http://informahealthcare.com/jic ISSN: 1356-1820 (print), 1469-9567 (electronic) J Interprof Care, 2015; 29(2): 156–158 ! 2015 Informa UK Ltd. DOI: 10.3109/13561820.2014.942777
SHORT REPORT
Identifying keys to success in clinical learning: a study of two interprofessional learning environments Klara Bolander Laksov1, Lena Engqvist Boman1, Matilda Liljedahl1 and Erik Bjo¨rck2 1
Department of Learning, Informatics, Management and Ethics (LIME), Karolinska Institutet, Stockholm, Sweden and 2Department of Molecular Medicine and Surgery, Karolinska Institutet, Stockholm, Sweden Abstract
Keywords
The aim of this study was to study the intrinsic system behind interprofessional clinical learning environments. Two health care units were selected on the basis of having received a reward for best clinical learning organization. Interviews were carried out with health care staff/clinical supervisors from different professions. The interviews were transcribed and analysed according to qualitative content analysis, and categories and themes were identified. Analysis revealed two different systems of clinical learning environments. In one, the interplay between the structural aspects dominated, and in the other, the interplay between the cultural aspects dominated. An important similarity between the environments was that a defined role for students in the organization and interprofessional teamwork around supervision across professional borders was emphasized.
Case study, interprofessional collaboration, interviews, leadership
Introduction A large part of undergraduate teaching in health professions education in Sweden is carried out in the environment of clinical wards or in primary care (Lindgren et al., 2011; Warne et al., 2010). Few studies have aimed to understand the inherent system of the context, in which clinical learning is carried out, which is essential in finding tools to improve clinical learning environments as organizations (Genn, 2001a, b). Suter et al. (2013) emphasized the importance of studying interprofessional learning environments from a sociological and management perspective, where a system perspective is dominant influenced by the ideas behind systems thinking, as introduced by Senge (2006). We strived to understand how different parts of a clinical organization interact and affect each other for the benefit of student learning. In system thinking, incidents or problems are not treated as isolated events, but instead regarded a part of a whole system. Therefore, to learn more about the system of clinical learning environments, the aim of this study was to study the intrinsic system behind two award-winning interprofessional clinical learning environments by exploring staff perceptions.
Methods A multiple exploratory case study approach (Yin, 2009) was used. In this approach, cases are selected to offer opportunities for understanding in real-world phenomena.
Correspondence: Dr Klara Bolander Laksov, PhD, Department of Learning, Informatics, Management and Ethics (LIME), Karolinska Institutet, Tomtebodav. 18 A, Stockholm 171 77, Sweden. E-mail: [email protected]
History Received 10 December 2013 Revised 21 May 2014 Accepted 5 July 2014 Published online 29 July 2014
Each case is understood as a bounded system of actors and their interactions. Setting Two health care units were selected because they were the first two winners of a prize rewarded by the hospital for commendable efforts in clinical undergraduate education. Clinical Learning Environment (CLE)-1 was a department of medical rehabilitation and CLE-2 was a psychiatric ward. Data collection and analysis Data were collected by the use of seven semi-structured interviews at the two clinics. Respondents of different professions were asked and agreed to participate: one physician (CLE-2), two nurses (CLE-1 + CLE-2), two physiotherapists (CLE-1 + CLE-2) and one occupational therapist (CLE-1). They were between 30 and 55 years old. The interviews were recorded, transcribed and analysed as cases according to qualitative content analysis (Graneheim & Lundman, 2004). Each author individually read the interviews to get an overall understanding before significant statements were selected and formulated into meaning units. Meaning units were clustered collaboratively into categories and labelled. The categories were then organized into major themes for each unit. As a way to contrast how the two clinics differed, we used (van Maanen, 2005) theory of viewing an organization through different lenses, the strategic design lens, the cultural lens and the political lens. Ethical considerations Ethical approval was obtained from the Swedish Central Ethical Review Board (2012/1785-32). Confidentiality was
Keys to success in clinical learning
DOI: 10.3109/13561820.2014.942777
guaranteed and informed consent was obtained from all participants.
