In the eye of the beholder: student perspectives on professional roles in practice Deirdre Bennett, 1 Marian McCarthy, 2 Siun O’Flynn 1 & Martina Kelly 1 CONTEXT Learning about professional roles in clinical settings is confounded by the gap between espoused theory and the professional practice of the workplace. Workplace learning is grounded in that which is afforded to learn- ers and individuals’ engagement with those af- fordances. The meaning students make of the real-world performance of professional roles and how this relates to formal professionalism frameworks remain unclear. Construal of experience is individual. Professional roles are enacted in the eye of the beholder. In their reflections, student subjectivities, intentional- ities and engagement with workplace affor- dances are revealed. Our research question was: How do students’ perspectives of professional roles in practice, revealed through written reflections, relate to the formal professionalism curriculum? METHODS Year 3 students (n = 108) wrote reflections during hospital and community placements. Thematic content analysis was performed. A priori categories based on the CanMEDS Physician Roles Framework were used to map content. RESULTS A total of 107 students consented to the use of their reflections (n = 315). The CanMEDS roles of Communicator, Professional and Scholar predominated. Students were seen applying prior knowledge to new situations and reflecting on them. For some, the confirmation of previous learning was the outcome; for others, the mismatch between practice and the formal curriculum led to the questioning of both. The roles of Manager, Collaborator and Health Advocate were less frequently reflected upon. Differences between the affordances of hospital and community placements were seen. Means to address findings are discussed with reference to Billett’s duality of workplace learning. CONCLUSIONS Reflective narratives reveal how students construe professional roles in practice. Mapping the content of reflections to a competency framework confirmed the mismatch between the formal and enacted curricula. Bil- lett’s duality of workplace learning provides a useful lens through which to identify means to address this, through the structural aspects of access and guidance, and through the promo- tion of individual engagement and reflection. professional roles Medical Education 2013: 47: 397–407 doi:10.1111/medu.12114 1 Medical Education Unit, School of Medicine, University College Cork, Cork, Ireland 2 Ionad Barra Centre for Teaching and Learning, University College Cork, Cork, Ireland Correspondence: Dr Deirdre Bennett, Medical Education Unit, School of Medicine, Brookfield Health Sciences Complex, University College Cork, College Road, Cork, Ireland. Tel: 00 353 21 490 1591; E-mail: [email protected]ª Blackwell Publishing Ltd 2013. MEDICAL EDUCATION 2013; 47: 397–407 397
Transcript
In the eye of the beholder: student perspectives onprofessional roles in practiceDeirdre Bennett,1 Marian McCarthy,2 Siun O’Flynn1 & Martina Kelly1
CONTEXT Learning about professional rolesin clinical settings is confounded by the gapbetween espoused theory and the professionalpractice of the workplace. Workplace learningis grounded in that which is afforded to learn-ers and individuals’ engagement with those af-fordances. The meaning students make of thereal-world performance of professional rolesand how this relates to formal professionalismframeworks remain unclear. Construal ofexperience is individual. Professional roles areenacted in the eye of the beholder. In theirreflections, student subjectivities, intentional-ities and engagement with workplace affor-dances are revealed. Our research question was:How do students’ perspectives of professionalroles in practice, revealed through writtenreflections, relate to the formal professionalismcurriculum?
METHODS Year 3 students (n = 108) wrotereflections during hospital and communityplacements. Thematic content analysis wasperformed. A priori categories based on theCanMEDS Physician Roles Framework wereused to map content.
RESULTS A total of 107 students consented tothe use of their reflections (n = 315). TheCanMEDS roles of Communicator, Professionaland Scholar predominated. Students were seenapplying prior knowledge to new situations andreflecting on them. For some, the confirmationof previous learning was the outcome; for others,the mismatch between practice and the formalcurriculum led to the questioning of both. Theroles of Manager, Collaborator and HealthAdvocate were less frequently reflected upon.Differences between the affordances of hospitaland community placements were seen. Means toaddress findings are discussed with reference toBillett’s duality of workplace learning.
