Seventeen graduates consented to be interviewed. To maintain anonymity, we have provided minimal biographical information (see Table 1). All participants were mid-career professionals, having been professionally qualified for at least 5 years.
Our initial thematic analysis resulted in three overarching themes: academic voice, infectious curiosity and expanding worldview (summarised in Table 2). The second phase of our analysis, using the lens of Bourdieu’s concepts, showed how these themes reflected changes in habitus, underpinned by particular combinations of different but interconnected forms of capital, and how they could influence a participant’s position within their field.
An important outcome of both programmes was the development of an academic voice, seen as integral to the development of professional identity. This involved the acquisition of new language and an ability to synthesise material and construct coherent arguments supported by evidence. Participant 10 conveyed the distinction this could bring to professional practice.
I gained a lot of self-confidence … you know, I’m the voice of clinical education in our organisation and to say I understand the theory behind this, I know best practice… and, you know, speak with that educated voice now on that topic. (Participant 10-CE)
“Speaking the language” built confidence in discussing theory in practice contexts, and enhanced legitimacy in both academic and practice settings. Awareness and application of theory could be profoundly practical, helping participants enact change in the workplace. In combination with “up-to-date” factual knowledge, theoretical knowledge could help to “bring people on board … and inform others of what you’re trying to achieve.” (Participant 17-MP). The capacity to articulate ideas and support them with sound, evidence-based arguments went beyond language. For Participant 6, “a vocabulary, some words and concepts to describe things or think about things” enabled him to develop a “framework for thinking”. Thus, the academic voice was underpinned by new ways of seeing and thinking, and these could be very empowering. For example, Participant 15 described a greater potential for analysis and problem solving, as not only could he express himself more effectively, he could also more effectively understand others.
… There’s times that I see patients that ten years ago I would have just scratched my head at. And part of that is the didactic input that I got from going through the course. But part of it also is a new way of looking at what the patients are saying and analysing it. (Participant 15-MP).
This allowed Participant 15 to be more influential across educational and clinical fields, with colleagues, students and patients.
It allowed me to organise what I already knew in a way that I could explain it other people, and by explaining it to my classmates and to the instructors I figured out a way to explain it to the patients. (Participant 15-MP)
For Participant 4, the development of an authoritative voice supported her capacity for leadership in the practice setting.
Before the course … I would never really have offered my own opinions…in terms of how things were organised…After having done the Masters, I definitely know the most within the practice now in terms of the language of education and the theory behind it. That, for me, has given me huge confidence and definitely I’m more willing to lead and I will put myself forward and put my own ideas forward. (Participant 4-CE)
The combination of confidence, the capacity to argue persuasively, and new tools for problem solving, analysing and learning combined to support a sense of developing agency and autonomy, even in the absence of formal authority.
I’m doing a lot of new roles without necessarily the authority to impose new direction. So some of that needs to come just from convincing people that this is a good idea.” (Participant 10-CE).
Another important outcome that came through clearly in the data was a change in attitudes and approaches to understanding. The increased confidence described in the previous theme could produce a capacity to deal with uncertainty and complexity. This, in turn, supported participants to pursue their curiosity around previously inaccessible areas of knowledge, and to more easily question different points of view.
I suppose, by the end of the second year of the course, I was getting a bit more confident in thinking, well I don’t agree with what they said. And so I’m going to ask this question about it. (Participant 5-CE).
Participant 5 gained confidence in questioning and clarification, which was “definitely useful in medicine [where we] have to get clarification, or have a discussion about what is the right thing to do for the patient.” For Participant 14, the authority that came with the development of an academic voice was tempered by a recognised need to be open to questioning and to learning from mistakes. For her, postgraduate study had increased her awareness of the contentious nature and the personal and collective limitations of knowledge. She felt that evidence, the opinions of others, and also her own ideas, should all be subject to “external scrutiny” (e.g. by programme tutors and peers). Similarly, for Participant 13, the programme provided access to valuable, external points of view from a “learning community which was completely [outside of] the people that I would normally speak to about education stuff.”
