The Situational Analysis of Teaching-Learning in Clinical Education: Methodological Development in Medical Education Research

Clinical teaching-learning is a context-bound phenomenon. One of the problems related to research in clinical education is the lack of sucient attention to coherent and context-appropriate methodologies. The clinical learning environment is inherently an integration of teaching and clinical care, which has made the nature of clinical education complicated and multifaceted. Improving and developing clinical teaching-learning requires not only an explanation of the current situation, but also the development of new research methods is necessary to reconstruct the teaching-learning system and, as a result, clinical education reinforcements.


Results
the teaching-learning situation in clinical education on general medicine in Iran was represented in three maps; situational, social worlds/arenas, and positional. In addition, the results showed, clinical education of general medicine in Iran in 6 positions has serious problems and challenges. As a result, recommendations were provided to develop and support effective clinical teaching.

Conclusions
The ndings of this research revealed key messages that can be explained using Foucault's discourse. In addition, from the methodological point of view, the present study encourages the use of the situational analysis approach to study complex systems and in order to educational excellence and improvement calls for further methodological development in medical education research.

Background
Clinical education plays an important role in medical education since it provides the opportunity for medical students to learn. The clinical practice is an essential and irreplaceable component and resource in preparing medical students for their professional roles (professional identity) [1]. Clinical education can be considered a set of activities that facilitate learning in the clinical environment, which is to make measurable changes in the students to perform clinical care. Clinical education provides medical students with an opportunity to develop competency and skillsets to function within dynamic and complex settings. The importance of clinical education has been considered throughout the literature as a vital and essential element for the continuous growth of students [2].
Clinical education is the most important and integral part of medical education and the heart of professional education because it is during this phase of training that what has been learned is put into practice, skills are taught, and the realities of the workplace can be explained to students. Students' learning in the clinical environment is essential for clinical education [3,4]. This training helps students to link theory to clinical practice [5]. In clinical education, students gain the necessary experience through clinical practices and are provided with opportunities to translate theoretical knowledge into mental, psychomotor, and social skills, which are necessary for patient care [6].
Clinical teaching-learning is a phenomenon that is impacted by the context. The student in this learning environment is immersed in the clinical environment's culture and acquiring knowledge, skills, and problem-solving strategies [7]. Therefore, drawing and explaining this special situation using the situational analysis approach is of particular importance. In addition, developing and improving the quality of teaching-learning in clinical education requires explaining the current situation, identifying the challenges and problems (injuries) and its strengths. In this regard, the results of such research can pave the way for future plans. Therefore, in this study, the teaching-learning system was represented in the clinical education of general medicine in Iran with a focus on its pathology.

Aim Of This Study
Using situational analysis as one of the version of grounded theory, this study aimed at explaining the fundamental components and elements of teaching-learning and identifying the challenges and problems (injuries) that stand in the way of effective teaching-learning in clinical education of general medicine in Iran.

Research approach
This qualitative study was conducted using the situational analysis approach. Clarke [8], developed situational analysis based on Anselm Strauss's legacy. Although grounded theory and situational analysis are fundamentally rooted in social constructionism and seek to explore the diversity of perspectives and the processual and contingency nature of social life by a relational ecological framework, Clarke [8], has critiqued grounded theory and developed situational analysis that is situationcentered (primarily context-driven). She believes it addresses shortcomings in traditional ground theory such as positivist tendencies, a lack of re exivity, simplicity rather than addressing differences, and a lack of power analysis. One of the key advantages of situational analysis is that it provides a reliable and rigorous method for resolving complicated issues in research [9]. Also, situational analysis is rooted in symbolic interactionism and pragmatist philosophy. This approach also has new roots, such as analyses of Foucault's discourse that go beyond "the knowing subject," paying special attention to and explicitly acknowledging non-human actors and analyzing implicated actors and actants. The juxtaposition of these cases has led to the transition to the situation as the center of gravity of the analysis and its perception as an analytical unit [9].

Study Context And Participants
Undergraduate Medical Education (UME) in Iran has two courses that include four stages, pre-clinical course (including two stages of basic sciences and physiopathology/semiology) and clinical training (including two stages of clinical clerkship and internship). The focus of this inquiry is the teachinglearning phenomenon of clinical training.
There are two groups of participants in this study; the rst category of humans includes; expert clinical teachers, medical education specialists and students, and the second category of non-human beings such as; documents and analysis of the general medicine curriculum (clinical training). Table (1) shows the human participants and the method of their selection.   Table (2) the number of participants in the web-based qualitative survey and semi-structured telephone interview for the groups of clinical teachers, medical education specialists, and students is reported separately. In the web-based qualitative survey, 31 people answered questions and returned them. Also, seven key experts and key informants were interviewed in the semi-structured telephone interview.