CONCLUSIONS Reflective narratives revealhow students construe professional roles inpractice. Mapping the content of reflections to acompetency framework confirmed the mismatchbetween the formal and enacted curricula. Bil-lett’s duality of workplace learning provides auseful lens through which to identify means toaddress this, through the structural aspects ofaccess and guidance, and through the promo-tion of individual engagement and reflection.
professional roles
Medical Education 2013: 47: 397–407doi:10.1111/medu.12114
1Medical Education Unit, School of Medicine, University CollegeCork, Cork, Ireland2Ionad Barra Centre for Teaching and Learning, University CollegeCork, Cork, Ireland
Correspondence: Dr Deirdre Bennett, Medical Education Unit,School of Medicine, Brookfield Health Sciences Complex,University College Cork, College Road, Cork, Ireland.Tel: 00 353 21 490 1591;E-mail: [email protected]
Professionalism is a key element in the undergradu-ate medical curriculum1 and accrediting bodiesrequire that we teach and assess our students in thisdomain.2 The definition of professionalism hasproved challenging. Although frameworks have beendeveloped,3–5 static aspirational statements seemremote from the dynamic and contextual nature ofprofessional practice. Nonetheless, such frameworksare used to guide curriculum design and competency-based assessment.6
For the purposes of this paper, we take a broadperspective on the meaning of professionalism and usethe CanMEDS (Canadian Medical Education Direc-tives for Specialists) Physician Roles Framework3 as areference point. This framework, produced by theRoyal College of Physicians and Surgeons of Canada,describes seven professional roles of the doctor,including those of Medical Expert, Communicator,Collaborator, Manager, Health Advocate, Scholar andProfessional. Each of these roles is defined by compe-tencies extending across the individual, interpersonaland societal dimensions of professionalism, describedin the Ottawa Consensus Statement on the assessmentof professionalism.7 When we refer to learning medicalprofessionalism, we mean learning how to ‘be a doctor’across this full breadth of professional practice.
Students learn most about professionalism in theclinical practice setting. From a socio-culturalperspective, learning to ‘be a doctor’ requires theappropriation and remaking of the socio-culturalnorms and practices of the medical workplace, ratherthan simply the enactment of theoretical knowledgegained elsewhere.8 There is a gap between espousedtheory and the professional practice of the work-place.9,10 The conflicts between negative aspects of thehidden curriculum, the tacit and systematic influenceof the social structure, and the formal ideals ofprofessionalism, are much emphasised.11–14 However,formal standards may also fail to transfer to thecomplexity of the ‘swampy lowlands’ of authenticpractice.15 Therefore, there is a mismatch between theformal and enacted curricula. The meanings studentsmake of the real-world performance of professionalroles and how these relate to formal professionalismframeworks remain unclear. Reconceptualist curricu-lar studies, such as that described here, focus onendeavours to understand and address this issue.16
The work of Billet17–19 provides a lens throughwhich to examine how students construct profes-
sional roles in authentic settings. Building a theo-retical bridge between the acquisition andparticipation metaphors for learning,20 Billet takesaccount of both cognitive and socio-cultural per-spectives. He describes workplace learning as arisingfrom a relational interdependence between thesocial structure of the workplace and the aspectscontributed by the individual learner.18 It is basedon the duality of what is afforded to learners by theworkplace and individuals’ engagement with thoseaffordances. Although clinical rotations are the coremeans by which students are expected to learnabout professionalism, the workplace environmentmay not consistently support the achievement ofcompetencies.21 Billet’s pedagogy of workplacelearning has contributed to understanding of learn-ing in the postgraduate medical educational envi-ronment22 and how it might be optimised.23
Reflection is central to workplace learning. Throughreflection learners make meaning of experience inlight of prior understandings, which over time may betransformative.24 Students make meaning of boththeir own participation in the clinical setting andtheir observation of the artistry of experts.25 Theanalysis of student reflections provides powerfulinsights into the enacted curriculum from thestudent perspective.26–28 Construal of experience isindividual.17 Professional roles are enacted in the eyeof the beholder. In their reflections, student subjec-tivities, intentionalities and engagement with work-place affordances are revealed. Subjectivity refers toindividual interpretations of experiences, and cogni-tive, emotional and spiritual perceptions and mi-sperceptions, whereas intentionality refers to themanner in which individuals construct representa-tions of experience.