Findings When comparing the themes that resulted from the analysis of the two cases, we saw two different systems. These systems were, according to our interpretation, the result of a complex interaction between four different aspects: (i) organizational lens, (ii) conceptualization of leadership, (iii) supervisory practice and (iv) philosophy of care. The main outcome of each case is presented in Table I. Below summaries of the analysis are also provided. Clinical Learning Environment 1 In this environment, a department of medical rehabilitation, the interactions between three levels of the organization, the university, the health care unit and the individual supervisor, were interpreted to create a successful system with emphasis on strategy and structure for learning in clinical education (Table I). This was also appreciated by students, as expressed in Citation 1a. The conceptualization of leadership emphasized three important roles that were central for student learning: the educational manager, the adjunct clinical lecturer (ACL) and the supervisors. These roles interacted to support student learning towards achievement of the learning outcomes, as exemplified by Citation 1b in Table I. Supervision practice included regular meetings regarding professional development in supervision and discussions on how interprofessional collaboration could be used in student learning. Due to the organization of clinical education, the student participation was an obvious feature of interprofessional teams. Supervisors’ professional role was described as making a difference in the individual patient’s life based on an explicit philosophy of care supporting patients to take charge of their own lives. These professional competences and values were also communicated with the students, as is expressed in Citation 1c in Table I. Clinical Learning Environment 2 In this environment, a psychiatric ward, the intricate interactions between structure, learning and culture were emphasized as important parts of the successful learning environment. The leadership, an ACL and the head nurse collaborated to provide clear structures and routines to create a culture of trust among
157
staff and more time to focus on the students’ needs, as expressed in Citation 2a. The students were invited to regular meetings to discuss the patients’ care and the working situation of the unit. A project manager from the university had a strong position in developing teaching and learning routines towards a model of clinical education ward. The philosophy of care was organized according to the principle of primary nursing – that aims to empower patients to regain health and autonomy as soon as possible (Manthey, 1992). Thus, the unit provided students with opportunities for interprofessional work in a team of supervisors consisting of nurses, psychiatric nurse assistants and medical doctors. This was made clear in citations such as 2b. Even patients were viewed as important members of the team. Interprofessional collaboration was considered a prerequisite for a successful treatment of the patient (Citation 2c).
Discussion The findings show two systems of clinical learning environments where leadership was seen as an essential part of the system. The leadership role of the ward management has previously been identified as integral to the capacity of staff to develop student learning (Henderson et al., 2010). The major difference between the two environments in our study concerns the approach to leadership and management of the environment. In CLE-1, a strategic approach emphasized the functionalities and different roles within the system, and in CLE-2, the cultural approach emphasized values and relationships. According to van Maanen (2005), a strategic approach to organizational change includes viewing the organization as a system consisting of different parts in a machinery, where the structure of different organizational sections, in relation to each other, are the focus. The way to make changes to the organization is through planning and reorganization. Applied to the issue of managing education within a clinic, the cultural lens might be expressed as how doctors and nurses view and value the clinical supervision of students, as a result of how educational activities historically have been prioritized within that specific clinic and hence constructed the underlying assumptions about one’s work. In both environments teamwork across professional borders was emphasized, allowing students a defined role in the health care organization. Contrary to traditional clinical supervision structures, where the supervision relationship is a one-to-one relationship, an interprofessional team was in this study, similarly
Table I. Keys to success in two clinical learning environments.
System interactions (i) Organizational lense (ii) Conceptualization of leadership (iii) Supervision practice (iv) Philosophy of care Examples from interviews
CLE-1
CLE-2
University, Health Care Unit, Supervisor Strategic approach Role focus Interprofessional and shared Generating autonomy and capacity 1a: ‘‘The students appreciate it a lot. They say they have got a lot of information and many say: ‘We haven’t got this much information anywhere else, it feels safe’.’’ (Physiotherapist). 1b: ‘‘. . . if a supervisor indicates that a student does not fulfil the intended learning outcomes I usually go through the intended learning outcomes and become more involved.’’ (Nurse). 1c: ‘‘I come here because I really enjoy my work a lot. And . . . I am here for the sake of the patients, and that’s why the students are so important because they are the future care providers who will take care of the patients in the future.’’ (Occupational therapist).
