On learning in the clinical environment

Sammanfattning: The clinical environment is acknowledged as an important setting for learning within healthcare professional education programmes. Learning that takes place in a setting primarily designed for work is usually referred to as workplace learning. Socio-cultural views on workplace learning recognise the affordances of the workplace and the engagement of individuals to interdepend in a relational manner. Invitational abilities of workplaces as well as how individuals elect to engage in workplaces thus constitute the bases for workplace learning. The aim of the thesis was to explore workplace learning among undergraduate medical and nursing students which was performed in four consecutive studies. The thesis adopted a socio-cultural perspective on learning and employed qualitative approaches embedded in an interpretative tradition of inquiry. Study I explored students’ experiences of clinical learning environments through individual interviews. Studies II and III analysed the interdependence between affordances and engagement by employing observations and interviews with an ethnographic approach. Study IV identified teaching and learning regimes in the clinical environment using observations and interviews. For the medical students, workplace learning entailed access to a variety of activities in the role of a marginal member of healthcare. As marginal members, students needed to navigate through authentic environments, to some extent, on their own. Thus, medical students adopted an adaptive approach to workplace learning. For the nursing students, workplace learning involved being entrusted to take active part in, and hold responsibility for, patient care. As participators in practice, nursing students needed to negotiate their basic values with those of the workplaces. Nursing students hence adopted a hesitant approach to workplace learning. Workplace learning was built upon fundamentally varying perspectives on learning in the medical and nursing context respectively. The way in which workplace learning was practiced was therefore based on the epistemological assumptions in each context. The current arrangement of medical students’ workplace learning does not seem to support students’ active participation in practice, in part due to the individual focus in learning. By contrast, nursing students’ workplace learning entailed active participation; however, with substantial side effects due to the heavy focus on relational aspects of learning. The thesis alluded to limitations with the influential theoretical framework of communities of practice. Instead, workplace participatory practices are suggested to reflect to the nature of workplace learning to a higher degree, not the least as student agency are adequately addressed. In line with a shift in the understanding of clinical learning environments from a measureable and stable institution towards acknowledging the social nature of learning in the clinical environment, the main message in this thesis argues for an upgrading of students as a powerful stakeholder in workplace learning; so as not to view students as consumers of clinical education.

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