Optimizing Health Professions Education through a Better Understanding of “School-Supported Clinical Learning”: A Conceptual Model

Abstract

Interventions connecting school and clinical practice can align requirements and enhance learning outcomes. Current models and theories of clinical learning leave gaps in our knowledge about how learning processes and outcomes can be optimized by schools. In this paper, we discuss findings about threats and opportunities in the use of school standards, tools, and support in clinical learning, including underlying mechanisms, in the context of nursing education. Opportunities include competency frameworks that can challenge students to push their limits despite a task-oriented ward culture. Assignments and tools can deepen students’ understanding of patient care, help them compare different experiences and stimulate self-regulated learning. Threats include rigid performance criteria that guide students’ selection of learning opportunities, extensive written formats, and individualization of self-regulated learning. These threats can lead to added workload and disengagement. Based on the critically constructed argument that the role of schools in clinical learning should be acknowledged in the literature, we present a conceptual model to do so. The use of this model provides design principles for learning environments at the interface of school and practice within health professions education. Eventually, learning outcomes can be achieved efficiently without unnecessary interference with students’ engagement in patient care and student-supervisor interactions.

1. Introduction

Healthcare education programs consist of both “school” learning, which takes place in universities or universities of applied sciences, and practical learning, which occurs in clinical settings. Integration of school and practice learning is important for students’ development of conceptual knowledge and transfer of learning across settings in health professions education (HPE) [1]. Moreover, alignment of expectations between different learning contexts can help design training trajectories that are both effective and socially accountable [2]. A body of literature exists on successful interventions and practices to connect school and clinical practice, as well as on potential caveats [1,3,4,5,6]. However, the knowledge of opportunities and threats in the use of school tools, structures, and support in clinical learning, linked to different learning outcomes, remains fragmented [1,7,8,9]. In this paper, we reflect on our current understanding of clinical learning and discuss some findings about its interrelatedness with school learning. Based on this reflection, we propose a conceptual model of “school-supported clinical learning” that acknowledges the interrelatedness of clinical and school learning. We anticipate that using this model for future studies will help strengthen practice learning while avoiding pitfalls such as bureaucratization and assessment-driven learning. Ultimately, this may result in more effective and more accountable clinical learning trajectories in HPE.

2. Learning in Clinical Practice: Indispensable but Intangible?

Unlike learning that occurs in schools, which is subject to increasing regulation and standardization, learning that takes place in clinical settings allows for variability [10,11]. Having actual patient care as a starting point, clinical learning processes and outcomes are dependent on the setting, the patient population, staff behavior, and their willingness and ability to facilitate learning experiences. Each student has his/her own individual journey to become socialized in the professional community, affected by personal characteristics such as identity, preferences, and previous experience [12,13,14,15].

The diversity of learning opportunities in the clinical setting complicates the formulation and measurement of its desired outcomes. Indicators of competence are difficult to uniformly assess in clinical practice [16]. Recently, Entrustable Professional Activities (EPA)-based curricula have provided outcome measures that are more intuitive for clinical staff [17]. However, not all attainments of clinical learning are quantifiable [10]. Moreover, not only current competence but also the ability to respond to future situations are important in HPE [18]. This makes it difficult to determine if and when a clinical placement period has been successful.

As a result, a lot of research on clinical HPE is dedicated to understanding, measuring and improving the clinical learning environment, with the most commonly used outcome measure being student satisfaction [19]. Second, there is a focus on studying students’ engagement in the learning process and actively regulating their learning process instead of studying which outcomes are achieved [10,20].

3. Opportunities and Threats in School-Supported Clinical Learning

Ever since separate institutes in HPE offer theoretical preparation and practical training, connections between the two have been studied. Factors that affect students’ integration of theoretical knowledge in clinical work include supervisor support, clinical teaching, and school–practice collaborations [3,21]. Successful interventions include (mobile) tools to refresh classroom knowledge in practice, assignments, simulation training, and tools to prompt reflection [1,3]. The school’s involvement and efforts towards clinical faculty development can help put theory to practice [1,3,22]. Shared assessment criteria and portfolios can help maintain uniformity in competency criteria and provide tools for self-regulated learning [23]. Increasingly, integrated curricula are developed to ensure that subjects and concepts are repeated throughout the curriculum in different contexts [24]. However, schools and practice settings have their unique aims, interests, and characteristics [4,25] Integrating the school and practice learning requires an understanding regarding the mechanisms that explain how the two can either reinforce or conflict with each other [1].

