professional
identity that makes them fit for practice.
Supported participation (provisional definition): An interaction between medical
student, practitioner, and (usually) patient that helps the student learn by
participating at a level appropriate to their stage of training and the complexity of
the clinical situation.
Workplace: Any place where patients, learners, and practitioners come together
for the dual purpose of providing medical care and learning.
A recent book chapter written by one member of the TRG reviews the broader
theoretical background and provides a theoretical orientation for the review.4
In line with BEME’s general direction of travel, this review moves away from a
traditional systematic review, whose main concerns are comprehensiveness,
selection of evidence for its quantitative strength, objectivity, and experimental
nature, and a data-driven interpretation. It sets out to be comprehensive, if not
exhaustive, admit qualitative as well as quantitative data, admit non-experimental
study designs if they are informative, and arrive at an interpretation through a
dynamic interaction between theory, evidence, and reviewers’ understandings of
the field. Indeed, depending on the evidence base, the review may be mainly or
even solely of qualitative evidence. As well as a scholarly report, the review team
aims to place a bibliography at the disposal of other researchers and
communicate its findings to practical clinical teachers.
Review questions and objectives
Just as experience based learning postulates causal links between context,
process, and outcome, this proposed review will seek evidence (dis)confirming
those links. According to Schmidt’s classification of research (“this is what we
did”, “justification”, and “clarification” research), it will admit both justification and
clarification research but its primary purpose is to clarify how clinical workplace
experience can contribute to the basic education of doctors-to-be, not make
summative judgements about whether it does. Helpful though it would be to
estimate effect sizes or review evidence of cost effectiveness, little evidence
pertaining to the former and even less pertaining to the latter was identified in the
previous review. So, the review questions are:
•
How do undergraduate medical students learn in clinical workplaces and how
do education and practice relate to one another?
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What are the outcomes of clinical workplace learning activity and how do they
result from it?
How do conditions – including the different workplaces in which medical
students gain experience and the human, organizational, and material factors
that pertain there – affect the processes and outcomes of clinical learning.
Search sources and strategies
Existing bibliographies
Several members of the review group have personal bibliographies of ExBL,
including over 150 citations in the thesis review. Using EndNote reference
manager, the bibliographies will be pooled and duplicates eliminated to produce
a set of articles for an initial scoping phase of the review.
Development of a set of search terms
The team will use concept mapping software to organise and depict the very
provisional set of search terms in annex 2, add to it and (likely) reorganise it.
Search
Databases will include BEI, Eric, Medline, Cinahl, and Embase. Cochrane
reviews will also be searched. The search period will be 1982-2006 inclusive (25
year period) though any earlier evidence identified will be admitted. Hand
searching is not planned since:
• Members of the review group have been identifying relevant articles in their
current awareness reading for many years and noting them in their personal
bibliographies
• The range of relevant journals is too wide for such a search to be very
sensitive
• The review does not set out to be “systematic” in the sense of identifying
every shred of evidence
• Careful scrutiny of the reference lists of the large number of articles that are
likely to be identified should lead back to previous literature.
The team will conduct a scoping search to refine the search strategy and
probably narrow the inclusion criteria, depending on a preliminary review of the
evidence base. A definitive search will use Ovid Software. All articles with
relevant titles will be retrieved in full text.
Study selection criteria
Any articles concerning empirical research into the conditions, processes, or
outcomes of clinical workplace learning, as represented by a refinement of the
inclusion criteria and search terms in Annex 2, will be considered subject to the
following criteria:
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Exclusion criteria
•
•
•
•
•
Not in the English language unless known by review group members to be
informative (eg Dutch language) because the Early Experience (EE) group
found translation disproportionately expensive to its benefits
Not empirical
Not authentic experience (eg simulation)
Not workplace learning
Profession other than medicine
Procedure for extracting data
In a pilot phase, a new version of the BEME EE coding sheet will be developed,
evaluated, and refined. The dataset will include:
• Full citation
• Details of the curriculum
• Stage(s) of the curriculum involved
• Study design
o Comparative/non-comparative
• Context(s) in which learning occurred
• Number of subjects and their demographic details
• The intervention
o Its nature
o “Dose” and duration
• Free text description of every outcome
• Coding of the intervention and outcome according to the ExBL condition,
process, and outcome classification
• Coding of any links between condition, process, and outcome demonstrated
in the study
• For each outcome, an assessment of its strength, using the standard BEME
5-point scale
• A binary rating of the importance of each outcome, as in the EE review, as
Kirkpatrick level 1 (satisfaction) or higher
• Short narrative comment about the study
Each paper will be coded by two people; disagreements will be resolved by
consensus, seeking the opinion of the whole group if they cannot be resolved.