Exposure to different ways of thinking, alternative epistemologies, different cultures and the varied practices of student peers, could provide ways into unfamiliar conceptual terrain. For Participant 4, the Clinical Education programme gave her the tools to “find her way into new areas” where “the answers aren’t so clear.” Participant 6 had deliberately chosen to pursue new ideas and perspectives through a supervised dissertation using qualitative research. Like many participants, Participant 6 had been trained in positivist scientific enquiry, but had learned to be able to see through a different epistemological perspective.
I suspect [my epistemological position has] changed, because I’m aware of alternatives. I think that alone is sufficient for it to have changed. I recognise that I do not know enough to have a firm position… My approach to the world [is now] a little bit more accepting of the idea of discourse and discursive ideas, and is much less positivistic. (Participant 6-CE)
The result was not simply that he had learned about new things but that he had developed an awareness of the uncertainty and complexity of the areas of enquiry with which he was dealing. His expanding theoretical understanding and epistemological versatility had changed his practice across multiple fields.
Having a framework to think about thinking, has helped me… manage my clinical work, possibly even my personal life, and certainly how I teach others, and how I mentor others. (Participant 6-CE)
This enhanced capacity for reflecting on practices and ideas allowed participants to rethink fundamental concepts, opening up problematic assumptions that could be examined and redressed, as discussed by Participant 15.
…the whole concept of pain. I was reaching back to: “what is pain?”… I’d never really taken the time, I guess, to examine the first assumption, and the biggest problem we as providers, and scientists in general, [have] is a failure to question our first assumptions… [Before the programme], I pretty quickly decided, “oh, I know what’s wrong there,” and that doesn’t always work out… it’s broadened my perspectives. (Participant 15-MP)
In many cases, enhanced curiosity and reflection across academic and clinical settings continued beyond graduation. This was evident in an ongoing commitment to scholarship. Beyond staying abreast of research and developments in their respective fields, many participants became involved in the active generation of new knowledge. Participant 13’s aspiration, for example, “to contribute, rather than just recite” showed a desire for agency in the construction of knowledge and advancement of her field.
We have characterised this theme as “infectious” because the desire for scholarship and knowledge spread to the participants via engagement with peers, tutors and literature, and then also from the participants to their peers and students. For example, Participant 17 spoke of new possibilities for appropriately guiding students in their own pursuit of knowledge.
The Masters has made me realise I need to step up… I’m quite keen to try and spark an interest in the trainees that I work with regarding the importance of having an inquisitive mind, and just not accepting that people do things just because, and making sure that you have an understanding why people are doing things. (Participant 17-MP)
The theme of expanded worldview captures a change in perspective, as participants came to see the fields of healthcare and education as more complex and nuanced, with less clear-cut answers and borders. It reflects a shift from a narrow focus where specialisms, disciplines, teams, workplaces, cultures or epistemologies were often taken for granted and viewed in isolation; to a wider view in which they were seen as interacting. Both programmes recruit a range of health professionals from different disciplines and countries, resulting in wide multidisciplinary and multicultural representation in discussions. Participant 8 gave a sense of what this was like for her.
Your thinking is broadened because you are not in a four walled classroom with people who you know from your town or city…We had different accents, everybody had a different background and different experiences, so when they used to share their experiences it was very engaging … (Participant 8-CE).
Such discussion involved formulating specialised, disciplinary language into terms that could be understood by outsiders. The acquisition of new academic language and vocabulary, while allowing participants to articulate complex and nuanced concepts, also needed to be balanced by a recognition that simplified language was sometimes necessary within multidisciplinary dialogue to break down barriers to communication.
We talk about this a lot at work, saying we need the MDT approach. But, in truth, physios speak to physios and nurses speak to nurses. But, actually, what this course meant was that we had to stop using jargon. We had to actually use a language that was a little bit more accessible. (Participant 14-MP)
At the same time, for some participants, understandings shifted from absolute facts and clear right and wrong answers, towards negotiating and balancing different views. This required authentic opportunities for students to participate in dialogue.
