Date Published: October 26, 2016
Publisher: Springer Netherlands
Author(s): Margaretha H. Sagasser, Anneke W. M. Kramer, Cornelia R. M. G. Fluit, Chris van Weel, Cees P. M. van der Vleuten.
Clinical workplaces offer postgraduate trainees a wealth of opportunities to learn from experience. To promote deliberate and meaningful learning self-regulated learning skills are foundational. We explored trainees’ learning activities related to patient encounters to better understand what aspects of self-regulated learning contribute to trainees’ development, and to explore supervisor’s role herein. We conducted a qualitative non-participant observational study in seven general practices. During two days we observed trainee’s patient encounters, daily debriefing sessions and educational meetings between trainee and supervisor and interviewed them separately afterwards. Data collection and analysis were iterative and inspired by a phenomenological approach. To organise data we used networks, time-ordered matrices and codebooks. Self-regulated learning supported trainees to increasingly perform independently. They engaged in self-regulated learning before, during and after encounters. Trainees’ activities depended on the type of medical problem presented and on patient, trainee and supervisor characteristics. Trainees used their sense of confidence to decide if they could manage the encounter alone or if they should consult their supervisor. They deliberately used feedback on their performance and engaged in reflection. Supervisors appeared vital in trainees’ learning by reassuring trainees, discussing experience, knowledge and professional issues, identifying possible unawareness of incompetence, assessing performance and securing patient safety. Self-confidence, reflection and feedback, and support from the supervisor are important aspects of self-regulated learning in practice. The results reflect how self-regulated learning and self-entrustment promote trainees’ increased participation in the workplace. Securing organized moments of interaction with supervisors is beneficial to trainees’ self-regulated learning.
In postgraduate education, trainees mainly practice medicine independently under supervision. Clinical practices offer trainees rich, authentic and varied situations, in which they can learn from experience (Dornan et al. 2007; Stok-Koch et al. 2007; Teunissen et al. 2007b; Watling et al. 2012; Yardley et al. 2012). To learn more consciously self-regulated learning (SRL) skills are important. There is ample literature on SRL, describing definitions, models and stages of SRL, and the cognitive and meta-cognitive processes, such as goal-setting, planning learning activities, self-assessment, and motivation that drive it (Artino and Jones 2013; Boekaerts 1997; Puustinen and Pulkkinen 2001; Sandars and Cleary 2011; Sitzmann and Ely 2011; Zimmerman 2000). A well-known definition comes from Zimmerman, who termed SRL as ‘self-generated thoughts, feelings, and actions that are planned and cyclically adapted to the attainment of personal goals’ (Zimmerman 2000). From a socio-cognitive perspective, an individual reflects on his/her behaviour in the environment and purposefully makes choices on what to do (Artino and Jones 2013; Puustinen and Pulkkinen 2001; Sandars and Cleary 2011; Zimmerman 2000). Self-assessment is important in SRL but error-prone and therefore in need of external calibration (Bjork et al. 2013; Brydges et al. 2010; Regehr and Eva 2006). Therefore supervisors have an essential role in the assessment of trainees. In this respect the literature describes informed self-assessment, facilitated reflection and directed self-guided learning (Brydges and Butler 2012; Brydges et al. 2010; Butler and Brydges 2013; Sargeant et al. 2008; Schumacher et al. 2013). Furthermore, supervisors can support trainees and encourage them to engage in learning activities and reflection (Boendermaker et al. 2000; Brydges et al. 2010; Kilminster et al. 2007; Mann et al. 2001; Sandars and Cleary 2011; Sutkin et al. 2008; Wearne et al. 2012).
We based our research on the epistemological assumption that multiple truths are constructed by and between people (Bergman et al. 2012; Carter and Little 2007). From this constructive perspective we designed a non-participant observational study. In non-participant observation the researcher is present as an observer but does not participate in the activities being observed (Angrosino 2007; Liu and Maitlis 2010). To focus on the meaning of the experience, we used a phenomenological approach to data analysis (Creswell 1998; Giorgi 2006).