The central research question for this study was: Howdo students’ perspectives of professional roles inpractice, as revealed in their written reflections, relateto the formal professionalism curriculum?
METHODS
This study was conducted in Year 3 students(n = 108) in an undergraduate programme, on theirfirst full-time clinical placements in the academic year2008 ⁄ 2009. Students rotate through two hospitalplacements and one community placement, each ofwhich is 4 weeks in duration. The placements areacross six hospital and 54 general practitioner (GP)practices. The school accepts mature-entry studentsand comprises a mix of students entering directly
from school (Irish and Malaysian students) andpostgraduate students (Irish and Canadian ⁄ Americanstudents).
Students are introduced to reflective practice inYear 1. In Year 3, students are asked to record a‘parallel chart’29 at the end of each rotation. Thiscomprises a written reflection on a subject that thestudent feels is relevant to the patient’s care, butwhich does not constitute part of the traditionalmedical record. Students are given guidance on levelsof reflection30 and are shown exemplars from previ-ous students’ work. The reflections are discussed atthe end of each clinical attachment in a small-groupsession with peers, facilitated by a tutor.31 There is nomark for the reflections, which are submitted withinportfolios.
Students are introduced to the domains of profes-sional practice from the outset of their training.Our school uses the CanMEDS Framework,3 inconjunction with the Irish Medical Council’s EightDomains of Professional Practice,5 for curricularblueprinting. CanMEDS has been recommendedfor use as a guide for curriculum planning3 and hasbeen used to redevelop postgraduate curricula inthe Netherlands6 and Denmark.32 We thereforechose to use the CanMEDS Physician Role Frame-work to represent the formal curriculum in thisstudy.
Ethical approval was granted by Clinical ResearchEthics Committee of the Cork Teaching Hospitals.Students were asked to consent to the use of theiranonymised written reflections for researchpurposes. One student who declined to giveconsent was not included in the study. A smallminority of students (n = 6) did not return areflective piece on an individual attachment. Thetotal number of reflections examined was 315,from 107 students.
Reflections were imported into NVivo Version 9.0(QSR International Pty Ltd, Doncaster, Vic, Austra-lia) and a thematic content analysis33 was performedby two independent coders (DB and MK). Both DBand MK are medical doctors and are qualified ineducation. Both are senior lecturers within themedical school and are well known to students.Following their preliminary independent analyses,DB and MK met to discuss initial coding and refinedefinitions. As data analysis progressed, theresearchers met to compare emerging issues, resolvediscrepancies and categorise codes into largerthemes. MM is an educationalist who independently
reviewed data and contested themes. Although datasaturation was reached prior to finishing coding, allreflective pieces were coded in order to ensure thatno codes were missed and that the results reportedaccurately represented the proportions in whicheach code was present across the student cohort. Upto this point in the analysis, coding was open andgrounded in the data. The units of text coded variedfrom a single sentence to a paragraph. The codeswere then mapped to a priori categories based on theseven roles defined by the CanMEDS Physician RolesFramework.3 The codes were checked against theelements, key competencies and enabling compe-tencies of each of the CanMEDS roles. It is recog-nised within the CanMEDS model that there isoverlap between certain of the roles; in suchinstances, codes were mapped to both roles. Thefrequency with which each of the CanMEDS roleswas reflected upon was calculated. Table 1 illustratesthis process for the Communicator role.