One of the things I really valued about it was that it did bring together a whole bunch of people from all around the world from different disciplines all involved in different teaching activities… I found value in being able to kind of learn from them and ask relevant questions. So it wasn’t just about what I was getting from the presentations or lectures or necessarily the questions that came up during tutorials, it was more the learning community I was part of. (Participant 7-CE)
Enhanced understanding could generate a sense of agency, even as it increased the conceptual complexity of the field in which graduates were operating. Participant 6 commented that, before starting, applicants may not be in a position to understand what they are going to learn, nor the utility of learning about principles and theoretical frameworks to guide their own development of educational practices.
The types of transferable skills that I thought I would gain from the programme, were much more limited than the skills that I did gain… I think that I was under a common misconception, that I would learn a little bit more about some of the practical aspects of one on one education et cetera, and I think the focus was on the bigger picture and how things fit together, and the theoretical frameworks, and evidence that underpins some of the decisions that people make within medical education, and education in general, and I’m glad that it did. So, yeah, I think that the scope of my conception of education and teaching was much more limited and that my expectations fit within that more limited scope. (Participant 6-CE)
It may not be feasible to express the attributes that students gain from these programmes in ways that can be understood by those who have not yet been through the experience, since students may require an expanded, complex and nuanced view of education to grasp the possibilities and benefits of developing such a view.
Field, habitus and capital
In the second phase of our analysis, we synthesised the themes above in relation to Bourdieu’s (1977, 1986) concepts of field, habitus and capital. We see our three themes as reflecting changes in habitus, because they convey durable changes in dispositions and capacities from which practices are adapted and developed and which, in turn, enhance the participants’ agency within their fields. Learning, then, involves developing the habitus that is required to successfully operate within a particular field. As Schatzki (2017, p. 29) noted, “the more the habitus is acquired, the better someone can proceed in these fields, and in a greater range of situations.” However, it is important to recognise that these capacities and dispositions are not simply acquired by individuals, they are caught up in other forms of capital that are brought about by understandings of the institution and accreditation of qualifications (institutionalised capital), as well as the social connections generated through enrolment and engagement with the programme (social capital).
The acquisition of a postgraduate degree in itself represents enhanced cultural capital: it is a valuable resource, as reflected in its common appearance in job descriptions and promotion criteria and its potential for mobilisation to progress a participant’s career and professional status.
Working here, I needed a postgraduate qualification… the fact that I am now theme head, [as a nurse] it’s quite unusual, so I think having the Masters has given me that credibility. (Participant 3-CE)
Graduates are inducted into their new status through rituals of graduation and the wearing of robes that denote the level of the qualification and the awarding institution. One is left in no doubt that one has graduated and entered into a community of highly-educated peers. The association with an internationally-recognised University (“Edinburgh is one of the top universities in the world”, Participant 16) also adds value in the form of symbolic capital (i.e. the attribution of particular qualities to that resource simply because of its source) (Bourdieu 1986). In the following excerpt, the symbolic capital that this particular institution lends its qualifications through its reputation and its grand estate is given priority over the accumulation of embodied capital (enhanced skills and knowledge).
It was a really nice moment to graduate from the University of Edinburgh, to be honest and candid; it’s a beautiful building we graduated in. I felt very proud of myself and even now, when I mention that’s where my master’s was from, you get a different look and you feel quite chuffed…. (P16-MP)
Participant 16 portrayed the intertwining of different forms of capital within the perceived value that the Master’s had for her, not just in terms of advancing in her field but also in economic terms:
You get respect, recognition, people listen to you… you know what you teach, you have confidence. You are not teaching just because you [have read] something… No, you lived it, you are the professional, you are qualified, certified… you are a resource. And definitely in terms of your income, you are more [highly] paid than others. This is obvious: for something where you have worked hard and sweat[ed], you have to be paid. (Participant 16-MP).
The value of a Master’s programme also related to the cost of studying, in terms of money, time, effort, and emotion. For Bourdieu (1986) embodied capital implies a personal investment of time, but the appearance of this investment also added to the available symbolic capital. Crucially, however, symbolic capital was, in turn, supported by the practical value of knowledge, attitude, and confidence. Thus, these Masters conferred “credibility” and “legitimacy” through a combination of skills and knowledge, status, social connections, and accredited qualifications.
