https://orcid.org/0000-0001-6308-0974
ABSTRACT
Introduction
Each clinical learning environment (CLE) requires learners to navigate a different set of complex interactions to engage in safe patient care while learning from real patients. Orientation forms the foundation for learning, yet CLE models in the literature are primarily written for an educator audience and practical advice for orienting learners to a new CLE is limited. To address this gap, we designed resources to support both supervisors and learners in the orientation process.
Materials/Methods
We reviewed the CLE literature to select critical content for orientation and interviewed high performing residents to identify their best practices. We synthesized the literature and resident interviews into a visually appealing and easy to digest infographic designed to simultaneously remind teachers of the critical areas to cover in orientation and empower learners to ask about them. We integrated these principles into an online module for Graduate Medical Education onboarding and surveyed users about how well they could meet the module learning objectives.
Results
We organized the literature review and resident advice regarding questions learners should ask about a new CLE into the typical question categories (why, who, what, when, where, and how) and described strategies for orientation to each category. Our infographic has been incorporated into CLE orientation for multiple types of learners at our institution. After completing the orientation module, 112/124(90%) residents indicated that they could, ‘Orient yourself or a learner to a clinical learning environment using orientation questions’ moderately to extremely well.
Discussion
We developed resources that can be used by educators to create orientation materials and by learners to ensure they understand important features, resources, and expectations in a new CLE. Because the foundational principles of CLE apply to a variety of clinical settings and learner types, the resources may be broadly applicable.
Introduction
To safely and constructively engage in a clinical learning environment (CLE), health professions learners navigate complex interactions between patient care, learning from real patients, and practice improvement [Citation1]. In contrast to the classroom, learning within the CLE is more opportunistic and dependent on the setting, patients, supervisors, and leaner needs [Citation2]. The variability of CLEs challenges clinical learners to recurrently acculturate to new roles, relationships, expectations, and processes [Citation3].
The evolving CLE conceptual frameworks acknowledge the complexity and inter-relatedness of CLE components [Citation2,Citation4,Citation5]. The CLE literature, primarily targeted toward educators, may have limited practical utility for learners, and only a few studies superficially mention orientation concepts [Citation6,Citation7]. To address this gap, we developed resources to help supervisors guide CLE orientation and learners to understand important CLE components and elicit further orientation information.
Materials/methods
We convened a development team representing multiple clinical disciplines, professional backgrounds, and experience educating medical students and postgraduate physician trainees. We searched the literature for articles characterizing the CLE and selected those that could inform learner orientation. To organize the content in a learner-centered format, we translated each component of the selected CLE models into a question that a learner might ask their supervisor as they acclimate to a new CLE which we will call ‘orientation questions.’ Using directed qualitative content analysis, we categorized the CLE components according to the typical question types (who, what, when, where, why, and how) and summarized each category.
Following exemption from review by Dartmouth Committee for Protection of Human Subjects, we interviewed 9 first and second year residents (3 General Surgery, 3 Internal Medicine, 1 Radiology, 1 Urology, and 1 Pediatrics), who were identified by their programs as ‘high-performing.’ A resident peer (EC) used a structured interview guide to ask residents about how they orient themselves and others to a new CLE. We recorded and transcribed the interviews, identified concepts that should be added to our list of questions, and summarized the resident advice.
We used the orientation questions to create an infographic that captures critical CLE orientation topics in an easy to understand and visually appealing format applicable to a variety of clinical settings (clinic, emergency room, inpatient unit, and operating room). We embedded the resources into an online module for Graduate Medical Education (GME) onboarding, which was approved by the GME curriculum committee. Residents evaluated how well the module met the learning objectives on a 5-point Likert scale (not at all to extremely).
Results
A PubMed search for (‘clinical learning environment’ OR ‘workplace learning’) AND ‘medical education,’ yielded 430 articles about humans and in English. We reviewed titles and abstracts for relevance, which yielded 48 articles from which we identified 13 articles with models to describe the CLE. The selected studies included learner perspectives [Citation6-10], clinical observation[Citation11], literature review [Citation1,Citation12,Citation13], and expert consensus [Citation2,Citation14-16].
All interviewees reported that their first step to prepare for a new CLE was to talk to a resident who completed the rotation previously, including asking ‘what’ their responsibilities are, ‘where’ to find resources, ‘when’ things happen, ‘how’ to complete tasks and ‘who’ to ask for help. Interestingly, the majority of residents stated ‘attending preference’ was critical to learn prior to starting a new rotation, yet this feature was not identified in the CLE models in our literature review.
Residents provided the following advice for learners starting a new CLE.
Talk with residents who have completed the rotation previously
Read orientation materials
Learn about attending preferences
Review skills for common procedures
Arrive early on the first day
Develop a system or routine
Make a to-do list
Take responsibility for patient care
Ask for help when you don’t know something
A description of the question categories derived from our literature review and advice from resident interviews are summarized in , with suggestions for addressing the questions in orientation.
Table 1. Question themes and strategies to guide orientation
The infographic (supplement 1) has been used by attending, fellow, resident, nurse practitioner, and medical assistant supervisors to structure orientation or improve orientation practices and by our medical school to prepare students for the transition to clerkships. Supplement 2 summarizes suggested uses of the infographic.
Following the onboarding module, 112/124(90%) residents indicated that they could, ‘Orient yourself or a learner to a clinical learning environment using orientation questions’ moderately to extremely well.
Discussion
Educational leaders and clinical supervisors can structure orientation for learners transitioning to a new CLE using the resources we designed, which are grounded in the literature and the expertise of our GME community. The topics covered in these resources align with the limited literature about orientation [Citation6,Citation7] and existing CLE frameworks [Citation2,Citation4,Citation5,Citation17]. A simple, visually appealing guide that reminds supervisors and learners of important orientation topics may support a comprehensive orientation, particularly when time is limited. The foundational principles of CLE orientation are transferable, and we designed the resources to be used across a range of clinical settings and learner types.
Supplemental Material
Download Zip (1.2 MB)Acknowledgments
The authors thank Cara DeLura, Logan Stahler, James McCarthy, the DHMC Graduate Medical Education Curriculum Committee, and Greg Ogrinc for contributions to the development of the infographic.
Disclosure statement
No potential conflict of interest was reported by the author(s).
Supplementary material
Supplemental data for this article can be accessed here.
Additional information
Funding
References
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