Data analysis was not started until after the end of theacademic year in order to ensure that the researchwould have no impact on the authors’ interactionswith the students. Analysis was lengthy and by thetime it was completed, the opportunity to presentfindings directly to the students had passed. Themeswere triangulated with topic lists recorded by facili-tators contemporaneously following each reflectivesmall-group session and findings were presented tothe facilitator group.
Research that uses student reflective narrativesraises significant ethical issues.34,35 Such narrativesmay include material that refers to students’emotional distress and the unprofessionalbehaviour of faculty staff. Failure to respond to oract upon student narratives may feel uncomfort-able for the researcher, particularly when he or shealso has a role as a faculty member with responsi-bility for the well-being of students. In this instance,the reflective narratives are part of the corecurriculum and the facilitated reflective groupsessions served as a safety net to support students inthis process.
RESULTS
A total of 315 reflections from 107 students wereanalysed. The gender ratio within the student groupwas 58 : 49 female : male. The mean age of thecohort was 22.9 years (range: 19–35 years). Fifty-ninestudents were Irish, 18 were of Canadian or US originand 30 were Asian.
The initial round of coding generated 78 codesreferring to the subject matter of the reflections. Atotal of 828 references were coded, ranging from asingle sentence to a paragraph. A small number ofunits were double-coded. Each reflection yielded amedian of four codes (interquartile range: 3.5).There were no codes which could not be mapped to aCanMEDS role. Figure 1 illustrates the relative fre-quencies of representation of the CANMEDS roleswithin student reflections.
The role of Communicator was that most frequentlyreflected upon (40%), followed by the roles ofProfessional (29%) and Scholar (15%). The rolesof Manager (7%), Collaborator (4%) and HealthAdvocate (1%) were reflected upon far lessfrequently.
Exemplars of the student perspective in relation toeach CanMEDS role are presented below with thematching CanMEDS competency.
Table 1 Mapping of open codes to competencies of the Communicator role in the CanMEDS Physician Roles Framework3 (total referencescoded, n = 828)
‘Physicians are able to… Demonstrate insight intotheir own limitations of expertise via self-assess-ment.’3
‘I felt bad that I could not tell her anything. She beganto probe me and then became concerned that I wasn’tgiving her information because the diagnosis was soserious that only a consultant could relay the infor-mation. I explained to her my role as a student as bestI could and reassured her that the team would beavailable to see her shortly and explain everything toher. This was an uncomfortable situation for both thepatient and I. I began to think that maybe I could havejust told her what the situation was and avoided a lot ofconfusion. But is this far beyond the role of themedical student?’(Female, 21 years, hospital setting)
This student understands that her role and compe-tence are limited, but when she applies this formallearning in a real-life situation she finds herselfacutely uncomfortable and vulnerable to the patient’sprobing and misinterpretation. She feels the inade-quacy of her response to the patient, explaining herrole ‘as best I could’. This unexpected outcome ofapplying professional rules leaves her questioning thereal-world practicality of the limits of her role. Thestudent seems to address her teachers with thequestion: ‘Why have you told me to follow these ruleswhich don’t work in practice?’
This student’s reflection highlights the necessity forspace within the curriculum for students to discussand debate professionalism issues with senior practi-tioners. Clinical teachers can validate the ideals of theformal curriculum while exploring the complexitiesof their application with students.
