Table 4 Emergent themes related to the Context dimension of self-directed learning

Learning environment

  Education orientation

Students gain adequate support from the team members to try, explore, and learn in a clinical setting.

33 excerpts,14 interviews

“I think if I were to be doing something wrong, my attendings and the residents that I worked with have always been very helpful in terms of just either being there and available for questions.” (Case No.10)

  Psychological safety

Students feel safe to speak up, make mistakes, and learn something they are not familiar with.

30 excerpts,8 interviews

“If you have a good learning environment, they [the residents] really make it so you can feel comfortable just like doing your best, … and then if you’re wrong, it’s completely okay.” (Case No.8)

  Student engagement

Students can feel engaged when the team members invite them to talk, discuss, or practice.

9 excerpts,6 interviews

“If they extend the invitation like, ‘Do you want to come?‘ Then, that’s also an opportunity to see more.” (Case No.14)

  Opportunities for ownership of patient care

Students have chances to take the responsibilities for the care of their patients assigned by the team.

10 excerpts,6 interviews

“I feel like I do have more ownership of the patient. And so, in that setting, and because of smaller group team setting, I definitely feel more proactive and wanting to figure out other things.” (Case No.13)

  Sense of urgency

Students notice the team members just want their jobs quickly done without spare time for teaching.

20 excerpts,11 interviews

“It was drilled into me that people are busy, so don’t ask them questions… It’s just a consequence of the busy system that is there, it should change… That was my biggest struggle.” (Case No.1)

Impression management

  Looking good

Students want to perform well, look good, and get a great evaluation which benefits their application for residency.

25 excerpts,11 interviews

“I think there’s always a fear of not looking smart enough… I don’t think any curriculum is really going to be able to help you get over that.” (Case No.4)

  Being constantly  evaluated

Students are evaluated almost all the time when they are in the workplace interacting with others.

30 excerpts,14 interviews

“The evaluations of the clerkship are so subjective. It adds a lot of stress. And in some ways, I described to people that it feels like you’re being interviewed every day for a year.” (Case No.2)

  Not seem disinterested

Students fear that they will get a bad evaluation if they seem disinterested in clinical learning activities.

9 excerpts,5 interviews

“If you’re doing questions, … it looks like you may not be paying attention to what’s going on and that makes you look not engaged. It goes back to that so much of your grade is being part of the team and being engaged.” (Case No.12)

Group learning culture

  Collaborative learning

Students are encouraged to collaborate with the team members, learn from them, and contribute to the team’s learning.

15 excerpts,7 interviews

“I think it’s just really important in the medical profession to work closely with colleagues and collaborate and feel comfortable speaking up when there are questions and you’re not sure how to proceed.” (Case No.5)

Learning activities

  Formal and informal learning activities

Students can participate in all sorts of learning activities, even if some of them are not mandated in the clinical course.

10 excerpts,7 interviews

“This is actually my advice when I do talk to the younger students, this idea of looking for opportunities outside the formal (activities) like rounds, go see exams, go see tests, go talk to consultants.” (Case No.7)