It has been argued that HPE curricula, and competency-based education curricula in particular, are inherently integrative: competencies are outcome measures that integrate both knowledge, attitude, and skills that can be achieved across contexts. However, this integration is not reflected in the HPE literature [26]. Theory–practice connections, on the one hand, and clinical learning processes, on the other hand, are packed into separate bodies of the literature [27]. In the former, the role of the school and academic institution is explicitly highlighted, often focusing on the content of the curriculum or a single intervention that can help transfer school knowledge into practice. In the literature on clinical learning processes, the role of school structures, tools, and support is glaringly absent. For example, a recently well-established model of the learning environment in HPE acknowledges curriculum resources, structures, and guidance as one of the organizational aspects that affect clinical learning [19]. However, it does not address interactions between school resources, people, and regulations. Likewise, different concept analyses in the area of clinical learning either limit school resources to an “antecedent” of clinical learning or fail to specify the school’s contribution [28,29]. Whereas the tension between “work” and “learning” within the clinical learning environment is acknowledged [30], the relative contribution of the school and clinical learning environment to both creating and resolving this tension has received little attention in the literature.

School’s tools, structures and support may intentionally or unintentionally affect students’ daily learning processes and outcomes, even in the absence of a fully integrated curriculum. For example, learning goal programs, portfolios, and assessments can affect learning opportunities students seek and interactions they engage in. Conversely, guidelines and criteria may conflict with clinical work, eventually leading to extra work and faculty disengagement [4,6,23,25].

We recently conducted some studies in the context of competency-based clinical learning programs to identify opportunities and threats in the use of school structures, tools, and support in clinical learning as well as underlying mechanisms [7,8,9]. Using theoretical frameworks such as Boundary crossing [31] and Cultural-Historical Activity Theory [32], we found that school-supported clinical learning could challenge students to seek a variety of learning opportunities within a task-oriented ward culture, to contrast learning experiences across settings, to develop learning skills and to gain a deeper understanding of the profession as well as patient care. Competency frameworks, formats for development plans or reflections, practice assignments that stimulated the use of evidence-based practice, as well as school-led peer-review meetings, were found to support students to engage in these learning processes. We identified some factors that compromised the positive effects of these structures and tools, such as: (a) assessment standards evoking a tick-box mentality towards achieving goals, (b) detailed, individual criteria for practice assignments complicating linkage to relevant issues in patient care (c) extensive formats to support students’ learning process leading to disengagement of students and supervisors, and (d) resources to link practice to theory not being easily accessible on the ward. Moreover, we found that without a culture that satisfies students’ basic psychological needs (autonomy, competence, and relatedness [33]), the implementation of tools to apply self-regulated learning behavior may not lead to better learning outcomes [34]. Individual differences exist in how students and supervisors interpret standards and frameworks and how they act around them [7,9].

These findings display how inherent differences between the school and clinical context may strengthen each other but can also create tensions. They also demonstrate how learning processes, the learning environment, and assessment are intertwined and cannot be understood in isolation. Viewing students’ learning as a journey into each community of practice is reductionist in nature, as it fails to acknowledge how this learning is embedded in a larger landscape of practice and how it should result in knowledge and skills that can be applied in different contexts [35,36]. For example, understanding students’ self-regulated learning behavior requires insight into the final goals students work towards, the way they have to document their learning, as well as their individual engagement and interactions with ward staff. Although the findings presented from the nursing context above resonate with other findings in the HPE literature [6,21,23,25], they require replication and refinement within other phases of training and educational tracks.

4. Description of a Conceptual Model to Study and Optimize School-Supported Clinical Learning

To do justice to how school and practice learning are intertwined and to guide further studies, we propose a conceptual model of “school-supported clinical learning” that may help in extending the knowledge of clinical learning processes within their context (see Figure 1). We choose this terminology over similar concepts such as “work-integrated learning” [3] or “cooperative education” [37] to highlight the influence of different, interrelated contexts on one learning process. We developed the model based on our empirical findings [7,8,9,27,34]. Moreover, from the HPE literature, we used typologies and models of the clinical learning environment and school–practice collaborations to inform our model [3,5,19]. From outside the HPE literature, we used models of non-formal learning in the workplace and learning environments at the interface between school and practice in higher education and vocational education to construct the conceptual model [38,39,40,41]. The central notion of the model is to outline factors and interactions that should be acknowledged when designing learning environments at the interface between school and practice.