Communicator
‘Physicians are able to… Establish positive therapeu-tic relationships with patients and their families thatare characterised by understanding, trust, respect,honesty and empathy.’3
‘It was the first time I’d seen a consultant addressingfamily members. It was good to see the way shehandled it, the way she reassured the family, and usedterminology they could understand. The encounterstarted off with the family anxious and worried, andthe doctor did a lot to alleviate their fears.’(Female,22 years, hospital setting)
‘The patient was also worried about taking themedication which had been prescribed for her. TheGP said he believed that they could do more harmthan good and gently suggested that she might dowithout them and keep talking to her family when shefelt upset. This brought great relief to the patient. Itstruck me how through simply being an active listenerand offering full support to a patient in a difficult timethat the patient left the GP surgery a lot less anxiouswith a plan of action to deal with her emotions andwas able to leave her tablets behind her on the GP’sdesk.’(Male, 21 years, community setting)
Both students here can name the components ofbeing a good communicator. Their prior knowledgeof the theory of communication skills means theyrecognise the use of these skills as an importantaspect of being a medical professional. They dissectthe artistry of good communication as performed byexperts and relate it to positive outcomes for thepatient or family, confirming their prior under-standings.
Collaborator
‘Physicians are able to… Effectively work with otherhealth professionals to prevent, negotiate, andresolve interprofessional conflict.’3
‘I am not trying to say that a doctor is always right …nurses have much more personal contact with thepatients and are in a better position to know how thepatient is feeling and behaving. However, when… the
Figure 1 Relative frequencies of representations of theCanMEDS roles in student reflections (n = 315)
physician has made a thought-out decision, based on factand expert opinion, the nurse should respect this decisionand appreciate that the doctor’s knowledge base is farmore extensive than their own and accept that thedoctor is likely right…’(Male, 21 years, hospitalsetting)
This student brings his beliefs about the certainty andsuperiority of medical knowledge and experts to thisinterprofessional encounter. He knows that inter-professional teamwork is a ‘good’ thing and makes atoken effort to see both sides by referring to theunique role of the nurse. However, knowledge thatteamwork is part of the repertoire of a medicalprofessional is not sufficient to counteract his pre-existing beliefs. He strongly aligns himself with theposition of the doctor and the idea that doctor viewsshould be respected and accepted. He does notconsider that the doctor might negotiate or commu-nicate more effectively to resolve conflicting opin-ions. It would appear that this episode has served toconfirm his beliefs. The voice of the doctor is notheard directly; it is possible that the student simplyobserved a situation and interpreted it in light of hisexisting beliefs. However, it may be that the doctor inthis scenario has modelled negative attitudes tointerprofessional working which have been appro-priated by the student.
A contrasting view was seen in community settings,which afforded positive examples of interprofessionalworking:
‘Practice nurse[s] in [the] GP setting are an inter-esting, professional group … very much like doctor[s]… highly skilled, competent and well respected … haveadditional skills in the management of particulardisease[s] such as asthma… This makes me think that[the] nurse is really vital in or I can say [the] backbonein a health care team.’(Female, 22 years, communitysetting)
Manager
‘Physicians are able to… Allocate finite health careresources appropriately.’3
‘I could not understand how a patient may be left sittingin hospital unnecessarily for 3 weeks with nowhere togo. The fact that this happens makes me question thehealth care system and its efficacy. I would like to thinkthat when I am 80 years of age after paying my taxesall my life and if I needed care, there would besomewhere for me to go besides a hospital ward.’(Female, 21 years, hospital setting)
This student has observed how the application of theprinciple of primacy of patient welfare is confoundedby the reality of health care rationing. The ‘system’has failed a patient, who has a right to be cared for.The student puts herself in the place of the patient –‘when I am 80’ – rather than considering the role ofthe doctor within the ‘system’. It is unclear whethershe is aware that doctors may be managers of healthcare resources.
Health advocate
‘Physicians are able to… Identify vulnerable ormarginalised populations within those served andrespond appropriately.’3
‘The impact of patients’ economic status and thedoctor’s role in ensuring they get the best possible care,is an area I was exposed to over this attachment whichI would have previously been virtually oblivious to …many of the patients in the GP practice had been‘‘laid off’’ … the doctor sympathised with them andadvised them to apply for medical cards [entitlement tomeans-tested free medical care]. This was importantto do as it ensured they would not jeopardise their healthcare due to an inability to pay the doctor’s fee. Theseare real considerations which a GP [is] most likely toencounter and it was an eye-opening experi-ence.’(Male, 22 years, community setting)
This student had no prior understanding of thisaspect of a doctor’s role; however, he has observedand recognised the importance of this real-worldactivity. This knowledge appears to have been easilyaccessed, without specific guidance, and is congruentwith his understanding that patients should be giventhe ‘best possible care’. Examples of health advocacywere identified exclusively in the community setting,highlighting the differences between hospital andcommunity workplace affordances.
