Wednesday, 20 April 2011

Location and Learning

SP: Nurse on the job
Image: SP Nurse on the Job by dharder9475
In the last few weeks I've been thinking about how we can support the learning that takes place when medical students are on placement. We know that entering wards can be a daunting experience for students. They don't feel part of a team. They don't know who everyone is. They don't understand what is happening. They don't want to interrupt nurses attending to patients or junior doctors catching up with paperwork at desks.They see other members of the team wandering in and out of the ward but they don't know what their role is. They don't recognose the social worker or the pharmacist or the OT.   They might not even know what their own role is. They miss out on opportunities to attend meetings and teaching sessions because they don't know they are happening. In fact they spend too long waiting around for someone else to turn up to teach them, and on activities that have little educational value. They generally have a haphazard learning experience.

But placements are very rich environments with many unique opportunities to learn.

So what can we do?

Imagine instead that before coming to the ward the students had access to a network which let them find the profiles of all the staff who worked on that ward. They could see the timetables for teaching. They could even see what the last students who had been on this placement had seen and learnt. They can select what they would they would particularly like to gain from the placement, and this will become part of their profile which will also be available to all the staff on the ward. The network will also contain links to information about initiatives that are happening in the ward to address patient safety and quality improvement. They students can see if there are opportunities for them to get involved in this work and learn about the input their colleagues have had in the past.

When they turn up on the ward the students check in. They can see the profiles of the staff who are working there and when they should be finishing, when they will be on call and what clinics or theatre sessions they will be doing that week. Their calendar updates with activities that are happening that day that they should know about.

The network that they are tapping into is the same one that all the staff in the hospital use to keep themselves up to date. The students can record their learning and their thoughts about how the ward works. Their input is valued by the staff on the ward and their fellow students from other disciplines.

Do you think this will happen soon? Why hasn't it happened already? And how could patients use this network?


  1. It would be fairly easy to set up something like this just using wordpress (assuming the hospital is ok having something on the outernet as opposed to an intranet

    You just need someone who's pretty web friendly to set it up and a volunteer/ dedicated staff member to take on the admin role for upgrades. From your description it's just a community site with different access levels for staff and public. a frequent hospital visitor (sadly) I agree this would be a great resource for patients too - knowing a little about your caregiver can really help relieve some of the stress of attending.

  2. This is right on the money! Even now, as a final year student who's effectively sign-hunting, approaching nurses and doctors is a little daunting. Students appreciate that everyone has a job to do - but actually, for me, that makes it a little harder to approach them. Knowing that there are important tasks for them to do and that I am ultimately, a distraction. It's not helped by the attitude that seems to place students below patients, doctors, physios, OTs, nurses, family members, cleaners etc - they all form part of the decision making process and are actively 'part of the solution' in the immediate future. Medical students are tomorrow's doctors - and tomorrow's problem.

    The real problem here is that medical education is too fragmented and too separated from medicine as it is practiced within the hospital. If you gave medical students swipe cards, logins, access codes etc, this initial cost would be offset by the realisation that less needs to be given in the way of teaching and more needs to be done to make medics feel like they're members of a team. In truth, the most valuable teaching experiences are those which are not organised simply because medics who seek to read textbooks may already have some knowledge of the condition or treatments or diagnostic tests that are being discussed. If they don't, then they'd learn it better in context, ie, to do with a patient. To me (and I accept that this entire post is highly subjective), opportunistic learning from a senior whose trust I have earned by being part of a team (even if only for a few days) is something that I will remember for longer because of the environment in which the teaching is given.

    People often bemoan those who are classed as being 'all style and no substance.' A very real problem in medical education is that there is literally no attention to the surroundings of learning - or to the style of teaching. If you make medical students feel like doctors (even the lite version!) then maybe they'll remember why they signed up in the first place - and maybe they'll learn more from these surroundings.

  3. Wow, I'm seeing it as a mobile app. Your phone gives you the lay of the land, so that you are not overwhelmed- so that you can see the forest in the midst of all the trees of a busy ward.

    I really like the personal aspect of it- more engaging when you can access someone's profile and get a sense that they're a real person. Otherwise, this might come across as simply more info for an overwhelmed student to learn.

    Mobile phone apps that offer the lay of the land, and that others can update from within their own personal profile, I really like it. If someone's personality has a large impact on life on the wards, then this would be great to see ahead of time.

