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      Possibilities for interprofessional learning at a Swedish acute healthcare ward not dedicated to interprofessional education: an ethnographic study

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          Abstract

          Objectives

          Almost all healthcare today is team-based in collaboration over professional borders, and numerous students have work-based learning in such contexts. However, interprofessional learning (IPL) in clinical settings has mostly been systematically explored in specially designed contexts dedicated to interprofessional education (IPE). This study aimed to explore the possibilities for IPL activities, and if or how they occur, in an acute ward context not dedicated to IPE.

          Design and setting

          Between 2011 and 2013 ethnographic observations were performed of medical and nursing students’ interactions and IPL during early clerkship at an acute internal medicine ward in Sweden. Field notes were taken and analysed based on the framework of IPE: learning with, from and about.

          Participants

          21 medical, 4 nursing students and 30 supervisors participated.

          Results

          Learning with—there were no organised IPE activities. Instead, medical and nursing students learnt in parallel. However, students interacted with staff members from other professions. Learning from—interprofessional supervision was frequent. Interprofessional supervision of nursing students by doctors focused on theoretical questions and answers, while interprofessional supervision of medical students by nurses focused on the performance of technical skills. Learning about—students were observed to actively observe interactions between staff and learnt how staff conducted different tasks.

          Conclusion

          This study shows that there were plenty of possibilities for IPL activities, but the potential was not fully utilised or facilitated. Serendipitous IPL activities differed between observed medical and nursing students. Although interprofessional supervision was fairly frequent, students were not learning with, from or about each other over professional borders.

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          Most cited references23

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          Experience-based learning: a model linking the processes and outcomes of medical students' workplace learning.

          To develop a model linking the processes and outcomes of workplace learning. We synthesised a model from grounded theory analysis of group discussions before and after experimental strengthening of medical students' workplace learning. The research was conducted within a problem-based clinical curriculum with little early workplace experience, involving 24 junior and 12 senior medical students. To reach their ultimate goal of helping patients, medical students must develop 2 qualities. One is practical competence; the other is a state of mind that includes confidence, motivation and a sense of professional identity. These 2 qualities reinforce one another. The core process of clinical workplace learning involves 'participation in practice', which evolves along a spectrum from passive observation to performance. Practitioners help students participate by being both supportive and challenging. The presentation of clear learning objectives and continuous periods of attachment that are as personal to the student(s) and practitioner(s) as possible promote workplace learning. The core condition for clinical workplace learning is 'supported participation', the various outcomes of which are mutually reinforcing and also reinforce students' ability to participate in further practice. This synthesis has 2 important implications for contemporary medical education: any reduction in medical students' participation in clinical practice that results from the patient safety agenda and expanded numbers of medical students is likely to have an adverse effect on learning, and the construct of 'self-directed learning', which our respondents too often found synonymous with 'lack of support', should be applied with very great caution to medical students' learning in clinical workplaces.
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            Programmatic assessment of competency-based workplace learning: when theory meets practice

            Background In competency-based medical education emphasis has shifted towards outcomes, capabilities, and learner-centeredness. Together with a focus on sustained evidence of professional competence this calls for new methods of teaching and assessment. Recently, medical educators advocated the use of a holistic, programmatic approach towards assessment. Besides maximum facilitation of learning it should improve the validity and reliability of measurements and documentation of competence development. We explored how, in a competency-based curriculum, current theories on programmatic assessment interacted with educational practice. Methods In a development study including evaluation, we investigated the implementation of a theory-based programme of assessment. Between April 2011 and May 2012 quantitative evaluation data were collected and used to guide group interviews that explored the experiences of students and clinical supervisors with the assessment programme. We coded the transcripts and emerging topics were organised into a list of lessons learned. Results The programme mainly focuses on the integration of learning and assessment by motivating and supporting students to seek and accumulate feedback. The assessment instruments were aligned to cover predefined competencies to enable aggregation of information in a structured and meaningful way. Assessments that were designed as formative learning experiences were increasingly perceived as summative by students. Peer feedback was experienced as a valuable method for formative feedback. Social interaction and external guidance seemed to be of crucial importance to scaffold self-directed learning. Aggregating data from individual assessments into a holistic portfolio judgement required expertise and extensive training and supervision of judges. Conclusions A programme of assessment with low-stakes assessments providing simultaneously formative feedback and input for summative decisions proved not easy to implement. Careful preparation and guidance of the implementation process was crucial. Assessment for learning requires meaningful feedback with each assessment. Special attention should be paid to the quality of feedback at individual assessment moments. Comprehensive attention for faculty development and training for students is essential for the successful implementation of an assessment programme.
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              Self-organisation, integration and curriculum in the complex world of medical education.