Scholar
‘Physicians are able to… Recognise and reflectlearning issues in practice.’3
‘No-one in the hospital was keeping tabs on you, if youcame in, great, if you didn’t then that was your loss.When you did come in, if you wanted to learn andtake histories you could, equally if you wanted tospend all morning in the canteen that was yourprerogative. I did try and find the right balance and go toas many ward rounds, out-patient clinics and tutorials.But when no-one is on my back, I get lazy. Sometimes Ipreferred to go home early and study. So this month
taught me to take responsibility for myself. Even when Iknew that it would be more beneficial to study, I wouldcome in and try and gain experience that is sovaluable.’(Female, 21 years, hospital setting)
This student struggles to direct her own learning. Sheis frank about her weaknesses. She is focused on‘study’ and values it more highly than clinicalexperience. She is aware that this runs contrary to thevalues held by faculty staff. There is a sense that herconclusion is written with faculty staff in mind,providing a satisfactorily transformative outcome:assumption of responsibility for her own learning.She has realised that there are learning opportunitieswithin the workplace, but her engagement is prob-lematic. She attributes her lack of motivation to thelack of close supervision at the clinical site. However,it is likely that it also relates to what she believes isimportant. There is no sense that she links herlearning activities to her future care of patients.
Professional
‘Physicians are able to… Exhibit appropriate profes-sional behaviours in practice, including honesty,integrity, commitment, compassion, respect andaltruism.’3
‘I have thought about this consultation many times since.I can’t believe that someone was treated with such littlerespect. She was visibly upset, uncomfortable and vulner-able and it didn’t seem to even register with the doctor.I have had regrets since that I didn’t comfort her orleave or do something but I was just stuck to mychair… What I have learned is that you have to dosomething and not just be passive. I could have easilycomforted this lady but I didn’t. I could have left theroom to show how I was uncomfortable. It’s definitelysomething that I have learned.’(Female, 24 years,hospital setting)
This student focuses on her own response towitnessing unprofessional behaviour. The lastingimpact of the encounter is evident. Her failure toact, and reflection on what she could have donedifferently, dominate this narrative: ‘I didn’t’; ‘Icould have’; ‘you have to’, and ‘I was stuck’. Herfocus is not on the shortcomings of the doctorinvolved, but on her own professional role. She doesnot fully explore why she behaved as she did. Theethical issues of researching student reflections areapparent here. The student is distressed by theexperience and needs support. A doctor has, alleg-edly, behaved unprofessionally towards a patient. Forthe researcher, to hear this narrative but not to act
on it feels unethical. In this case, the studentreceived support from the facilitated peer reflectionsession. The reported unprofessional behaviour ofthe doctor was not acted upon.
DISCUSSION
Developing medical students as reflective practitio-ners is central to professional development.36–39
However, faculty staff can also learn from studentreflections. The elements of professional practiceseen in the clinical setting are named from thestudent perspective in their reflections. When theseelements are categorised in relation to the CanMEDSroles, representing the formal curriculum, it is clearthat students do not engage equally with the fullrange of doctor roles. This is in keeping withinternational literature.3,40 The degree to whichstudents reflect on different professional roles mayrelate to the structure of the workplace or individualagency. Billett’s duality of workplace learning,18
which refers to the contributions of the individualand the social context to learning, provides a usefullens through which to examine gaps between theformal and enacted curricula and to determine howthey might be addressed.
