A qualitative study of undergraduate clerkships in the intensive care unit: It’s a brand new world

Undergraduate intensive care clerkships are common. Qualitative research about student ICU learning is lacking. The ICU is a more challenging learning environment than non-ICU settings. The ICU rewards students with numerous positive learning opportunities. A chronological workplace model with a social cognitive framework can be used to better understand student learning during ICU clerkships. This model could be applied to guide ICU educational design and may find application for clinical workplace learning in other hospital settings.

Intensive care medicine (ICM) is a specialty that is becoming a standard discipline in undergraduate medical curricula [1, 2]. An ICM clinical clerkship offers several potential benefits when compared with those in a non-intensive care setting. Its ‘horizontal’ structure enables simultaneous exposure to numerous subspecialties [2]. It facilitates vertical integration between basic and clinical sciences and exposes students to the clinical and procedural aspects of acute and critical illness, infrequently found elsewhere [3, 4].

The intensive care unit (ICU), however, with its unique customs and norms, may be a challenging learning environment for students. They may feel intimidated by the unfamiliarity of the surroundings and the complexity of pathology and treatments [5], promoting uncertainty and disengagement, thereby hindering learning [6, 7]. Unfamiliar departmental culture and team structures may interfere with early clerkship socialization and identity formation [7]. Moreover, active student participation, important for effective learning [8‐11], may be harder to achieve in the complex, high-stakes ICU setting.

Numerous qualitative studies have evaluated undergraduate clinical workplace learning [7, 8, 11‐16] but none of these studies includes data on ICM clerkships. Existing research about undergraduate ICM learning, mostly quantitative with self-selected students doing 2‑ or 3‑month electives, suggests that it is popular and achieves measurable learning outcomes [17‐22]. To date, therefore, analysis of medical student learning within an ICU from an interpretive viewpoint is lacking.

A key aspect of clinical workplace learning is the interaction between the environment and the individual [23]. Social cognitive theory (SCT) views learning as the consequence of an individual’s interpretation of and interaction with an environment. It identifies with learners as ‘agents of experiences rather than simply undergoers of experiences’ (p4) [24]. The learner, through her thoughts, actions, motivations and behaviour – learner agency – exerts an influence over the learning environment. This dynamic process, whereby the environment, learner and behaviour all exert mutual determinative effects on learning, is known as reciprocal determinism [25, 26]. Central to this theory is the concept that an environment, for example an ICU, is a potential learning space until a process of ‘actualization’ is initiated by the arrival therein of an active, cognitive learner [25, 27]. How or whether this process occurs is in turn influenced by several factors, in particular the type of social environment, a learner’s emotional state and their skills in self-regulation – identifying learning goals and adopting strategies to achieve these goals [24, 28, 29].

SCT may be a suitable lens through which to view medical student learning in the ICU. The challenging nature of the environment may hinder the student’s ability to manipulate and self-regulate their learning or to exert a determinative influence there. Accordingly, they may not progress from observers of learning to agents of learning, the ICU may remain a potential learning space and the benefits of the ICU as an educational experience may not be fully realized. The suitability of SCT is further strengthened by its prior use in the evaluation of medical workplace learning, though in a non-ICU setting [14, 30].

Therefore, although much is known about how students learn in the clinical setting, student experience in the ICU is not represented in the current published literature. Qualitative research might offer valuable insights into these experiences. With an overarching motive to optimize undergraduate intensive care learning in the study institution, the study objective was to address this gap in current knowledge. Using an SCT framework, an interpretivist methodology and a qualitative descriptive strategy [31, 32], the purpose of this study was to answer the following research questions:

A majority of participants described the learning experience as ‘positive’, ‘a nice experience’, ‘enjoyable’ or ‘really good’, sometimes with qualifications (‘It was very good but I also found it very tough emotionally’ [FG3;F2]).

A key emergent theme was how the students’ physical, emotional and social engagement with the clerkship underwent a process of change, much of which could be explained in terms of SCT, characterized by negative emotions, apprehension and uncertainty prior to the clerkship, moving through a period of orientation and increasing familiarization, before reaching a state where positive learning experiences could occur. We divided this process into three stages which we termed (1) pre-clerkship, (2) early clerkship and (3) learning throughout the clerkship. Subthemes relevant to each of these phases emerged in the discussions (Table 2). Furthermore, a majority of these subthemes related to the differences between ICU and non-ICU clerkships.

Our study, apparently the first to qualitatively detail medical student ICM learning, provides a useful description of the ICU from a student perspective. While presenting challenges during preparation and induction, ICM clerkships offer students valuable learning experiences not readily available elsewhere. Factors hindering learning include the anticipation of complex illness in an unfamiliar setting, perceptions of uselessness and poor clerkship organization during student induction. Conversely, learning is facilitated by a welcoming, inclusive, supportive learning environment, where students can participate in patient-centred activities, and are motivated to pursue self-directed experiences.

The study suggests that social cognitive theory, in particular its key principles of reciprocal determinism and learner agency, offers useful insights into how students learn in the intensive care unit. Moreover, SCT can be used to explain the changing dynamics between learner and environment, as well as the factors influencing learning as students progress through different stages of an ICU clerkship. Finally, when compared with non-ICU clinical environments, the ICU may be more challenging to prepare for and more daunting to enter, but once entered, provides some unique and positive learning experiences.