Structure, learning and culture Cultural approach Personality focus (trust) Interprofessional and shared Generating autonomy and capacity 2a: ‘‘. . . the safer we [the staff] are, the calmer the students will be. The more we are able to be here and now in our routines, and lean on them, I am sure we will free more time for the students’’ (Nurse 1). 2b: ‘‘. . . you may have all knowledge about how you treat your patient but if you cannot collaborate with your team, it won’t work.’’ (Physician). 2c: ‘‘The patients are not here for us, but we are here because they are ill. And if they express needs, we have to be there with them.’’ (Psychiatric nurse).
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K. B. Laksov et al.
to previous research (Chipchase, Allen, Eley, McAllister, & Strong, 2012), found to be more open and flexible, accepting newcomers in several different roles. Another similarity was the underlying philosophy of care, which in both cases strived for patient participation and autonomy, something that seemed to have a spill over effect into the philosophy of learning. In both environments a strong clinical leadership was seen, with a leader as a driving force regarding the development of teaching and learning. However, rather than emphasizing the role of the ACL, as in CLE-1, the personality of the head nurse seemed to influence the climate and the culture of CLE-2. Another similarity between the two cases was that the leader also worked well together with a person from the university organization, working together to develop the teaching and learning at the unit.
Declaration of interest The authors report no conflicts of interest. The authors alone are responsible for the content and writing of this article. This work was supported by grants provided by the Stockholm County Council in Sweden.
References Chipchase, L., Allen, S., Eley, D., McAllister, L., & Strong, J. (2012). Interprofessional supervision in an intercultural context: A qualitative study. Journal of Interprofessional Care, 26, 465–471. Genn, J.M. (2001a). AMEE Medical Education Guide No. 23 (Part 1): Curriculum, environment, climate, quality and change in medical education: A unifying perspective. Medical Teacher, 23, 337–344.
J Interprof Care, 2015; 29(2): 156–158
Genn, J.M. (2001b). AMEE Medical Education Guide No. 23 (Part 2): Curriculum, environment, climate, quality and change in medical education: A unifying perspective. Medical Teacher, 23, 445–454. Graneheim, U.H. & Lundman, B. (2004). Qualitative content analysis in nursing research: Concepts, procedures and measures to achieve trustworthiness. Nurse Education Today, 24, 105–112. Henderson, A., Twentyman, M., Eaton, E., Creedy, D., Stapleton, P., & Lloyd, B. (2010). Creating supportive clinical learning environments: An intervention study. Journal of Clinical Nursing, 19, 177–182. Lindgren, S., Bra¨nnstro¨m, T., Hanse, E., Ledin, T., Nilsson, G., Sandler, S., Tidefelt, U., & Donne´r, J. (2011). Medical education in Sweden. Medical Teacher, 33, 798–803. Manthey, M. (1992). The practice of primary nursing. Boston: Blackwell Scientific Publications. Senge, P. (2006). The fifth discipline: The art & oractice of the learning organization (5th ed.). London: Doubleday Business. Suter, E., Goldman, J., Martimianakis, T., Chatalalsingh, C., DeMatteo, D.J., & Reeves, S. (2013). The use of systems and organizational theories in the interprofessional field: Findings from a scoping review. Journal of Interprofessional Care, 27, 57–64. van Maanen, J. (2005). Three lenses on organizational analysis and action. In D.G. Ancona, T. Kochan, M. Scully, J. Van Maanen, & D.E. Westney (Eds.), Managing for the future: Organizational behaviour and processes (3rd ed.). Boston: South-Western College Publishing. Warne, T., Johansson, U.-B., Papastavrou, E., Tichelaar, E., Tomietto, M., den Bossche, K.V., Moreno, M.F., & Saarikoski, M. (2010). An exploration of the clinical learning experience of nursing students in nine European countries. Nurse Education Today, 30, 809–815. Yin, R.K. (2009). Case study research: Design and methods (Vol. 5). Thousand Oaks: Sage.