Students bring their prior knowledge, understandingand awareness of professional roles to the clinicalworkplace. These pre-existing subjectivities impact onhow students engage with learning in these domains.The roles of Communicator, Professional and Scholarwere most frequently reflected upon in our study. It islikely that this frequency relates to the emphasis onthese areas in the early part of the curriculum, priorto clinical attachments. Students are already aware ofthese roles and perceive them to be important. Theclinical workplace, in both hospital and communitysettings, provided opportunities for students toobserve and participate in practice within thesedomains. They are seen to be applying their priorknowledge to new situations and reflecting on them.For some, confirmation of previous learning was theoutcome, allowing the translation of conceptualknowledge to practice. For others, the mismatchbetween workplace practice and the formal curricu-lum was problematic and resulted in questioning ofboth. The need for space within the curriculum toaddress this questioning through discussion withsenior practitioners is made clear.
The roles of Health Advocate, Collaborator andManager were reflected on much less frequently inour study. The Health Advocate and Manager roles
are recognised as being more difficult to teach andevaluate than others.3 The cultural and historicalnorms of the workplace may contribute to the lackof engagement in these domains. The role of HealthAdvocate has been rated the least important of theCanMEDS roles by doctors in both Canada41 andDenmark.42 Clinical teachers, therefore, may fail toemphasise this domain or even transmit negativeattitudes to students. The structure of clinicalattachments may not afford students opportunitiesto observe the enactment of the Health Advocateand Manager roles, which are played out at timeswhen students are not present, such as in board-rooms. Lack of prior student awareness of theseroles or the belief that they are unimportant maymean that they are not identified even whenobserved.41 Understanding of these less apparentdomains of professional practice might be develop-mental and it has been suggested that the com-plexity of the Health Advocate role relies on theprior development of competences within the othersix CanMEDS roles.43 However, literature frompostgraduate education suggests that awareness ofthese roles does not improve over time.41,42
The clinical workplace is replete with opportunitiesto observe teamwork and this domain is well
covered in our early curriculum. We had anticipatedthat students would notice and reflect on theCollaborator role, but this was not the case. At thisearly stage of their learning students may be moreinterested in the interpersonal doctor–patientdimension of professional practice, as has beenfound in other studies.27 Differences were apparentin the ways students perceived teamwork in hospitaland community settings. Negative reflections onteamwork in practice arose primarily in the hospitalsetting, with some students expressing negativeattitudes towards other health care workers. In thecommunity setting, however, views were positive andbenefit to patients strongly identified as an out-come. This would suggest that the workplace affor-dances in this domain differ between the learningenvironments.
Through this study we have identified gaps betweenstudent perceptions of professional roles in practiceand the portrayal of those roles in the formalcurriculum. For students to achieve learning out-comes, new learning opportunities must be devel-oped. This is likely to be achieved through amultimodal approach that maximises the affordancesof the workplace, which comprise access and guid-ance, and promotes individual student engagement
Table 2 Suggestions on student workplace learning of professionalism derived from a template based on the work of Billett17–19
Suggestions
Affordances Access When planning student placements, consider the affordances of
fered by different learning environments. Community and hospital
environments may have different strengths in terms of access to
professional roles
Consider specific placements to target challenging domains, such as
that of the Health Advocate
Faculty development can use student reflections to build understanding of
how students learn about professionalism and the role of clinical faculty
staff in that process
Guidance Clinicians should be encouraged to consider how students can be
intentionally guided to less obvious professional domains, such as by
bringing students into meetings
Engagement Prior knowledge Curriculum prior to clinical placements should prime students to recognise
the full range and dimensions of all professional roles, to see them as
important and to reflect on how they are enacted
Reflection Create space in the clinical setting to allow students to reflect on
professionalism issues with peers and experienced clinicians. This allows
the challenging of misperceptions and discussion of the relationship of
and reflection. Table 2 outlines a summary of sug-gested actions. Consideration should be given towhether the learning environment provides oppor-tunities to observe and participate across all profes-sional roles. Our study pointed to differencesbetween the affordances of hospital and communityplacements, with community placements providingbetter access to Health Advocate and Collaboratorroles.
