Conceptual orientation

This is an integrated mixed methods study which has been conducted from a pragmatic epistemological stance. This position emphasises the utility of both quantitative and qualitative research approaches to answer a research question, over any epistemological or ontological discordance between them. Within this perspective the interpretative elements of our study have been conducted from a socio-cultural stance, which holds that learning takes place during social interaction in cultural and historical settings [49].

Setting

This national study was conducted in the Republic of Ireland, which has a comprehensive, government funded public healthcare system. On completion of a medical degree programme graduates spend a year as an intern before becoming fully registered medical practitioners. Those entering hospital specialties then spend 6–8 years in training programmes which are similar to UK Foundation, Core and Specialist training and broadly analogous to North American residencies and fellowships. A variety of terms are used, both internationally and nationally, to describe doctors in postgraduate medical education, these include; junior doctors, trainees, doctors-in-training, non-consultant hospital doctors and residents. Similarly, terms to describe senior doctors include consultants, attending physicians, supervisors and trainers. The latter two terms suggesting a formal educational role. In this paper we will use the terms resident and senior doctor unless directly quoting participants.

This study is part of a larger project funded by the Health Research Board, Ireland. The research team is a multi-disciplinary group including residents, senior doctors, medical educators, experts in organisational behaviour, and representatives of nursing and allied healthcare professions as well as patient representation.

Recruitment and participation

We issued an invitation via email to experts and stakeholders in postgraduate medical education nationally to participate in a consensus building process. We purposively selected attending physicians, residents, health service managers, allied healthcare professionals and patient representatives, on the basis of their expertise and experience of clinical learning environments. Doctors with senior roles in postgraduate medical education were targeted, as were clinicians who supervise trainees daily in the workplace. A range of allied healthcare professionals were targeted in a similar manner. Each of the stakeholder groups included interfaces with postgraduate training ‘on the ground’ in the clinical environment and/or contributes to the policy and structures which govern training. We hypothesised that they might provide unique perspectives in respect of our research questions.

Data collection

Group Concept Mapping (GCM) is a novel integrated mixed method approach to identify an expert group’s understanding about a topic. GCM builds on the strengths of other structured consensus building methods, such the Delphi method, mitigating some of their weaknesses [50]. The aim of GCM is to depict unique ideas on a particular topic by converting complex qualitative data into conceptual maps [51] showing how individual ideas are related to each other, and generating rating data relating to the relative importance of an idea, and its perceived achievability [51].

GCM consists of five phases:

Phase 1: Brainstorming & Pruning: We provided participants with a web-based link to an online platform for data collection [52]. Participants completed a short demographic questionnaire and identified facilitators and/or barriers to learning in clinical environments in response to the following prompt:

Participants could provide as many statements as they wished and we asked for a minimum of five from each. The second step was idea pruning, a data cleaning process undertaken by the research team. We reviewed the initial list of statements for any repetition, ambiguity or more than one idea. We deleted, re-worded or split statements as required.

Phases 2 & 3: Sorting & Rating: In keeping with the GCM method, a subgroup of the original participants was selected to sort the edited list of statements into groups, based on similarity of the ideas therein. These participants were then asked to rate each statement for importance using the following prompt;

The process was then repeated for each statement regarding ‘ease to address’.

Phase 4: Data Analysis: Concept System Global software was used for the quantitative data analysis. Multi-dimensional scaling produced a point map of the statements based on the principle that statements which participants had more frequently grouped together during the sorting process on the basis of their similarity, appear close to each other on the point map [53]. A bridging value was calculated for each statement. This is a statistic ranging from 0 to 1 which indicates how often a statement is grouped with others adjacent to it on the concept map, and whether participants have grouped it with others further away.

Hierarchical cluster analysis embedded in GCM initially treats each individual idea as a separate cluster, and continues to merge ideas until it arrives at one cluster [54]. Mean bridging value for a cluster is calculated on the individual bridging values of statements composing that cluster [55]. A lower bridging value indicates that a statement has greater cohesion with others in that cluster. Lower mean bridging value for a cluster corresponds to a greater level of agreement on the content of that cluster [55].

Mean rating scores for importance and ease to address for each statement and cluster were calculated. The clusters and ratings produced by doctors were compared with those produced by the other participants.

Phase 5: Interpretation of the results: The GCM software generated an initial cluster solution and offered a sequence of cluster merges which could be undertaken if there was sufficient conceptual similarity between clusters to do so. This qualitative element of the mixed methods analysis is underpinned by researcher interpretation and judgement [53]. DB, AW and CK co-constructed a thematic interpretation of the statements in each cluster during a series of meetings. Judgements to merge clusters or not were based on similarity of meaning of the statements therein. Once merges were agreed, DB, AW and CK proposed meaningful labels for the final clusters, informed by our orientation towards social theories of learning e.g. Communities of Practice. These were labels were debated and finalised with the wider multi-professional research team.

Rating

Individual statements

Protected time for teaching and learning was a second prominent theme;

Principal findings

In this study stakeholders identified ten distinct domains within clinical learning environments. These domains were mapped to provide a visual representation of their relationships. Workplace culture lay in a central position on the cluster map (Fig. 1), directly adjacent to 7 of the other clusters, suggesting that most aspects of clinical learning environments are culturally embedded. There was consensus amongst doctors and other participants that all of the domains identified are important to address to enhance resident learning; however, some domains were rated more important than others.