Copyright of Journal of Interprofessional Care is the property of Taylor & Francis Ltd and its content may not be copied or emailed to multiple sites or posted to a listserv without the copyright holder's express written permission. However, users may print, download, or email articles for individual use.
SHORT REPORT
Identifying keys to success in clinical learning: a study of two interprofessional learning environments Klara Bolander Laksov1, Lena Engqvist Boman1, Matilda Liljedahl1 and Erik Bjo¨rck2 1
Department of Learning, Informatics, Management and Ethics (LIME), Karolinska Institutet, Stockholm, Sweden and 2Department of Molecular Medicine and Surgery, Karolinska Institutet, Stockholm, Sweden Abstract
Keywords
The aim of this study was to study the intrinsic system behind interprofessional clinical learning environments. Two health care units were selected on the basis of having received a reward for best clinical learning organization. Interviews were carried out with health care staff/clinical supervisors from different professions. The interviews were transcribed and analysed according to qualitative content analysis, and categories and themes were identified. Analysis revealed two different systems of clinical learning environments. In one, the interplay between the structural aspects dominated, and in the other, the interplay between the cultural aspects dominated. An important similarity between the environments was that a defined role for students in the organization and interprofessional teamwork around supervision across professional borders was emphasized.
Case study, interprofessional collaboration, interviews, leadership
Introduction A large part of undergraduate teaching in health professions education in Sweden is carried out in the environment of clinical wards or in primary care (Lindgren et al., 2011; Warne et al., 2010). Few studies have aimed to understand the inherent system of the context, in which clinical learning is carried out, which is essential in finding tools to improve clinical learning environments as organizations (Genn, 2001a, b). Suter et al. (2013) emphasized the importance of studying interprofessional learning environments from a sociological and management perspective, where a system perspective is dominant influenced by the ideas behind systems thinking, as introduced by Senge (2006). We strived to understand how different parts of a clinical organization interact and affect each other for the benefit of student learning. In system thinking, incidents or problems are not treated as isolated events, but instead regarded a part of a whole system. Therefore, to learn more about the system of clinical learning environments, the aim of this study was to study the intrinsic system behind two award-winning interprofessional clinical learning environments by exploring staff perceptions.
Methods A multiple exploratory case study approach (Yin, 2009) was used. In this approach, cases are selected to offer opportunities for understanding in real-world phenomena.
Correspondence: Dr Klara Bolander Laksov, PhD, Department of Learning, Informatics, Management and Ethics (LIME), Karolinska Institutet, Tomtebodav. 18 A, Stockholm 171 77, Sweden. E-mail: [email protected]
History Received 10 December 2013 Revised 21 May 2014 Accepted 5 July 2014 Published online 29 July 2014
Each case is understood as a bounded system of actors and their interactions. Setting Two health care units were selected because they were the first two winners of a prize rewarded by the hospital for commendable efforts in clinical undergraduate education. Clinical Learning Environment (CLE)-1 was a department of medical rehabilitation and CLE-2 was a psychiatric ward. Data collection and analysis Data were collected by the use of seven semi-structured interviews at the two clinics. Respondents of different professions were asked and agreed to participate: one physician (CLE-2), two nurses (CLE-1 + CLE-2), two physiotherapists (CLE-1 + CLE-2) and one occupational therapist (CLE-1). They were between 30 and 55 years old. The interviews were recorded, transcribed and analysed as cases according to qualitative content analysis (Graneheim & Lundman, 2004). Each author individually read the interviews to get an overall understanding before significant statements were selected and formulated into meaning units. Meaning units were clustered collaboratively into categories and labelled. The categories were then organized into major themes for each unit. As a way to contrast how the two clinics differed, we used (van Maanen, 2005) theory of viewing an organization through different lenses, the strategic design lens, the cultural lens and the political lens. Ethical considerations Ethical approval was obtained from the Swedish Central Ethical Review Board (2012/1785-32). Confidentiality was
Keys to success in clinical learning
DOI: 10.3109/13561820.2014.942777
guaranteed and informed consent was obtained from all participants.