Clinician-teachers play a key role in the cognitiveapprenticeship of professionalism,44,45 intentionallyguiding students towards conceptual knowledge,access to which is an acknowledged limitation ofworkplace learning.19 Attention to teaching thecognitive base of all professional roles, andemphasising the macro-societal aspects of profes-sionalism,7 as well as the individual and interper-sonal, will ensure students are primed to identifythese elements in practice. Faculty members need tounderstand how students learn about professionaldomains and their own roles in this process. Theimportance of discourse role-modelling by clinicalteachers in relation to working collaboratively withother health professionals, for example, is key tocountering negative attitudes.46 Promoting aware-ness amongst clinicians of the informal and hiddencurricula has been shown to change faculty staffbehaviour.47 Highlighting the need for faculty staffto make explicit the full range of their professionalroles will allow the appropriate guidance of studentsin the workplace.18 Specific interventions, such asthe early introduction of interprofessional learn-ing,46 can support understanding of the morechallenging roles.
The provision of space within the curriculum to allowstudents to talk to senior practitioners about theirreflections on professional practice can help toaddress the challenges imposed by the mismatchbetween the formal and enacted curricula. Thatstudent perspectives require to be discussed andsometimes challenged is evident in our findings. Ourstudents discuss their reflections in small-groupsessions facilitated by clinicians. Faculty staff explorewith students their reflections in and on action,including their own and that of observed experts. Theways in which professionals deal with authenticpractice issues are examined in the manner of areflective practicum.15
The outcome of this study is that we have gained agreater understanding of student experiences ofprofessional practice in the clinical setting and will beable to ground teaching in these experiences across
all professional roles. The findings are being used ina series of faculty development sessions.
This study has a number of strengths. We provideempirical data linking the student perspective ofprofessional practice as seen in authentic contexts toa framework used internationally to operationaliseprofessionalism and to plan curricula. The study useda good sample size of student reflections from adiverse range of hospital and community contexts,delivered over the course of an academic year.Descriptive validity and the student perspective areenhanced by the use of direct quotes to illustratelearning linked to CanMEDS roles.
The weaknesses of the study refer to its originatingfrom a single institution and the limiting of itsgeneralisability imposed by the key role of context inshaping the hidden curriculum. Furthermore, bothDB and MK are medical doctors with leadership roleswithin the medical school. This may have introducedbias into the analysis. We attempted to overcome thisby having each author conduct initial coding inde-pendently and by drawing on the expertise of MM, ofthe university’s teaching and learning centre. We didnot have the opportunity to present our data directlyto the cohort of students studied. However, keyquotes were presented to Year 4 students as a basis fordiscussion of their own experiences in the clinicalsetting. What remain uncovered by this study are thetacit unprofessional values, attitudes and behavioursthat are absorbed by students without reflection.
CONCLUSIONS
Reflective narratives reveal how students construeprofessional roles in practice. Mapping the content ofreflections to a defined competency frameworkhighlighted the mismatch between the formal andenacted curricula. Billett’s duality of workplacelearning18 provided a useful lens through which toidentify means to address this mismatch. This processwas a useful curriculum evaluation which mayenhance staff development and curricular reform.
Contributors: DB and MK conceived and designed thisstudy. They jointly collected and analysed the data. MM andSO were involved in the interpretation of the initial dataanalysis and the further refinement of that analysis. Allauthors contributed to the discussion of the findings andtheir implications. DB wrote the first draft of the article. Allauthors contributed to the critical revision of the paper andapproved the final manuscript for publication.
Ethical approval: ethical approval was obtained from theCork Research Ethics Committee.
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Received 18 May 2012; editorial comments to authors 27 July2012, 2 October 2012; accepted for publication 29 October 2012