Synthesis of extracted evidence
Procedures developed for the EE review will be followed; namely, outcomes and
their metadata will be clustered and organized into an explanatory structure, from
which a narrative report will be written.
Project timetable
Jan-March 07:
Pilot phase:
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a. Develop a search strategy
b. Conduct a scoping search
c. Review existing bibliographies
d. Test proposed methods and develop a coding sheet.
April-June 07:
Conduct definitive search and select informative articles.
July-Dec 07: Code articles
Jan – June 08: Analyse
July – Dec 08: Present and submit for publication
Conflict of interest statement
No member of the review group has any conflict of interest to declare.
Plans for updating the review
Establish a current awareness search using the same syntax as the main search
and maintain an up to date bibliography relevant to the review. A major change in
the evidence base would prompt a reanalysis and further report.
Changes to the protocol
See version table on cover page.
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Annex 1. Theoretical orientation of the review
Precis of Karen Mann’s chapter, “Learning and Teaching in Professional
Character Development”
This chapter concerns how professionals "develop a moral sensitivity, motivation,
and conduct to undergird, frame, and guide his or her actions and judgements". It
addresses the question: "How can the foundation for moral conduct be laid, and
what is the role of the individual teacher, the institution, and the profession in
facilitating that development?" However, its content is very relevant to a review of
clinical workplace learning because practice and practitioners are important
agents in the process of moral enculturation.
Section 1 concerns professional values in teaching and learning. It reports a
fundamental shift in the discourse of medical education to include learners as
well as teachers, and recognise the role of the learner. That discourse changes
the teacher from transmitter to facilitator of learning. "Physician education is more
than learning the what and how doctors do. It is about learning to be a physician."
At the same time, "the strong and essential scientific basis of medicine
accompanies a belief that the world is knowable, that knowledge is objective, and
can be discovered." Medical education is built on an apprenticeship tradition,
where apprentices "learned through observation, and practice and experience, to
practice as the master did." As medical education progressed and evolved:
• Curricula became more defined and standardized
• The emphasis on knowledge increased
• Moral character and desirable personal attributes were taken for granted.
This discourse of medical education separates competence from personal
growth. There is a shift from education to training. "Education aims to help
learners gain understanding by constructing and reconstructing meaning for
themselves, and/or by inquiring critically from a range of perspectives into events
from their practice in order to illuminate and thus improve it". "Training focuses
on the learning of knowledge, skills, procedures, and responses without the
necessity of reference to the context of the society in which they occur, or the
values that underlie the actions." "Even professionalism itself (has) being defined
as a set of skills to be mastered". "We risk equating the acquisition of appropriate
behaviours with understanding and professional growth." "We may come to think
about ourselves less as being teachers, and more about teaching as something
that we do."
The chapter goes on to compare Schon's "technical rationalist" versus
"professional artistry" views of professional practice. The latter views practice "as
a continuing process of framing problems in complex situations and using
practical wisdom and professional judgement to address the problems, guided by
moral principles." It reviews how complex attributes such as values and systems
of belief underpin the behaviour of practitioners.