Data Collection And Triangulation
The data of this study were collected using a combination of multiple methods and sources. In other words, the data were collected through the methods of documents and literature review, analysis of the general medicine curriculum (clinical training), web-based qualitative survey and semi-structured telephone interview. The data of this study were collected from July 10 to August 16, 2021. Thirty-one participants were involved in the web-based qualitative survey, while seven participants took part in the semi-structured phone interview. All interviews were conducted by the second researcher who is quali ed in conducting qualitative interviews. Five participants agreed to have their voices recorded during the semi-structured telephone interviews, and the second researcher transcribed their recordings verbatim. The other two refused to have their voices recorded, so the content of their interviews was noted and transcribed during the interview. An introductory question was asked to establish rapport with the interviewees, followed by ve key and main open-ended questions. Because new questions developed during telephone interviews, the semi-structured telephone interview was introduced in this study.
However, because these questions were delivered via Porsline (web-based) to many medical education professionals, clinical teachers, and students, and they only responded to those ve questions, it was termed the web-based qualitative survey. The ve recorded interviews lasted 30 minutes on average (between 15 and 40 minutes), while the two immediately noted and transcribed interviews lasted 45 minutes on average (between 30 and 60 minutes).

Data Analysis (Mapmaking As An Analysis Tool)
In this study, the data analysis process began after the rst interview and its transcription. The main strategies of situational analysis are the three maps that researchers perform across the full path of the research project process (from design to report). The rst map is a situational map, which analyzes the research situation at a macro level. These maps enable the researcher to articulate the major elements in the situation from their own ontological perspectives. The second map, the social worlds/arenas map, depicts all of the collective actors as well as the arena(s) of commitment in which they are involved in ongoing discourses and negotiations. This map is a meso-level analysis. The third map is the positional map. This map is a micro-level analysis and focuses on the main positions taken and not taken in the data. In general, situational analysis can deeply study research projects individually, collectively, organizationally, temporally, geographically, materially, discursively, culturally, institutionally, visually, symbolically, and historically.

Memos And Memoing
Memoing is an analytical process that ensures the quality of the grounded theory, particularly situational analysis [10]. According to Stern [11], if data are the building blocks of a developing theory, memos are the mortar). In this study, the researcher used theoretical, methodological or operational, and diagrammatic memos to re ect evolutionary analysis of the situation, especially relational analysis on the situational maps. Examples of these are presented in supplementary information le (See supplemental 1, 2, and 3).

Rigor And Trustworthiness
A qualitative inquiry's rigor and trustworthiness are critical components. In fact, if a reader of a study report can audit the data collecting and analysis procedure, the study is likely to be reliable [12]. Lincoln and Guba's criteria were used to increase the trustworthiness of the data in this study [13]. Table (3) presents these criteria and the strategies that guarantee them.

Results (Presenting Maps)
The data of this study, collected through documents and literature review, qualitative survey, interview and analysis of general medicine curriculum (clinical training), analyzed and represented in the form of three maps as follows:

A) Presenting Situational Maps
The fundamental question to be answered in creating the situational maps is: Who and what are in the broader situation?
In this research, the question is: What are the components and elements (human, non-human, material, symbolic and discursive) of the teaching-learning situation in the clinical education of general medicine in Iran?
To answer this question, situational maps were represented in two versions: messy version and ordered version.
Presenting situational map: messy version According to this map, a situation encompasses all human, nonhuman, material, symbolic, and discursive components and elements and is constructed and represented by the people involved in the situation and the researcher. Figure (1) represents the components and elements of the teaching-learning situation in clinical education of general medicine in Iran.
To represent the messy map of the situation, the researcher asked participants to write down all the components and elements in the situation under study. Also, the researcher wrote down all the components and elements in this situation based on documents and articles. This is precisely what the situational map should be; thus the researcher did not limit himself to providing an organized list and instead invited the participants to think freely, extensively, and with a big picture in mind about the topic under investigation. They were asked to present all the components and elements they have experienced about the situation, no matter how marginal they may seem. This step of situational analysis allowed the researcher to tell stories without removing important aspects of the situation.