Domains rated most important were those which related to residents’ connection to and engagement with more senior doctors and other members of the clinical team (Resident Support, Time to Learn with Senior Doctors during Patient Care and Interaction and Feedback in Clinical Teams). This is in keeping with social learning theory, for example Communities of Practice theory [3], which emphasises the importance for newcomers to a community to learn by working alongside more senior members. Learning, through observation, role modelling, discussion and feedback all takes place in this context. Participants identified shorter working hours, subsequent to the implementation of the European Working Time Directive (EWTD), as disrupting learning through a reduction in time spent with senior doctors and a disintegration of clinical teams. Under the EWTD residents work no more than 48 h per week in total. Participant statements indicated that less time spent in the clinical environment reduces opportunities to learn through clinical work, to benefit from mentorship and to follow the patient pathway, compounding the challenges of learning in a healthcare system under strain. These perspectives are consistent with some of the literature examining the effects of restricted duty hours [56]; however, published data on the impact of EWTD on training has been mixed [40], perhaps due to the influence of local differences in how the regulations are implemented. In keeping with the GMC national training survey report [57] our findings suggest that poor rota design and scheduling has a negative impact on learning.

Organisation and conditions of work was a strongly coherent and relatively more important domain also identified by participants. Barriers in this domain referred to busyness, service pressure and overcrowding. This emphasises the dual purpose of clinical environments; supporting both patient care and learning, and confirms that service pressures impact opportunities to learn, resulting in cognitive overload, limiting time to reflect and discuss [33], and through constraints on physical space.

Domains relating to the structure and organisation of residency programmes, such as Content, assessment and continuity of training, and Trainer (senior doctor) skill and support were viewed as somewhat less important. When mapped (Fig. 1), it was also apparent that these domains, and that of Management and facilities, were grouped together, distant from Time to learn with senior doctors during patient care, Trainee support and Motivation and morale. The former group of domains can be conceptualised as the imprint of training programmes and management, on the historically, socially and culturally constructed practice of patient care; the formal versus the informal aspects of postgraduate training. Participants identified these formal areas as relatively easy to address, in keeping with fact that improvements and innovations in postgraduate training typically involve changes to content, format and organisation [58–60]. The impact of such changes on day to day learning and supervision has been questioned [59, 61]. Dijkstra et al. [13] found the influence of structural changes on trainees’ learning was mediated by ‘on the ground’ features of the clinical learning environment. It has been suggested that local approaches to cultural change may be effective [59, 62] in improving clinical learning environments. Our findings suggest that our participants recognised a separation between daily practice and externally determined format and organisation. Programme directors and policymakers need to recognise the limitations of approaches which focus on the latter.

Organisation and conditions of work and Time to learn with senior doctors during patient care were rated as the most difficult areas in which to make improvements. The consensus amongst our participants the combination of heavy clinical workload and duty hour restrictions would be challenging to address may arise from the fact that both are seen as beyond the sphere of influence of academic medicine and healthcare management, but rather the consequences of national economic recession and European legislation. None the less, it is clear that regulators expect those ‘on the ground’ to deal with these challenges. The General Medical Council (UK) places responsibility for adequate staffing, workload and rota design to support learning on Local Education Providers within the NHS [31] and the Medical Council of Ireland has identified the need for an integrated approach at clinical sites, joining up corporate areas within the health service with responsibility for patient safety and quality of clinical care and those responsible for management of the clinical learning environment [63].

Trainee Support was identified as the most important area to address. This domain refers to reception into the clinical team, collegiality, respect and support to work within scope of practice and to challenge constructively. Participants rated this aspect as moderately easy to address, perhaps because it is within the control of individuals to be welcoming, supportive and respectful of residents. Bullying, and rude, dismissive and aggressive communication are features of healthcare environments internationally [64]. Workload and workplace stress have been shown to trigger such behaviour. Junior members of staff are more likely to be on the receiving end of such communication and it has a negative impact on mental health [64, 65].

Implications for practice

The link between clinical learning environments and the quality and safety of patient care is a strong driver for stakeholders in postgraduate medical education and health service delivery to work together to strengthen both. Our findings point to the relatively greater importance of the informal over formal aspects of workplace learning and a need to prioritise the preservation of residents’ opportunities to learn and work alongside senior doctors when service delivery is being planned and structured. There is some evidence that the manner in which restricted duty hours are implemented can mitigate the impact on learning [66]. It has been suggested that affording training programmes flexibility [67] and undertaking precise workload analysis might be helpful [66]. Such an approach would enable learning to be taken into account and optimised in the implementation of compliant rotas and schedules. This approach was recommended in Sir John Temple’s 2010 report into the impact of EWTD in the UK [56]; however, there is very little published literature describing innovative ways to comply with duty hours regulations while maximising learning. Further research should focus on exploring the implementation of duty hours’ regulations in the full range of training contexts.

A continual focus on residents as learners, in need of and deserving of support from all in the healthcare environment, is essential. Faculty development has been flagged as a key element of high quality postgraduate medical education and provides a means to enhance the value placed on learning and learners in clinical environments [59]. It could also contribute to the ‘easy win’ identified by participants of ensuring that resident receive more high quality feedback. Culturally embedded negative behaviours towards residents present a significant challenge. Illing et al. [68] make recommendations arising from their review of the literature on bullying which emphasise the importance of senior leadership in initiating culture change. Exploration of other means to generate cultural change with meaningful impact on CLEs and the learning experience of residents is needed [62].

Strengths and limitations

A strength of this study is that it is a national study which included a wide range of stakeholders in postgraduate medical education and used a rigorous methodological approach to describe their consensus. These are individuals at the frontline of medical training as well as those with more strategic roles; therefore, our findings are rooted in both practice and policy. A limitation of the study is that it was undertaken in the context of the Irish healthcare system and may not be fully transferable to other contexts.