The conceptual model represents the intersection between learning at school (green circle), in which the primary aim is theory and skills education and learning in clinical practice (blue circle), in which the primary aim is patient care. Within this intersection, learning takes place, which is situated around clinical practice, but is intentionally or unintentionally affected by the larger curriculum of which the placement period is part.

The student (top) enters the clinical practice period with prior knowledge and experience, specific personality characteristics, including identity, learning preferences, and motivation. These elements shape what students expect from the placement periods, how they prefer to learn and to be approached, and which knowledge and skills they can build further on.

To allow for students’ learning, the environment has to allow their basic psychological needs to be satisfied: Ward staff can provide students with choices and grant them gradual independence (autonomy), give them confidence by providing development-oriented feedback, and guide them to work at an appropriate level (competence), and give them the safety to learn by caring about their well-being, including them in the team, acknowledging their vulnerable position and giving the possibility to provide critical feedback to the staff (relatedness) [42].

Following the typology of Eraut [38], the learning process that the student engages in, can be either implicit (unconscious and spontaneous, e.g., learning the rules and the daily routine of the ward), reactive (unplanned, but conscious, e.g., having a reflective discussion after a patient encounter) or deliberative (conscious and planned, e.g., presenting a patient case to peers or planning to practice a nursing skill on a patient). All three types of learning can happen simultaneously and can mutually reinforce each other. The source of deliberative learning can be both practice itself (interesting learning opportunities that the students select to engage with) and school (assessment criteria to be met).

In the clinical setting, school and practice come together in the design of clinical learning. This design should be based on an underlying design rationale (a view on the relative contributions of school and practice). This design includes planning placement periods (which kind of placements can students take, how long are they, how do placement periods alternate with periods or days of classroom learning), agreed-upon assessment standards (what will students be assessed upon, how is a formative assessment designed, who is responsible for assessment), tools and aids that can enhance the learning process such as portfolios, reflection tools or mobile tools to refresh classroom knowledge in practice and teaching, and mentoring. Finally, the design includes social interactions that happen at the interface between school and practice, such as mentoring, teaching, or peer learning. It should be noted that the magnitude of the overlapping space (i.e., the extent of collaboration and interrelatedness between school and practice) can vary, and those shared design elements exist alongside design elements that belong exclusively to either the practice setting or the school setting. The effectiveness of these design elements in promoting learning depends on the conditions at both the school and practice settings. In the school setting, these conditions relate to the alignment of the curriculum and what students encounter in practice or the opportunity to connect the two. In the practice setting, these conditions relate to the opportunity to experience learning opportunities as well as the support to turn these opportunities into learning.

Finally, (outside the circles) these learning processes can lead to different types of outcomes: the development of clinical competence, of change agency skills (skills such as practicing evidence-based medicine or leadership skills which help critically analyze and eventually improve patient care), professional identity development, and (self-regulated) learning skills necessary for a life-long learning attitude. These outcomes feed forward into students’ future experiences.

5. Use of the Conceptual Model in Practice and Research: General Guidelines and an Example

The organization of school and practice learning within HPE can vary along many dimensions, such as placement duration and planning, supervising model, practice pedagogy, and the curriculum. This model does not prescribe the extent of integration of different learning contexts, nor does it provide a blueprint for the organization of learning at the interface between school and practice. Yet, the model can inform the design and redesign of this learning within different organizational models by pointing out the different factors that need to be addressed and aligned to optimally achieve the required objectives. Improvement of school-supported clinical learning using this model can start with a definition and operationalization of the desired learning outcomes, followed by an analysis of how school and practice can each contribute to these outcomes. Such analysis can result in a restructuring of the training program and the addition of shared design elements. For example, to improve clinical competence, mobile tools to refresh theory and simulation sessions to prepare for clinical practice can be designed [43,44]. Collaborative projects with school and practice representatives can be designed, through which students can develop change agency. Staff should be supported to offer students a basic level of safety. Extensive and detailed regulations that undermine staff engagement can be replaced by concise handouts. Using the model to design learning environments at the interface between school and practice may result in more efficient and accountable training programs that do not put unnecessary burdens on patient care.

