Examining the clinical learning environment through the architectural avenue

Abstract

Medical education has traditionally focused on the learners, the educators, and the curriculum, while tending to overlook the role of the designed environment. Experience indicates, however, that processes and outcomes of medical education are sensitive to the qualities and disposition of the spaces in which it occurs. This includes the clinical education within the patient care environment, termed the clinical learning environment (CLE). Recognition of this has informed the design of some new clinical learning spaces for the past decade. Competency-based clinical education can drive design requirements that differ materially from those associated with general purpose educational or clinical spaces. In this article, we outline two conceptual frameworks: (i) materialist spatiality and (ii) actor-network theory and consider how they can guide the design of spaces to support competency-based medical education and to guide the evaluation and discussion of the educational impacts of the spaces once built. We illustrate the use of these frameworks through discussion of the educational ambitions that underpinned the design of some recent clinical educational spaces. We close with practical points for consideration by educators and designers.

Introduction

Globally, medical education is moving towards competency-based frameworks for teaching and learning (Frank et al. 2010; Holmboe, 2018; Holmboe et al. 2018). Competency-based medical education (CBME) aims to reform the medical education curriculum in response to motivators such as the social accountability of medical training (Caverzagie et al. 2017), the transparency of requirements for medical expertise (Ten Cate and Hoff 2017), and the responsiveness of medical education to the diversity of medical teachers and learners (Ten Cate et al. 2018). The ambition of CBME to make learning outcomes more visible to learners, faculty, and stakeholders permits its ready translation to local and national standards for medical education. As a result, CBME provides the context for an expanded examination of medical education by researchers and the education community, which has focused on curricula, the assessment system (Lockyer et al. 2017 and Holmboe et al. 2018), and the context in which education is delivered, including the social, cultural, and physical environment that creates the context for learning (Gruppen et al. 2017).

The term “clinical learning environment” (CLE) is used to describe the “social interactions, organizational cultures and structures, and physical and virtual spaces that surround and shape participants’ experiences, perceptions and learning” (Larson 2018, p. 2). For the past decade, there has been an increased interest on architectural aspects of educational spaces, particularly those that serve as the CLE for the education of physicians and other health professionals (Nordquist et al. 2011; et al. 2013; Nordquist and Laing 2014; Nordquist 2016). Research in this area has focused on curriculum alignment issues of architecture and various conceptual models to understand different forms of space and its inter-connections with learning and clinical activities that occur in the architectural space (Nordquist and Laing 2015). Another theme in the work on the impact of the physical environment is the study of space and identity (placemaking) (Kitto et al. 2013; Hawick et al. 2016; Hawick et al. 2018). From a practical point of view, there is interest in having the design and construction of new clinical learning spaces explicitly take into consideration alignment, placemaking, and interconnections with the intent to optimize these spaces for the clinical and learning function. The comprehensive redevelopment of the learning landscape at the Karolinska Institutet in Sweden and the development of its new university hospital is one example (Nordquist and Fisher 2018). Other examples include the Royal College of Surgeons of Ireland’s new building in Dublin, the new buildings at the Duke University School of Medicine (both in the USA and in Singapore), Faculty of Medicine, Teheran University, Iran, and major redevelopments at Sydney Medical School, among others. Despite these noteworthy efforts, a gap remains in the literature related to the architectural attributes of the CLE from a theoretical perspective and to translate this into designs that optimize the physical attributes of the CLE to serve the multiple functions of clinical care, teaching and learning, and acquisition of new knowledge. This is a concurrent need to find frameworks that can guide the medical education community in developing new physical environments for care and learning and evaluate how well physical space enables intended learning with the paradigm of competence-based education (Ellis and Goodyear 2018; Mulcahy 2018). The overall aim of this perspective is to introduce two novel frameworks to deepen the medical education community’s understanding of how the physical environment may influence the clinical learning environment.

Table

Practice points

A tool kit for applying sociomateriality to the physical environment of clinical education Adopting a material sensibility. Following the actor. Using rich descriptions.

From architecture as a neutral backdrop to increased awareness of the complexity of space

Studies on the impact of technology and other material elements in health care and education often use one of three theoretic frameworks: social essentialism, technological determinism, and what is now termed sociomateriality (Timmermans and Berg 2003). Social essentialism, the most common approach, foregrounds human behavior over materials, placing humans at the center (with some criticisms of this as bracketing or neutralizing of non-human actors) (Fenwick and Edwards 2011). In diametric opposition, technological determinism focuses almost exclusively on technology or tools as underpinning social change or reconfiguration. Technological determinist work often explores technologies or tools that are morally or ethically charged. The third framework, sociomateriality seeks the middle ground between technological determinism and social essentialism, balancing human and non-human factors rather than relying on “human-centric” explanations of educational phenomena (Fenwick 2014).