Presenting situational map: ordered version
The discourses and themes that emerged in the messy version can be organized and speci cally represented using the ordered version of the situational map. Table (4) presents the discourses and themes that emerged in the previous step in an ordered and categorized manner.   Related discourses (historical, narrative, and/or visual) (such as; normative expectations of actors, actants, and/or other speci ed elements; mass media and other popular cultural discourses; situation-speci c discourses, etc.) • Applying e-learning and online in clinical education • Opportunistic strategy (lack of a systematic program in clinical education) • Imbalance between roles of teaching and clinical care   (4) shows the components and elements of the teaching-learning situation in clinical education of general medicine in Iran using the ordered version of the situational map in different categories. It should be emphasized that, despite their xed appearance, these maps are not static and can include a great deal of dynamism and uidity. When categorized into an ordered map, however, each of the components, elements, discourses, and themes that emerged in the Messy form of the situational map can exist in more than one category, as shown in Table (4). In general, the representation of these components and elements in the ordered version is important to reveal the complex conditions in the situation (here, teaching-learning in clinical education of general medicine in Iran).

Presenting Relational Analysis With Situational Maps
After creating messy and orderly versions of the situational map, the next step is to pose the question based on these maps and the researcher's memos. In fact, in this step, the researcher pondered the situational map and represented important relationships. These relational maps assist the researcher in deciding which stories and relations to explore as an analyst. In the present study, relational analysis was represented for clinical education (Supplemental 4) as well as teaching-learning in clinical education In addition, as shown in schematic Figure (2), different social worlds are identi ed in the arenas of teaching-learning of clinical education. In the hospital arena and its sub-arenas, there are social worlds such as the clinical teachers and educators' social world, students' social world, hospital physicians' social world (specialist and attending physicians), residents' social world, nurses' social world, the social world of non-educational staff and personnel and simulation and technology world. In the health centers arena (comprehensive health services) and its sub-arenas, there are social worlds such as the clinical teachers and educators' social world, students' social world and family physicians' social world. Finally, there are social worlds in the universities and medical school arenas and their sub-arenas, such as the clinical teachers and educators' social world, students' social world, and simulation and technology world.

C) Presenting Positional Map
The positional map is the nal category of map used to chart data. It shows various positions within major discursive issues arising in the data (Figure 3).