One way in which the model can be used is to help achieve specific outcomes in contemporary clinical education. For example, one of the challenges in various disciplines is the application of evidence-based practice in the clinical setting in different undergraduate disciplines [45,46]. Based on the current model, an analysis, as well as an improvement plan can be designed. Analysis and redesign of the environment to reach this objective can start with an analysis of students’ capabilities and motivation to acquire evidence-based practice skills. Next, learning processes that may contribute to the development of evidence-based practice in the clinical setting can be described. These learning processes can be implicit (e.g., by applying healthcare protocols), reactive (by matching healthcare practice with current standards), or deliberate (by discussing best evidence in a peer group meeting). These processes should allow for choice (autonomy), match students’ competencies, and allow for relatedness with staff and/or peers. Next, the different design elements can be negotiated between school and practice (How can supervisors be empowered to help students with questions or concerns? When are students supposed to do this without disturbing their patient care duties? How can students consult the required resources, and who provides these?). The conditions in the model can help to refine the proposed design. Do enough clinical situations on the ward occur to elicit evidence-based practice? Does the ward climate allow for reflection and discussion? How do the suggested learning processes relate to assessment criteria around evidence-based practice? This example shows how acknowledging the role of both school and practice in the clinical learning environment can help optimize their respective contributions and think beyond the “transfer” from school knowledge to clinical practice [47].

Likewise, the model can be used to analyze and tackle challenges and issues in other fields within HPE that have been addressed in the literature, such as the reform towards EPA-based curricula in undergraduate medicine and nursing [48], the challenge to balance between strict regulations and flexibility in postgraduate medical education [6], the challenge to design education tracks in which continuity of learning is established, and the challenge to adequately prepare students for independent practice in nursing education [49].

In research, the model can inform problem analysis and study design in clinical HPE. The model will help adopt a broad view of the context in which clinical learning occurs. Questions that deserve further exploration include: How can self-regulated clinical learning best be understood and supported within the constraints of a curriculum? How can we prepare students to become tomorrow’s change agents in today’s healthcare system?

6. Critical Discussion of the Model and Directions for Future Research

Whereas the model is informed by previous literature and models can be instantly used to inform practice and research, the completeness of the entire model as well as its practical applicability, should be demonstrated in future research. Future work should reveal whether using the components of the model helps in analyzing or redesigning the learning environment and whether the categorization and descriptions are too broad or narrow to be of use within existing or newly developed school–practice collaborations. Although the model recognizes the cyclical nature of students’ learning processes (using the outcomes of one placement period as the starting point for the next period), future studies should reveal whether the model is suitable to analyze and redesign students’ journey across settings within the landscape of practice [35].

The model can be improved and refined through its application in different contexts and types of curricula. Specific training programs or phases of training might result in different types of learning outcomes and require different conditions. The model might be less applicable to organizational models in which school and practice are fully integrated, such as in apprenticeship models. Future studies should reveal the breadth of contexts this model can be used for.

A strength of this model is the inclusion of a typology of non-formal learning and the acknowledgement of intentional or unintentional influences of the school environment on clinical learning. It can be used to strengthen learning in different settings and disciplines. At the same time, this lack of specificity can be considered a limitation: for each context, criteria for ‘good practice’ have to be defined.

In line with sociocultural theories of learning [50], the model acknowledges how personal characteristics shape students’ experiences in the clinical learning environment. It outlines the importance of students’ basic psychological needs satisfaction as a predictor of intrinsic motivation, well-being, learning and development [42]. Future studies should reveal whether students’ characteristics and identity affect how school and the clinical setting contribute to their development.

7. Conclusions

To make HPE effective, efficient, and accountable to society, we must consider clinical learning processes within the context of their educational program. Whether intended or not: assessment standards, portfolios, reflection formats, etc., that are largely developed in the school context, do affect how students go about in practice settings, which learning opportunities they choose, how they make sense of them, and how their supervisors respond to them. In this article, we were able to highlight some opportunities and threats of school structures, tools, and support to optimize clinical learning and present a model to guide future studies and practices about the integration of school and practice learning.