Potential theoretical frameworks for understanding the role of physical environments in medical education

Researchers examining the role of physical environments in medical education are confronted by difficult choices between widely discussed and less well-known theoretical constructs. In this perspective, we concentrate on two theoretical frameworks: materialist spatiality and actor-network theory (ANT). We chose them as the most widely used and relevant to the discussion of the architectural and physical environment, and acknowledge the existence of other frameworks for exploring the impact of the physical environment on medical teaching and learning, including cultural-historical activity theory (Varpio et al. 2008; Ellaway 2014; Larsen et al. 2017), feminist materialism (Mol, 2002; 2008), complexity science (Fenwick 2009; Regehr 2010), and human factors engineering (Catchpole 2013; Carayon et al. 2014; Holden et al. 2015).

Framework 1: materialist spatiality

A framework concentrating on materialist spatiality in medical education draws insight from architecture, design, and pedagogy (Fenwick and Edwards 2011). Scholars in this area start from a materialist paradigm that focused on the orientation and organization of space and objects. Influenced by architectural design and learning theories, spatiality theories in medical education have primarily focused on the ways learning spaces and curricula can influence one another in productive and non-productive ways.

This focus on space and its physical properties has much to offer to designers of clinical education spaces. Functional design briefs are technical reports about space and are an established tool, which architects and designers use to characterize how their intentions for space will be used. Functional design briefs explore how many people a space should accommodate, whether they will sit or stand, what they will do, where they will come from, where will they go when they leave, and what facilities and functionalities they need to access. An effective functional design brief considers daily human interactions in relation to broader spatial networks like city infrastructure, architectural design, and local ecology (Nordquist et al. 2016).

At the same time, the design process for a physical environment cannot be a simple spreadsheet exercise of the numbers of individuals to be accommodated and the facilities required. Architects, designers, policymakers, engineers, and clinicians may have distinct suggestions for the size and position of furniture, the distribution of people and subgroups, how and whether learners at different levels or from different health professions will interact and whether these individuals will have shared workstations. A spatiality perspective argues that these decisions play a critical role in determining the nature of the educational experience within this space.

The designers of educational spaces in clinical environments also are confronted with an issue common to all educational spaces – the environment within the space itself can drive the educational process. The difficulties inherent in trying to promote educational activities based on small group work in large tiered lecture theaters are well known, as are the various architectural and pedagogical approaches to overcoming them (Nordquist et al. 2016; Nordquist and Watter 2017).

Clinical educational activities rarely, if ever, take place in spaces designed exclusively for an educational purpose. In most locations, patient rooms, nurses’ stations, outpatient clinics, and so on, the primary purpose is the delivery of appropriate, safe clinical care, which needs to take precedence. In addition, economic considerations may lead to educational spaces in clinical environments for which usage may at best, intermittent, or even rare, to be “value-engineered” out of the construction program, or to be re-purposed following construction. For example, even if constructed, tutorial spaces or educational small group rooms often end up being converted into offices, general meeting space or storerooms. Similarly, the consideration of how learners may comfortably join the care team in a patient’s room and then withdraw to a location to discuss the clinical and educational issues raised by the patient’s case, requires challenging discussions about the standard size of a room, the location of the bed and the proximity and nature of locations for confidential discussions. Thus, the proponent of education in clinical environments is confronted with the challenge of creating spaces that can be sustainably shared by both clinical and educational activities.

Meeting these challenges leads researchers and designers to move beyond a focus on spatiality, the architectural properties of space, for example, plans and 3 D reconstructions, to a consideration of how people behave in spaces and the impact of spaces on them. One framework that can assist in this consideration is actor-network theory.

Framework 2: actor-network theory

Actor-network theory (ANT) originated as a theoretical framework for understanding the sociology of science during the late 1970s. ANT has evolved into as a body of work leading educators and researchers to conduct their work from an ontology that de-centers humans (Fenwick and Edwards 2011). ANT researchers write rich narratives aiming to map heterogeneous assemblages. Imported from the work of French philosopher, Bruno Latour, the term assemblage has come to favor for describing how humans and non-human actors are mutually constitutive. Assemblage means both a collection and joinery; a group of parts and an intersection. Tracing assemblages is a core part of sociomaterial research of people and things. Like action research, ANT narratives seek to disrupt the conventional view on situations or settings by focusing equally on the social roles of people and things. Recent work in medical education has used actor-network theory to explore boundary objects in oncology rounds (Heldal 2010), simulation (Gormley and Fenwick 2016), distributed medical education (Macleod et al. 2015, 2017, 2018), and team collaboration (McDougall et al. 2016; 2018).