We identified numerous examples of what Bandura calls the ‘complex interplay’ (p5) [24] between learner and learning environment – reciprocal determinism; the triadic relationship between the student, their behaviour and the ICU [26, 28]. Also apparent was the importance of students’ personal agency, for example effecting an educational change in the ICU environment or pursuing self-directed activities [24].

These factors, however, did not remain constant throughout the clerkship. A key theme that emerged in the data was the concept of a sequential process of familiarization, socialization, participation and affective change that developed as students engaged emotionally and physically with the clerkship. When viewed from an SCT perspective, a dynamic picture of workplace learning became apparent. Accordingly, prior to and at the start of the ICU clerkship, students were more likely to be apprehensive about the unfamiliar, complex environment and unsure about the role they would play there. Self-regulatory activities such as preparation, setting learning goals and adopting learning strategies were infrequent and students favoured high levels of support and guidance. It is likely that, at this time, the students felt ill-equipped to manipulate and influence the ICU environment and were more observers of learning than agents of learning. Consequently, the ICU environment was, in the early stages, a potential learning place awaiting a more active interaction with the student learner.

Conversely, as the clerkship progressed, students became more confident, participatory and self-directed. This development may have coincided with the students’ greater familiarity with the ICU and its norms as well as their perceived acceptance therein. Reports of students driving and directing their learning become apparent. Students recognized their ability to influence the environment to enhance their learning. Some recognized a need to adjust their learning methods (from traditional history taking and clinical examination to a more deductive method of clinical reasoning) to pursue their learning goals. Others recognized and sought clinical experiences unique to the intensive care setting. In summary, a picture emerged of dynamic co-interaction between the active student and a mutable environment which could not be explained by social learning theory alone. These findings were combined and used to construct a clinical workplace learning model (Fig. 1). This presents a chronological basis for learning reflecting the co-dynamics between ICU and student and the factors influencing the active, cognitive learner during clinical clerkships.

Our results overlap with those of previous studies using non-sequential approaches to workplace learning. For example, Dornan et al.’s experiential model of workplace learning also emphasizes the importance for learning of active participation, supportive, encouraging healthcare staff, and effective clerkship organisation [8, 44]. The model proposed in Boor’s (2008) mixed-methods study of undergraduate obstetric clerkships, in common with our study, prioritizes learner participation, in turn influenced by environmental factors such as legitimacy and clerkship organization, and by student motivation [15]. Two previous studies [45, 46] demonstrate that the early clinical career of a medical student is notable for the challenge of induction into new clerkships, so-called ‘professional socialization’ (p113) [45] when students navigate new ‘socio-emotional space(s)’ (p364) [46], seeking an identity with attendant roles, responsibilities and expectations. The results of our study and others advocate a combination of a welcoming, ‘invitational’ (p542) [13] environment with good guidance and organization which, by supporting this period of induction [8, 10, 13, 15, 16], may promote early self-regulatory activities and learner agency. This is an important message for educators involved in providing orientation and ‘developmental space’ (p363) [46] for students.

Our study adds to existing knowledge in four main areas. First, it suggests that although student learning in the ICU and in the non-ICU setting share some overlap, ICU workplace learning is unique and may be incompletely explained by current workplace learning models. A search for models better suited to the ICU may therefore be warranted. Second, we have used our results to propose a new workplace model of ICU learning. Third, our findings, and the proposed model, are practical, suggesting ways of structuring ICU undergraduate education according to the students’ transition through the clerkship; welcoming, supportive, non-threatening and informative at the start, and delegatory, participatory and challenging as the clerkship progresses. Finally, our results apply to the ICU environment Bandura’s theory that an ‘actual learning environment’ is unique to each learner; it is a product of the ‘potential environment’ (the ICU) and the cognitive and behavioural influences of the learner therein (p196) [25]. These interdependent factors, however, are not constant. From our study, we postulate that students’ personal agency dynamically changes during a clerkship; accordingly, the ‘potential environment’ may also need to change to assist students in navigating through the stages of the clerkship and for effective learning to occur.

There are limitations to the study. With low student recruitment, data saturation was not achieved, therefore additional perspectives on ICU learning that might have emerged in further discussions may have been overlooked. Notwithstanding this, our study ‘offers new insights that contribute substantially to or challenge current understandings’ (p7), a criterion used by Malterud et al. (2015) [47] to describe a satisfactorily powered, though potentially incomplete, qualitative study. A selection bias was suggested by a predominance of positive feedback from participants. To counter this and to explore outlier views, focus group questions specifically probed for negative aspects of the clerkship. As an example of practitioner research – EOC is an ICM consultant and lecturer in the study institution – the study was at risk of bias during recruitment, data collection or during data analysis and interpretation. Third party recruitment, data triangulation, an analysis audit trail, a researcher reflexive diary and peer debriefing were used to counter this risk of bias.

In summary, this study reinforces the value of the ICU as a rich, unique, social learning environment. It also suggests that effective learning of complex medical concepts even in the setting of an unfamiliar clinical workplace, is achievable, and is aided by facilitating student socialization in each new clerkship and by recognizing and responding to the sequential change in students’ interaction with the clerkship. Our proposed sequential workplace learning model may find application in the ICU setting as a tool to inform educational practice.