Findings When comparing the themes that resulted from the analysis of the two cases, we saw two different systems. These systems were, according to our interpretation, the result of a complex interaction between four different aspects: (i) organizational lens, (ii) conceptualization of leadership, (iii) supervisory practice and (iv) philosophy of care. The main outcome of each case is presented in Table I. Below summaries of the analysis are also provided. Clinical Learning Environment 1 In this environment, a department of medical rehabilitation, the interactions between three levels of the organization, the university, the health care unit and the individual supervisor, were interpreted to create a successful system with emphasis on strategy and structure for learning in clinical education (Table I). This was also appreciated by students, as expressed in Citation 1a. The conceptualization of leadership emphasized three important roles that were central for student learning: the educational manager, the adjunct clinical lecturer (ACL) and the supervisors. These roles interacted to support student learning towards achievement of the learning outcomes, as exemplified by Citation 1b in Table I. Supervision practice included regular meetings regarding professional development in supervision and discussions on how interprofessional collaboration could be used in student learning. Due to the organization of clinical education, the student participation was an obvious feature of interprofessional teams. Supervisors’ professional role was described as making a difference in the individual patient’s life based on an explicit philosophy of care supporting patients to take charge of their own lives. These professional competences and values were also communicated with the students, as is expressed in Citation 1c in Table I. Clinical Learning Environment 2 In this environment, a psychiatric ward, the intricate interactions between structure, learning and culture were emphasized as important parts of the successful learning environment. The leadership, an ACL and the head nurse collaborated to provide clear structures and routines to create a culture of trust among
157
staff and more time to focus on the students’ needs, as expressed in Citation 2a. The students were invited to regular meetings to discuss the patients’ care and the working situation of the unit. A project manager from the university had a strong position in developing teaching and learning routines towards a model of clinical education ward. The philosophy of care was organized according to the principle of primary nursing – that aims to empower patients to regain health and autonomy as soon as possible (Manthey, 1992). Thus, the unit provided students with opportunities for interprofessional work in a team of supervisors consisting of nurses, psychiatric nurse assistants and medical doctors. This was made clear in citations such as 2b. Even patients were viewed as important members of the team. Interprofessional collaboration was considered a prerequisite for a successful treatment of the patient (Citation 2c).
Discussion The findings show two systems of clinical learning environments where leadership was seen as an essential part of the system. The leadership role of the ward management has previously been identified as integral to the capacity of staff to develop student learning (Henderson et al., 2010). The major difference between the two environments in our study concerns the approach to leadership and management of the environment. In CLE-1, a strategic approach emphasized the functionalities and different roles within the system, and in CLE-2, the cultural approach emphasized values and relationships. According to van Maanen (2005), a strategic approach to organizational change includes viewing the organization as a system consisting of different parts in a machinery, where the structure of different organizational sections, in relation to each other, are the focus. The way to make changes to the organization is through planning and reorganization. Applied to the issue of managing education within a clinic, the cultural lens might be expressed as how doctors and nurses view and value the clinical supervision of students, as a result of how educational activities historically have been prioritized within that specific clinic and hence constructed the underlying assumptions about one’s work. In both environments teamwork across professional borders was emphasized, allowing students a defined role in the health care organization. Contrary to traditional clinical supervision structures, where the supervision relationship is a one-to-one relationship, an interprofessional team was in this study, similarly
Table I. Keys to success in two clinical learning environments.
System interactions (i) Organizational lense (ii) Conceptualization of leadership (iii) Supervision practice (iv) Philosophy of care Examples from interviews
CLE-1
CLE-2
University, Health Care Unit, Supervisor Strategic approach Role focus Interprofessional and shared Generating autonomy and capacity 1a: ‘‘The students appreciate it a lot. They say they have got a lot of information and many say: ‘We haven’t got this much information anywhere else, it feels safe’.’’ (Physiotherapist). 1b: ‘‘. . . if a supervisor indicates that a student does not fulfil the intended learning outcomes I usually go through the intended learning outcomes and become more involved.’’ (Nurse). 1c: ‘‘I come here because I really enjoy my work a lot. And . . . I am here for the sake of the patients, and that’s why the students are so important because they are the future care providers who will take care of the patients in the future.’’ (Occupational therapist).