Three researchers (MS, AK, CF) performed a qualitative analysis of the data, using a phenomenological analytic method (Angrosino 2007; Creswell 1998; Giorgi 2006). The method involved a search for themes and patterns and allowed for interpretations. The analysis consisted of independently reading and rereading, marking relevant text fragments, identifying and coding themes and patterns, and discussing these findings in the research team, which resulted in a description of findings. During the analysis, the researchers critically reflected on their differing backgrounds which brought various perspectives to the data, thereby promoting reflexivity and confirmability (Barry et al. 1999; Mays and Pope 2000; Tavakol and Sandars 2014). We iteratively collected and analysed the data, starting the analysis as soon as the first data became available, which technique bolstered dependability (Mays and Pope 2000; Tavakol and Sandars 2014). During the analysis MS kept a reflective diary, the review of which enhanced our understanding of observations. The analysis was an inductive process consisting of three consecutive phases (Fig. 1). First, we independently read and reread the data pertinent to the first three practices. During analytic sessions we discussed and searched for relevant themes. We developed time-ordered matrices describing per encounter trainees’ activities before, during and after the encounter, supervisors’ related activities, the related dialogue in the debriefing session, and supervisors’ and trainees’ accounts in their interviews (Miles et al. 2013). We searched for similarities and differences between the processes and for possible explanations. We also explored how educational meetings related to the encounters. We drew an initial concept map to bring this learning into focus (Miles et al. 2013). We developed an initial codebook for factors influencing this learning (Miles et al. 2013). Second, we analysed data from two more practices, and we verified whether the data could be organised by the concept map and the codebook. Continued interpretation resulted in refinement of the concept map and codebook. Finally, we analysed the data of the two remaining practices to ensure saturation. We carried out member checks by sending the preliminary results to trainees and supervisors, thereby enhancing credibility (Mays and Pope 2000; Tavakol and Sandars 2014).Fig. 1Analysis process
We collected data from November 2014 to March 2015. Seven supervisor-trainee pairs participated. Six supervisors were male and all trainees were female. Supervisors’ mean age was 53 years (range of 44–64) and trainees’ mean age was 29 years (range of 26–40). MS did not know the participants before. From the seven practices we included 112 patient encounters in total, varying from 5 to 40 min in length. Some encounters featured multiple symptoms or multiple patients. Five encounters could not be attended, since patients did not want the researcher to be present. Debriefing sessions lasted 26 min on average, educational meetings 41 min. Interviews with trainees took 45 min on average, those with supervisors 38 min. We will present the results by describing trainees’ activities related to patient encounters and trainees’ and supervisors’ interactions. Figures 2, 3 and 4 map out trainees’ activities before, during and after encounters respectively, and the data that informed these results. We observed that trainees managed most of the encounters independently, that they occasionally consulted their supervisors during the encounters, and that most of the encounters were discussed during debriefing sessions.Fig. 2Activities before the encounter. The right-hand column indicates from which sources the data were derivedFig. 3Activities during encounters that contribute to trainees’ learning. The right-hand column indicates from which sources the data were derivedFig. 4Activities after encounters that contribute to trainees’ learning. The right-hand column indicates from which sources the data were derived
Trainees’ self-regulated learning from patient encounters is a dynamic process. Trainees evaluate whether they know enough to manage the encounter and whether they feel confident enough to manage the encounter independently. They actively seek information, confirmation and feedback, engage in reflection and consciously decide whether to consult their supervisors. Supervisors have a key role in this process, as they foster learning by exchanging and discussing experiences, providing knowledge, reassuring, providing feedback and checking trainees’ knowledge and skills. Our results illustrate how trainees’ SRL contributes to their self-perceived growth of competence. In the following paragraph we will elucidate the role of confidence, reflection and feedback, and the supervisor, and discuss our results in view of socio-cultural learning theories and legitimate peripheral participation.