              The world of medical education is more complex than ever and there seems to be no end in sight. Complexity science is particularly relevant as medical education embraces a movement towards more authentic curricula focusing on integration, interactive small-group learning, and early and sustained clinical and community experiences. A medical school as a whole, and the expression of its curriculum through the interactions, exchanges and learning that take place within and outside of it, is a complex system. Complexity science, a derivative of the natural sciences, is the study of the dynamics, conditions and consequences of interactions. It addresses the nature of the conditions favourable to change and transformation (learning). The core process of complexity, self-organisation, requires a system that is open and far from equilibrium, with ill-defined boundaries and a large number of non-linear interactions involving short-loop feedback. In such a system, knowledge does not exist objectively 'out there'; rather, it exists as a result of the exchange between participants, an action that becomes knowing. Understanding is placed between participants rather than being contained in one or the other. Knowledge is not constructed separately in the mind of the knower, but, rather, it emerges; it is co-created during the exchange in an authentic recursive transactive process. Learning and knowing become adaptive responses to continuously evolving circumstances. An approach to curriculum based on self-organisation is characterised as rich, recursive, relational and rigorous and it illuminates how a curriculum can be understood as a complex adaptive system. The perspective of complexity applied to medical education broadens and enriches research questions relevant to health professions education. It focuses our attention onto how we are together as human beings. How we respond to and frame the issues of learning and understanding that challenge contemporary medicine and, by extension, medical education, in a complex and rapidly changing world can have profound effects on the preparedness of tomorrow's health professionals and their impact on society.
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                Author and article information

                Journal
                BMJ Open
                BMJ Open
                bmjopen
                bmjopen
                BMJ Open
                BMJ Publishing Group (BMA House, Tavistock Square, London, WC1H 9JR )
                2044-6055
                2019
                29 July 2019
                : 9
                : 7
                : e027590
                Affiliations
                [1 ] departmentDepartment of Health Scinces , Roda Korsets Hogskola , Huddinge, Sweden
                [2 ] departmentDepartment of Clinical Science, Intervention and Technology , Karolinska Institutet , Stockholm, Sweden
                [3 ] departmentDepartment of Clinical Sciences, Danderyds Hospital , Karolinska Institutet , Stockholm, Sweden
                Author notes
                [Correspondence to ] Dr Ann Hägg-Martinell; ann.hagg.martinell@ 123456rkh.se
                Author information
                http://orcid.org/0000-0001-6477-4441
                Article
                bmjopen-2018-027590
                10.1136/bmjopen-2018-027590
                6677984
                31362963
                cbd37fb7-d64f-4e39-968d-8115c7009733
                © Author(s) (or their employer(s)) 2019. Re-use permitted under CC BY-NC. No commercial re-use. See rights and permissions. Published by BMJ.

                This is an open access article distributed in accordance with the Creative Commons Attribution Non Commercial (CC BY-NC 4.0) license, which permits others to distribute, remix, adapt, build upon this work non-commercially, and license their derivative works on different terms, provided the original work is properly cited, appropriate credit is given, any changes made indicated, and the use is non-commercial. See: http://creativecommons.org/licenses/by-nc/4.0/.

                History
                : 30 October 2018
                : 28 June 2019
                : 09 July 2019
                Funding
                Funded by: FundRef http://dx.doi.org/10.13039/501100004348, Stockholms Läns Landsting;
                Categories
                Medical Education and Training
                Research
                1506
                1709
                Custom metadata
                unlocked

                Medicine
                interprofessional education,supervision,workplace learning,nursing students,medical students,intermediate care facilities,ethnography

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