Discussion
According to results of this study, when it comes to situational maps, it can be noted that because the data for this study was collected from a variety of sources and methodologies, there were some interesting ndings in terms of the components and themes that emerged. Human, non-human, symbolic, and discursive components and elements such as community-based medical education, small groups learning, problem-based learning, attention and focus on learners' needs, systematic approach in clinical education, and others have been considered in the clinical training of general medicine curriculum, while the results of the semi-structured telephone interview and web-based qualitative survey do not indicate this. As a result, there is no alignment or conformance between the planned and intended curriculum, what teachers teach (the delivered curriculum), and what the students learn (the experienced curriculum).
In fact, according to research by Kiguli et al. [14], sometimes, what is expected of a curriculum is not re ected in practice.
The data of this study showed that teaching-learning situations in clinical education of general medicine in Iran has arenas such as hospitals, universities and medical schools and health centers (comprehensive health services). The hospital arena includes sub-arenas such as hospital wards (education in inpatient settings and bedside teaching), ambulatory education (education in outpatient clinics), and the clinical skills learning center. Other arenas of teaching-learning in clinical education of general medicine in Iran are the universities and medical schools (which include the clinical skills learning center and classrooms). Health centers (comprehensive health services) are almost like other arenas of teachinglearning, which include outpatient education and [to some extent] community-based education. Although the ndings of previous research shows that clinical education has shifted from bedside teaching to classrooms and corridors [15], clinical education in general medicine in Iran remains primarily hospitalbased, despite the ndings of this study and the identi cation of three main arenas.
Another nding based on multiple data sources and methods is that the community-based education arena has been considered as one of the arenas of clinical education in general medicine in the curriculum analysis and literature review. Still, the data collected from the interview and qualitative surveys do not support this. Furthermore, many expert clinical teachers, medical education specialists, and students believe that health centers were originally designed for this purpose. In interviews, several professional clinical teachers and medical education specialists stated that the COVID-19 pandemic gave an outstanding and remarkable chance for general medicine clinical training that would be continuous from hospital to community-based education.
Another nding based on multiple data sources and techniques is that there is a gap between expert clinical teachers and medical education specialists in Iran regarding teaching-learning arenas in general medicine clinical education. According to several medical education specialists. Clinical teachers who teach believe that, despite these arenas being the curriculum's focus, clinical education in general medicine in Iran is primarily hospital-based (inpatient, outpatient and based on clinical skills learning center). This paradox, in general, conveys the notion of the divide between medical education professionals and clinical teachers or the gap between theory and practice.
Furthermore, the social worlds in the arenas of teaching-learning in the clinical education of general medicine in Iran were represented on the second map. In the hospital arena and its sub-arenas, there are social worlds such as the clinical teachers and educators' social world, students' social world, hospital physicians' social world (specialist and attending physicians), residents' social world, nurses' social world, the social world of non-educational staff and personnel and simulation and technology world. There are social worlds in the health centers arena and its sub-arenas, such as the clinical teachers and educators' social world, students' social world, and family physicians' social world. Finally, there are social worlds in the universities and medical school arenas and their sub-arenas, such as the clinical teachers and educators' social world, students' social world, and simulation and technology world.
In reality, in the teaching-learning situation in general medicine clinical education in Iran, some persons and groups have more connection and become closer to each other's social worlds, such as clinical teachers and educators' social worlds and students' social worlds. Also, some of these worlds participate in more than one arena, such as the clinical teachers and educators' social world and students' social world participating in all three arenas of hospitals, universities, medical schools, and health centers. The important point about the social worlds/arenas map is that no patients' social world is represented in the arenas for clinical education. In general medicine clinical education in Iran, patients are only treated as "subjects for teaching-learning." They are not allowed to participate in clinical teaching, curriculum design, or evaluation. In other words, they are present in these arenas, but not as collective actors in education, but as implicated/ silent actors/ actants, as explained by Foucault's discourse, which indicates that the patient's voice is not heard in relation to educational involvement. According to Foucault's book "The Birth of the Clinic," patients are only examined medically in the new era. Therefore, it demands that clinical education be humanistic in both education and service delivery and care.
Another important factor to consider is that, in the hospital arena, providing clinical care takes precedence over teaching because of the presence of hospital physicians' discursive and social worlds (specialist and attending physicians), nurses' discursive and social worlds, residents' discursive and social worlds, and the social world and discursive of non-educational staff and personnel. This important nding can also be explained by Foucault's discourse; it may be stated that the power of specialists and attendings, residents, and nurses in the hospital arena has dominated education in this context. Thus, this has led to the imbalance between the dual roles of education and clinical care in the clinical education system of general medicine.
Finally, the nal map was plotted challenges and problems (injuries) related to clinical education that are obstacles to effective teaching-learning (vertical axis) and components and elements to construct and support effective clinical teaching (horizontal axis), both based on research data.). The challenges and problems that obstruct successful teaching-learning were conceptualized and categorized according to

Conclusions
The results of this study contained important messages that was explained through Foucault's discourse. Although in this study observation was not used (as one of the important techniques of data collection in situation analysis method) due to the critical conditions caused by the Covid-19 pandemic and the urgent need for social distancing, we attempted to overcome this research problem as much as possible through triangulation and the use of multiple data collection methods, we attempted to overcome this research problem as much as possible through triangulation and the use of multiple data collection methods. Based on the present study results, while considering the horizontal axis of the positional map (components and elements to develop effective clinical teaching), the authors recommend other items to support effective clinical teaching, achieve the goals and outcome of clinical education and preparation competent graduates. These include; monitoring the implementation of the curriculum to increase the alignment and conformity between the planned curriculum and the delivered curriculum and the curriculum experienced by students, developing symbiotic relationships at the macro-level, at the mesolevel and at the micro-level, recruiting educational specialists (medical education specialists) to consult individual and collective, and optimizing clinical teachers' educational efforts in medical schools, focusing on systematic training in clinical education, adapting and aligning the student's job description to the learning objectives, developing the attitude of teachers and students towards clinical education as a career pathway, promoting and developing students' autonomy in clinical learning. Finally, from the methodological point of view, the present study promotes the use of the situational analysis approach to study complex systems and encourages medical education researchers to continue to improve methodological development in medical education research.