Learning and supervision in internship: a sociocultural framework for understanding learning and supervision in medical internship.
Degree GrantorUniversity of Canterbury
Degree NameDoctor of Philosophy
The context of this thesis is learning in internship in New Zealand (NZ). Internship is a period of apprenticeship in medicine which bridges the transition from medical school to practise as a registered doctor. It is a formal apprenticeship leading to the professional practise of medicine, and is central to the identity construction of the junior doctor. However, because the workplace is changing the traditional model of apprenticeship is described in the literature as failing. As a consequence, internship has been subject to cycles of review and reform since the turn of the century, first in the United Kingdom (UK) and more recently in Australia and NZ. Despite the reforms current literature and professional commentary indicate that the problems are not all solved by what are essentially structural reforms. A review of the literature on clinical learning and supervision identifies a gap in the research that is contributing to the wider problem. While it is recognised that supervision is a key component of internship there is no conceptual model or framework to guide supervisory practice or to inform the training of supervisors. This is the problem addressed in this thesis. This thesis proposes a solution using socio-cultural learning theory to understand learning in internship in order to offer an explanation of learning that can inform the supervisory practice; and then for the development of a model of learning and a supervision framework to guide and inform the practice of interns, supervisors and managers in health provider organisations. A review of the literature since 1990 (Chapter 2) shows that there has been very little research on postgraduate supervision but there has been considerable work investigating the learning environment (or the immediate context of learning), drawing on experiential learning theory, describing the attributes of supervisors, devising models for giving feedback, and more recently seeking to understand and explain learning at work and the development of expertise. However, the transference of research findings into a conceptual and structural model of supervision has not occurred. In addition, recent research (2002-2010) has demonstrated that social learning approaches exploring clinical/workplace learning can be useful in bridging this gap. While there is an emerging body of work exploring the immediate (ward or clinic) learning climate there remains an absence of research on supervision and little consideration of the wider organisational and professional context in which internship is conducted. Before proposing a solution, literature describing the learning demands placed on interns and the expectations placed on supervisors is used to develop criteria for a specification to guide the development of a model of supervision that will meet the needs of the sector. The specification recognises the importance of an underlying educational framework that: addresses how learning occurs, how competence is developed, the supervisee and supervisor relationship, relationships with the team, the structure and context of supervision in internship at both the micro-level (learner environment) and the macro-level (organisational and national). The specification also recognizes that within the NZ context a model of practicebased teaching and supervision must be flexible enough to be translated into varied health contexts, including Maori health environments. Certainly in a Maori world view, learning (ako) and health practice is seen as part of the community and knowledge is a treasure (taonga) owned by the community not by individuals. Practice must support the articles of the Treaty of Waitangi and therefore seek to encourage participation, partnership and self determination. (This is a legislative requirement in NZ.) The thesis is reported in three parts looking at the micro-level (learner - supervisor), and macro-level (organizational) levels of the problem, and then bringing these together to inform a framework for supervision. In Part I a series of studies explore interns’ perceptions of learning in clinical areas and support the proposition that a social learning perspective can be applied to internship. The initial exploratory qualitative study shows that interns recognise and value a participatory learning environment with supervision strategies that promote participation and engagement and which are linked to knowledge sharing and identity formation. From these outcomes a model is presented that sets out the critical components that ensure clinical settings are positive learning environments which encourage social interaction. The model also provides an evaluation tool to assess placements as learning environments. Finally, strategies are offered that both supervisors and learners can use to promote and support learning in clinical workplaces. Part II uses document analysis to describe the organisational and professional context of learning in internship in order to lay out clearly the wider environment in which internship is enacted, and to uncover the rich formal, and often tacit, informal learning opportunities available. Critical analysis of Wenger’s (1998) model of communities of practice (CoPs) shows that this conceptual model of learning can provide a framework to organize and consider the learning environment of internship in a way that is more compatible with a teambased approach to the delivery of healthcare than previous perspectives. Importantly, the CoP framework also appears to be compatible with a Maori world view and this offers a platform for future research by, or with, Maori practitioners to develop a blended model of supervision for Maori health contexts. The CoP framework and its potential as a conceptual model in the context on internship was shared and discussed within workshops at conferences and learning events with over 100 practitioners who identify and described three sites where CoPs naturally occur these are: the clinical team who provide patient care, the interprofessional ward or unit and the medical team. In Part III, descriptions of these three sites as CoPs, the data on support structures, formal and informal learning opportunities within health provider organizations and the outcomes from Part I are combined to develop a framework of supervision and to describe the roles and responsibilities of a supervisor. The result of combining these two streams of work is: 1. A model of learning by participation and engagement in clinical practice to guide supervisory practice and assist interns as they develop the skills needed to be active lifelong learners throughout their medical careers. 2. An alternative framework from which interns, supervisors and organisations can view, and therefore plan and coordinate internship. The thesis is upheld that social learning theory is useful as a framework for understanding learning in internship and for developing a framework to guide supervision. The potential to utilise socio-cultural models either as supplementary, or an alternative to individualistic models, and to utilise team and organisational learning is a strategy that fits with discourses about healthcare teams, patient safety, inter-professional learning and the emergent properties and facets of work within current post-reform health services. This thesis offers an alternative way to conceptualise and define the role of the supervisor and the supervisee and transform supervisory practice in a way that aligns it to modern healthcare systems of delivery and accountability with, and to, other health professionals and other stakeholders. This study concludes with recommendations for a framework and overarching structure that is neither implemented nor tested, and this is clearly a necessary direction for future research. It is hoped that publication of this framework will lead to further testing and refinement, including its applicability to Maori, and the exploration by Maori medical educators of the recommendation for a blended model of supervision. Internship as a period of identity formation is introduced within the framework, but is less well explained than was possible within this study and warrants further investigation. More work is also needed to explore the impact on learning of the hierarchical structures in health and the possibility that not all healthcare environments are friendly and supportive.