What the master’s degree gave me really, was a bit of credibility, not only in name - people know I have it - but also in terms of skills and analysis and presenting arguments and scrutinising… (Participant 14-MP).
The different forms of capital could manifest not only as a greater sense of legitimacy, but also a greater actualisation of authority, a perceived competitive advantage, and an increase in effectiveness and influence. Indeed, developing an academic voice was sometimes seen as necessary for the development of effective practices and for career progression. Participant 5 described an occasion where her words were interpreted against the backdrop of the qualification.
I feel like it definitely made a difference in performing well at a Consultant interview.’ Cause they were all like, oh you’ve got an MSc, oh that’s great. Or you’ve got a distinction, well done… I think people recognise that coming out with a higher degree is… a firm commitment…. a really important bit of my CV that was impressive to people. Impressive enough to help me get the job that I wanted. (Participant 5-CE).
She felt that her “impressive” qualification, in combination with her knowledge, distinguished her in her field. Thus, cultural capital was enhanced not only by acquiring attributes, but also by having other people know about them. Another kind of social capital may have been even more important over the longer-term: valuable networks of supportive and influential colleagues were formed that lasted beyond the programme.
When we finally “met” in graduation, we felt that we belong to each other. We are truly classmates. We shared discussions and tried to remember our memories together which was wonderful. We felt that we are one family: we support each other, attend presentations for each other and we have… felt that we are not alone. We have family that support us.” (Participant 12-CE)
These networks could be mobilised in various ways that were advantageous to the individuals. However, becoming part of a network required the development of contextualised skills and practices, and a shift in understanding of the value of online learning communities. Early on in her studies, Participant 14, had reservations that her programme would not be “meaningful for [social connections], because you don’t meet people face to face.” Later, she came to recognise the value of social connections with people distributed across the world, indicating a need to develop more sophisticated conceptualisations of online interactions. The expanded worldview, generated through exposure to the variation in practices, disciplines and perspectives available within these online networks, created opportunities for thinking about new ways in which things could be done and, thus, the potential to change one’s habitus. Participant 2 commented on the benefit of comparing and contrasting practices with other students.
Meeting people who were doing essentially the same thing as me, but in much different settings and realising how it’s similar and how it’s different… it opened my eyes a little to how things could be done and are done in other places. (Participant 2-CE).
Such dialogue, developed and practised through these programmes, could have a lasting effect on practice. Further, by accruing symbolic, social and embodied capital through a Master’s qualification, and the knowledge and social connections that came with it, graduates could compensate—at least to some extent—for a lack of other kinds of cultural capital (wealth, prior education, social status, etc.). By completing the considerable challenge of postgraduate study, other graduates had transformed not only what they could do or how they were seen, but how they understood themselves and the nature of their professional role. This transformation can be seen as the development of habitus necessary to advance in academic and professional fields. For example, the combination of the forms of capital discussed so far enabled Participant 7 to overcome cultural obstacles and gain access to higher status and increased agency.
At the time that I chose general surgery, no girls or ladies were allowed to visit surgery in our university, it was a department for men only… I have exerted maybe…trebled the effort that my male fellows have exerted. That’s what made me get my Master’s degree, and I got the position of assistant lecturer in general surgery department at our university. … [This] got the professors and the senior staff to see that I can be a surgeon, it’s not for men only. I have opened the door for a lot of ladies to join the department afterwards. (Participant 7-CE)
Thus, significant agency could be required in order to amplify the capital derived from the qualifications. Another example was Participant 11, who actively lobbied for formal recognition of his qualification. He became “the first [doctor in his country] to get a Master’s degree in education,” opening up significant opportunities for career progression. It was interesting to see how the attributes gained through these Master’s could disrupt existing hierarchies, in minor and major ways. Participant 7 (above) demonstrated a significant shift in power and legitimacy, becoming recognised as a female surgeon in a male-dominated field. Participant 11 raised the profile of clinical education in his country. Participant 13 spoke of the Master’s qualification as necessary to accessing particular areas of the field of medical education that would otherwise be inaccessible to nurses.