In the context of designing spaces that support clinical education activities, ANT offers a framework for analyzing the surprises that can emerge from the real-life use of even the most carefully designed and prototyped spaces. For example, the recent redevelopment of level 1 of the Westmead Education and Conference Centre (WECC) at Westmead Hospital in Sydney, included a small, highly structured space intended for clinical case discussions, the case-study theatre. It accommodates 36 people in two horseshoe-shaped tiers, positioned to minimize the difference in eye level between “audience” and session facilitators. The benches on the tiers are split into groups of three, in order to promote group work and to give easy ingress and egress to any called out of the session or who join it late. White boards are mounted around the space to promote group work. Once opened, the space proved to be highly popular, particularly for the case study sessions and multi-disciplinary team meetings that it was intended to support. Interestingly, there has been an increasing use of the space by clinical groups using the whiteboards to workshop ideas. Whiteboards are plentiful in the WECC and the center includes flexible flat floor spaces that would appear a more appropriate setting to workshop ideas, yet there is a strong apparent preference for the more structured space.

Another example of unexpected use of a carefully briefed and prototyped educational space is provided by the X-Lab in the Charles Perkins Centre at the University of Sydney. X-Lab is a wet biomedical teaching laboratory. It has a capacity of 240 students who can be in up to 8 different classes simultaneously, with the size of class being flexible between 8 and 240. Each workstation has a large screen which students can use to follow a presentation by the person leading the class, read the practical notes, or run and monitor their experiments and many students use the monitor for all of these tasks simultaneously. In the design of the X-Lab, it was thought that the natural grouping for group work would be along the bench (the equipment largely blocks sight lines across the bench). In reality, it turned out that the most natural groupings were forming between benches across the aisle.

A tool kit for applying sociomateriality to the physical environment of clinical education

Educational designers and researchers working with sociomateriality have described three techniques to bring human and non-human actors more into balance: adopting a material sensibility, following the actor, and using rich description.

Adopting a material sensibility

A material sensibility privileges descriptions of assemblages over social explanations. Sociomateriality eschews descriptions of phenomena that describe the influence of social forces like systems, institutions, power, markets, beliefs, or discourse. While there are time-honored approaches to research that rely on social forces to explain worldly action and human behavior, a material sensibility challenges researchers to articulate the composition of those forces through in-depth observation and description.

A material sensibility focuses if any phenomenon is complete when it reassembles the social (Latour 2005) into relevant, traceable assemblages of human and non-human actors. A recent study of Objective Structured Clinical Examinations (OSCEs) demonstrated how a material sensibility provides novel insights on this ubiquitous part of medical education (Bearman and Ajjawi, 2018). The authors situated this study as filling in the extensive research on the OSCE using a “humancentric” approach such as psychometric or competency discourses of assessment by extending their focus to include social relationships and physical objects. In their ANT-informed narrative, the paper proposes several insights into the OSCE: (1) that the OSCE as a holistic combination of people and objects, (2) that documentation such as checklists exert influence over an OSCE process and progress; and (3) that sociomaterial inquiry calls into question the primacy of standardization in OSCE training (Bearman and Ajjawi 2018).

Following the actor

Negotiating which actors to follow is a central tension faced in every sociomaterial study. What remains more important than the actor being studied is that researchers do not presume to know which materials powerfully influence social values nor do they presume that only the most exciting or novel materials are worthy of study. Sociomateriality tells researchers to “follow the actor”; this requires leaving behind a technology or object that they personally find compelling if it does not strongly feature in the data. To cite an example from surgical education, an ethnography of surgical fluid management techniques in neurosurgery traced the impact of fluids, measurement devices, and surgical tools to assess how these components affected the negotiation and interpretation of how patients defined themselves (Moreira 2004).

Using rich descriptions

Instead of explanations that rely on “social ideas”, the third analytic consideration for sociomateriality is its use of rich descriptions. While the term “rich description” originates in ethnography, it has a place in sociomateriality as a method reflective of modesty and openness. This work requires researchers to write reflective memos that pay close attention to how labels, signs, notes, slides, posters, blueprints, charts, articles, white papers, policy briefs, and objects—like assessment forms— provided descriptions of assemblages. Following Latour (2005) and Mol (2002), sociomaterial research also looks at how objects transfer knowledge and disseminate networks by way of interviews with people.

