‘Making room for student autonomy’ – an ethnographic study of student participation in clinical work

Abstract

Participation in clinical work is important for medical students’ professional development. However, students often report that they experience a passive observer role, and further research on contextual factors that influence student participation is needed. The theory of practice architectures contributes a new perspective to this challenge by elucidating how cultural-discursive, material-economic, and social-political arrangements enable and constrain student participation in clinical work. The aim of this study was to explore how practice architectures in clinical learning environments enable and constrain medical students’ participation. The study was designed as an ethnographic field study in three student clinics: 106 h of observation. Analysis comprised ethnographic analysis followed by application of the theory of practice architectures. The ethnographic analysis resulted in six themes: setting the scene, when to call for help, my room – my patient, getting in a routine, I know something you don’t, and my work is needed. Applying the theory of practice architectures showed that material-economic arrangements, such as control of the consultation room and essential artefacts, were crucial to student participation and position in the clinical workplace. Furthermore, co-production of a student mandate to independently perform certain parts of a consultation enabled a co-productive student position in the hierarchy of care-producers. The findings offer a conceptually generalisable model for the study of material and social dimensions of clinical learning environments. Although not all clinical learning environments may wish to or have the resources to implement a student clinic, the findings offer insights into general issues about the arrangements of student participation relevant to most clinical teaching contexts.

Appendices

Appendix 1: Agents and their participation in the student clinics

Even though medical students were the focus of this study, steps 1 and 2 in the ethnographic analysis established several agents related to medical student participation in the student clinics. Table 2 gives an overview of the observed agents and their roles.

Table 2 Agents in the student clinics (SC)

Appendix 2: Field note sheet

Observation number:
Observation place:
Observation date:
Rotation week in placement:
Activity:
Time (from-to):	Detailed description of: The scene (What does the room look like? Which artefacts are in the room?) Relatings (Which participants are present and how do they act towards each other? What makes them alike and what differentiates them?) Doings (What is done by whom, when and why? How are artefacts involved in the doings?) Sayings (How do the participants talk to each other in the present situation? How do they talk about other persons or more generally about the practices of themselves and others? Examples of words/sentences used in the specific situation, description of the participants body language)
The observer’s reflections: Comments on specific characteristics, emotions and questions that arise from this observation

Appendix 3: Questions to prompt student conversations

Student responsibility

• How do you work in the student clinic?

• How would you describe your responsibility?

• How do you know this? (Does your supervisor tell you?)

• How much independence do you have in solving these tasks?

• Which decisions are handed over to you?

• How do you prepare yourself for a day in the student clinic?

Student competence

• How do you assess your own level of competence?

• To which degree do you find yourself capable of solving the tasks in the student clinic?

• How would you describe your own development as a student in the student clinic?

Supervision

• What kind of supervision do you receive in relation to solving tasks in the student clinic?

• Please describe a situation where you felt that supervision worked well in the student clinic. What did you do? What did the supervisor do?

• Which supervisor characteristics do you value?

• Which goals or guidelines do you have in the student clinic?

• How do you receive feedback in the student clinic?

• Do you request feedback on your task performance in the student clinic?

Educational environment

• How would you describe the relation between you and your supervisor?

• How would you describe the relationship among the students in the student clinic?

• What is it that you like about being in the student clinic?

• What are the challenges?

Appendix 4: Taxonomic analysis

The taxonomic analysis, i.e., step 3 in the ethnographic analysis resulted in two models of how learning activities in the student clinics were related to each other. Each model represents a domain: ‘a day in the student outpatient clinics’ (Table 3) and ‘a day in the student ward’ (Table 4). Each domain had several underlying activities, which were connected to student participation in this domain throughout the day. Table 3 shows how student participation in the student outpatient clinic started with a pre-conference where students and teachers planned the consultation. The pre-conference was followed by other activities moving the students to other rooms, where other events could take place and other persons become involved. The learning activities in the student outpatient clinic were organised in dyads (medical/nurse students or medical/medical students) who had responsibility for approximately three patients per day. To simplify the display, Table 3 shows the learning activities related to one patient. The teachers in the student outpatient clinics were a nurse and a clinical teacher. All the learning activities in Table 3 could be defined as domains consisting of underlying activities, which could be analysed in more detail. The model is thus a simplified illustration of learning activities during the daily routine in student outpatient clinics, which is in reality much more complex if presented in detail. However, as the purpose of this taxonomic analysis was to show daily learning activities related to student participation, the level of analysis presented in Table 3 suffices.

Table 3 Learning activities during a day in the student outpatient clinics

Similarly, a model was made for ‘learning activities during a day in the student ward’. Table 4 shows how the learning activities in the student ward were organised in inter-professional teams around a patient from morning to noon. There were two medical students in the ward, and they each had responsibility for one, two or three patients in cooperation with a team consisting of one nurse student and one physiotherapist student. To simplify the display, Table 4 shows the learning activities related to one patient. The teachers in the student ward were nurses and physiotherapists, as opposed to a clinical teacher in the outpatient clinics. A clinical teacher was available for back-up but was not present with the students during preparation and feedback.

Table 4 Learning activities during a day in the student ward

Appendix 5: Componential analysis

The componential analysis, i.e., step 4 in the ethnographic analysis, revealed six attributes pertaining to how student participation was enabled across the three student clinics. The first attribute, ‘teacher present’, indicated whether students were given time alone with fellow students and patients in a specific learning activity. The second, ‘interprofessional student cooperation’, indicated whether students were in medical/nurse or medical/medical student dyads. The third, ‘medical student had exclusive knowledge about the patient’, the fourth, ‘medical student controlled the use of artefacts/room’, and the fifth, ‘medical student decided when to ask for help’, indicated the observed outcomes of the learning activities, where the students and patients had time alone in the consultation room without the teacher. The sixth attribute, ‘medical student was needed and contributed to daily work’, was found in the interviews and was not directly observable, as it related to student reflections on their role in the student clinic. By using a binary (yes/no) rating, as suggested by Spradley (Spradley, 2016), it became clear that there were similarities and differences in the learning activities and between the three student clinics. For example, all student clinics had a pre-conference where the teachers and students planned the consultation, followed by activities without teacher presence. In contrast, the activity ‘making a journal note’ was conducted similarly in the three student clinics. The analysis showed that three learning activities, ‘the consultation’, ‘ward round’, and ‘making a journal note’, enabled student participation similarly across the student clinics, while other learning activities varied. These three learning activities were based on student time alone with the patient, which enabled the students to acquire exclusive knowledge about the patient, control the use of artefacts and the room, be responsible for deciding whether to ask a teacher for help, and contribute to daily work in the clinic. Table 5 gives an overview of the differences and similarities in the learning activities in the three student clinics.

Table 5 Differences and similarities in the learning activities in the student clinics