Structure, learning and culture Cultural approach Personality focus (trust) Interprofessional and shared Generating autonomy and capacity 2a: ‘‘. . . the safer we [the staff] are, the calmer the students will be. The more we are able to be here and now in our routines, and lean on them, I am sure we will free more time for the students’’ (Nurse 1). 2b: ‘‘. . . you may have all knowledge about how you treat your patient but if you cannot collaborate with your team, it won’t work.’’ (Physician). 2c: ‘‘The patients are not here for us, but we are here because they are ill. And if they express needs, we have to be there with them.’’ (Psychiatric nurse).
158
K. B. Laksov et al.
to previous research (Chipchase, Allen, Eley, McAllister, & Strong, 2012), found to be more open and flexible, accepting newcomers in several different roles. Another similarity was the underlying philosophy of care, which in both cases strived for patient participation and autonomy, something that seemed to have a spill over effect into the philosophy of learning. In both environments a strong clinical leadership was seen, with a leader as a driving force regarding the development of teaching and learning. However, rather than emphasizing the role of the ACL, as in CLE-1, the personality of the head nurse seemed to influence the climate and the culture of CLE-2. Another similarity between the two cases was that the leader also worked well together with a person from the university organization, working together to develop the teaching and learning at the unit.
Declaration of interest The authors report no conflicts of interest. The authors alone are responsible for the content and writing of this article. This work was supported by grants provided by the Stockholm County Council in Sweden.
References Chipchase, L., Allen, S., Eley, D., McAllister, L., & Strong, J. (2012). Interprofessional supervision in an intercultural context: A qualitative study. Journal of Interprofessional Care, 26, 465–471. Genn, J.M. (2001a). AMEE Medical Education Guide No. 23 (Part 1): Curriculum, environment, climate, quality and change in medical education: A unifying perspective. Medical Teacher, 23, 337–344.
J Interprof Care, 2015; 29(2): 156–158
Genn, J.M. (2001b). AMEE Medical Education Guide No. 23 (Part 2): Curriculum, environment, climate, quality and change in medical education: A unifying perspective. Medical Teacher, 23, 445–454. Graneheim, U.H. & Lundman, B. (2004). Qualitative content analysis in nursing research: Concepts, procedures and measures to achieve trustworthiness. Nurse Education Today, 24, 105–112. Henderson, A., Twentyman, M., Eaton, E., Creedy, D., Stapleton, P., & Lloyd, B. (2010). Creating supportive clinical learning environments: An intervention study. Journal of Clinical Nursing, 19, 177–182. Lindgren, S., Bra¨nnstro¨m, T., Hanse, E., Ledin, T., Nilsson, G., Sandler, S., Tidefelt, U., & Donne´r, J. (2011). Medical education in Sweden. Medical Teacher, 33, 798–803. Manthey, M. (1992). The practice of primary nursing. Boston: Blackwell Scientific Publications. Senge, P. (2006). The fifth discipline: The art & oractice of the learning organization (5th ed.). London: Doubleday Business. Suter, E., Goldman, J., Martimianakis, T., Chatalalsingh, C., DeMatteo, D.J., & Reeves, S. (2013). The use of systems and organizational theories in the interprofessional field: Findings from a scoping review. Journal of Interprofessional Care, 27, 57–64. van Maanen, J. (2005). Three lenses on organizational analysis and action. In D.G. Ancona, T. Kochan, M. Scully, J. Van Maanen, & D.E. Westney (Eds.), Managing for the future: Organizational behaviour and processes (3rd ed.). Boston: South-Western College Publishing. Warne, T., Johansson, U.-B., Papastavrou, E., Tichelaar, E., Tomietto, M., den Bossche, K.V., Moreno, M.F., & Saarikoski, M. (2010). An exploration of the clinical learning experience of nursing students in nine European countries. Nurse Education Today, 30, 809–815. Yin, R.K. (2009). Case study research: Design and methods (Vol. 5). Thousand Oaks: Sage.
Copyright of Journal of Interprofessional Care is the property of Taylor & Francis Ltd and its content may not be copied or emailed to multiple sites or posted to a listserv without the copyright holder's express written permission. However, users may print, download, or email articles for individual use.