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Section 2 concerns contemporary approaches to learning and teaching, including
constructivism, social cognitive theory (including learning through observation,
role modelling, and self efficacy), self-determination theory, situated learning, and
informal learning. Each of those sections gives an extremely helpful review of the
theory in question. Most relevant of all to the proposed literature review of clinical
workplace learning is the final synthesis, which identifies perspectives common
to all those theoretical approaches:
•
The learner participates actively in the learning environment through both
observation and experience
•
Experience plays a vital part in promoting both cognitive and affective
learning
•
All those theoretical approaches see the educational enterprise as a
process rather than a product
•
The process involves the teacher and learner in a partnership where both
teacher and learner interact and share in the construction of
understanding
The section goes on to consider educational approaches including critical
literacy, reflective learning, and professional and pedagogical caring. The
multifaceted review of reflective learning is particularly helpful: Reflective learning
is relevant to situations "in which material is unstructured or uncertain and there
are no obvious solutions". The chapter considers common criticisms of reflective
learning. It makes the important point that "Common to all approaches to
reflection is the belief that a) individuals learn from experience, b) this learning
happens effectively when experience is critically and carefully revisited and
reexamined, c) affective elements of experience are also critical to learning, and
d) this process can form an ongoing source of professional development and
lifelong learning.” The review of reflective learning finishes by introducing the
notion of reflection as a collective activity within communities of practice as
opposed to a solitary activity. The review of professional and pedagogical caring
is pertinent to the literature review of clinical workplace learning because it
makes the point that "if students are to develop professional caring ability, they
must be cared for in their environment, and that a trusting, caring environment is
essential for students to learn to think critically." Again, the final synthesis is
extremely valuable. The three educational approaches have in common:
•
The need to develop a fundamental understanding or literacy that enables
learners to read and understand the complex environments of the
profession, their relationships, and of health care delivery
•
The importance of reflection as a means of integrating experience into
one's personal values and knowledge
•
The necessity of a trusting, caring environment, in which learners can see
and understand the moral elements of behaviour, and enact those in their
daily conduct
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Section 3 concerns implications for teaching and learning, particularly regarding
professional character development. However, it is pertinent to our review of
clinical workplace learning because it emphasises "the critical importance of the
learning environment as a formal and informal context for learning. It is also there
that the relationships between learners and teachers and their shared experience
are framed. " As teachers we have the opportunity to engage in a partnership
with the learners that has as its base a mutual respect and regard for each
other".
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Annex 2
Workplace Learning Literature Review – Suggested Search Strategy
Meeting 2/8/06
Inclusion criteria:
Include
In a workplace (broadly defined).
Any context – primary, secondary, etc.
Exclude
Simulations
During clinical years.
Pre-clinical years.
Undergraduate (pre-registration)1
Postgraduate.
Medicine
Nursing / Allied Professions
Within last 20 years (86-06)
Pre 1986
Core
All methodologies and “qualities”
Empirical2
Opinion pieces
Either process or outcome data
Benefits to all (student, teacher,
patient, organization, community
Search terms
Workplace learning /
teaching / education
Clerkship
Work based learning /
teaching / education
Clinical rotation / attachment
/ experience
Firms
Apprenticeship
Community based learning Clinical method attachment
Patient contact
Real patients
In-patients
Out-patients
Learning environment
Ward teaching
1
Clinical learning / teaching
/ education
Preceptorship
Ambulatory learning
Clinical skills
Real patient learning
Patient focused
Include graduate entry programmes
In the previous draft of this paper, I suggested “informative empirical”, allowing us to exclude
empirical data if, in our opinion (or by the application of eg BEME criteria), it is not informative
2
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REFERENCES
1. Dornan TL. Experience based learning. Learning clinical medicine in workplaces.
Maastricht: Universitaire Pers Maastricht, 2006.
2. Dornan T, Littlewood S, Margolis S, Scherpbier A, Spencer J, Ypinazar V. How can
experience in clinical and community settings contribute to early medical
education? A BEME Systematic Review. Med Teach 2006; 28:3-18.
3. Lave J, Wenger E. Situated learning. Legitimate peripheral participation. Cambridge:
Cambridge University Press, 1991.
4. Mann K. Learning and Teaching in Professional Character Development. 2006.