Originating in anthropology, sociomateriality roots are in the ethnographic tradition characteristic of anthropology and the later ethnomethodological tradition of sociology. Ethnography was the approach used by the classic anthropologists who traveled to remote cultural communities in order to understand other cultures and our own, for example, Margaret Mead’s Coming of Age in Samoa (Mead 1928). Ethnomethodology uses ethnographic methods, but instead of applying these methods in remote locations, it applies them to “everyday” settings. It describes the local practices of groups and organizations using a combination of interview methods and informal, incidental observations.

Importantly, like the other materials in a study, interviews are tools and networks. They can be seen as translations in a chain of activities that compose the research process. They did not begin as text documents and they did not end there. Instead, they represent artifacts of numerous activities in which I was directly engaged and where various materials influenced the study (Table 1)

Table 1. A tool kit for applying sociomateriality.

Technique	Definition	Research advice
Following the actor	Mapping assemblages requires paying close attention to actors. Sociomaterial explorations observe both human and nonhuman actors in order to map assemblages.	Closely observe a place and watch for sites of data collection or analysis.
		These sites of translation can often give voice to the nonhuman actors who do not speak for themselves (e.g. a microscope in a pathology laboratory).
		Do not resist the pull to change actors under observation.
		Watch how actors work together to create and modify knowledge and matter.
Avoiding social explanations	Sociomateriality encourages researchers to describe assemblages and action rather than the influences of systems, institutions, power, markets, beliefs, or discourse.	Pay attention for descriptions of activity that rely on markets, systems, or power. These descriptions often signal the presence of fascinating sociomaterial assemblages.
Using rich description	Sharing roots with the field of ethnomethodology, sociomaterialism involves writing and reflecting on rich narratives describing worldly action with an eye towards the interaction of people and things.	Write of reflective memos that pay close attention to how labels, signs, notes, slides, posters, blueprints, charts, articles, white papers, policy briefs, and objects—like assessment forms— provide descriptions of assemblages

Conclusion

The medical education community is moving away from social essentialism that simply sees the physical space as a neutral backdrop without any significant impact on human behavior or learning, to a stage where educators around the world are becoming more aware that physical space matters. At the same time, we only have a limited understanding of how space actually impacts learning. The two frameworks presented in this perspective (materialist spatiality and actor networked theory (ANT)) offer different lenses for thinking about the physical spaces that will optimize learning and other key activities in the CLE. Space is not neutral; at the same time, architecture is not deterministic in a causal way. We suggest and offer here – provided some empirical examples from Karolinska Intitutet, University of Sydney and the Royal College of Surgeons of Ireland – two models that might increase our understanding further and help us design physical space better in the future properly aligned with curricula, taking placemaking into account.

There is a need to better understand how physical spaces affect impact learning, as well as patient care. This will benefit from new theoretical perspectives to guide our thinking to ask relevant questions in the formulating research in this area, as well as in the design and construction of physical spaces.

Glossary

Heterogeneous assemblages: Imported from the work of French philosopher Bruno Latour, the term assemblage has come to favor for describing how humans and non-human actors are mutually constitutive. Assemblage means both a collection and a joinery; a group of parts and an intersection. Tracing assemblages is a core part of sociomaterial research of people and things.

Disclosure statement

The authors report no conflicts of interest. The authors alone are responsible for the content and writing of the article

Additional information

Notes on contributors

Jonas Nordquist

Jonas Nordquist, PhD, is working at the Department of Medicine (Huddinge), Karolinska Institutet, Sweden and Department of Research and Education, Karolinska University Hospital, Sweden.

Ming-Ka Chan

Ming-Ka Chan, MD, MHPE, FRCPC is working at the Department of Paediatrics, University of Manitoba, Canada.

Jerry Maniate

Jerry Maniate is working at the, MD, FRCPC Department of Medicine and Department of Innovation in Medical Education, University of Ottawa, Canada. He is also the Vice President of Education, The Ottawa Hospital, Canada.

David Cook

David Cook, MD, PhD is working at the Sydney Medical School, University Sydney, Australia.

Cathal Kelly

Cathal Kelly, MCh, BSc, FRCSI, eMBA, C. Dir. is working at the Royal College of Surgeons of Ireland, Ireland.

Allan McDougall

Allan McDougall, MA, PhD is working at the Faculty of Education, University of Ottawa, Canada.