  4. Great post...this is really a great opportunity for a quantum leap in health education...and integrate the learning with a way of documenting the learning...this is especially useful in the community health system environment where there is not a lot of educational overhead and support.

  5. @vics could have a big enterprise architecture solution, or you could have a go at something low key and local like this with minimal barriers to entry. Thanks:)

    I think your remark about 'sign hunting' is a BIG issue. We need to do something to emphasis that we want and need graduates who can do a lot more than recognising signs. Healthcare has changed over the last 50 years and our curriculum (and assessments) should reflect that.
    I really do think that we are starting to pay much more attention to the spaces and the situations in which medical education occurs. This is emerging as a theme in research and hopefully this is impacting on practice.
    Thanks as always for your comments.

    @astupple and @mike moore
    Many thanks for your thoughts from the other side of the pond. In some ways the tech is the easy part in a situation like this. It needs attention to culture as well. The tech and culture should bring change symbiotically.

    Just like to say it is wonderful to get feedback from current students so please feel free to post away.

  6. Brilliant idea! As a student myself I am all too familiar with the issues listed above.

    Some of my ward placements have actually had a similar system in place whereby the students have been granted access to look at the online sessions however to see this as a standard across all placements in all teaching hospitals would be ideal. Lets hope something like this comes into play and may benefit the foundation years as well as the students!

  7. Now I understand! This is a great idea! I'm currently working on an online course for mobiles so I think the technology is available just not used in this way.

  8. Great idea, as a student I would really appreciate access to something like this.

    When I first started my 3rd year I remember feeling very daunted by just the ward itself, and little things like where paper and blood forms lived.

    Looking back we all picked up that sort of thing pretty quickly, but over the rest of the year sometimes it would be difficult to find who was available/willing to do teaching, unless it was specifically scheduled.

    What really helped was being provided with a name and bleep number for whoever usually ran the teaching session. Sometimes these would be given to us informally by the juniors, but often our module handbooks would include reporting instructions and bleep details.

    Formalising this would be quite helpful and quite straightforward, and it wouldn't even need to be online really. Something like a who's who with name, photo and contact details would be sufficient.

    The only problems with it would be 1) that staff often rotate and this is at different times, 2) that keeping it up to date would be difficult, especially considering staff changes and 3) that establishing a website for it would come with all sorts of challenges.

    But glossing over the potential challenges, a ward who's who could be really helpful. As I've mentioned, in our module handbooks we are usually provided with contact details of members of the firm, but I'm not sure how widespread this is. Expanding this to include photos would be really useful so you know who to look out for.

  9. Learning can be haphazard as you describe but it does not necessarily need to be. My experience of supervising medical students in Cardiff, Bridgend and, more recently in Cornwall, has been more coordinated.

    A technological solution is feasible but not in the short term since not all the team on a particular ward would necessarily engage in the 'check in' and profile updates. Sounds a bit like SIMS for the hospital - if it was all automatic it might work. Name tags with Bluetooth capability sharing additional profile information might be a way of doing it [introducing strangers to medical students] too.

    However, more traditional teaching techniques could be used such as:

    - agreeing a learning contract
    - setting a 'networking' task
    - a multidisciplinary timetable of experiences
    - apprenticeship (close shadowing 1:1)

    These would rely on senior clinical leadership but it is not rocket science to negotiate the necessary permissions from all the members of the clinical teams.

  10. Thanks everyone!
    Dean, all great suggestions and I am sure that many medical schools do similar already. I am particularly interested in how students gain access to communities of practice on placements. I know you are not suggesting it but sometimes there is a temptation to formalise informal, work-based learning and I think that is a great pity. We need to help students learn how to learn in any workplace situation.
    Technology is not necessary for this but many people seem to think it is harder for students to negotiate these environments than in the past. I'm aware that sometimes we tend to see technology as a driver for the social and cultural changes that we want to see. I don't believe that technology makes changes by itself. Its use needs to be shaped and have buy-in from all involved.
    You're right that leadership is central to this, as with anything where change is desired.

  11. Ah ... so you're looking for legitimate peripheral participation then. :-)

    Technology can bring the 'community' together and enhance the social network but to have an identity in the ward the students need to be part of the practice (not simply observers). This can be done by adding formality. The formality gives 'permission' for the informal workplace learning to take place.

    Well ... at least it would if it were not for the hectic nature of wards. This sort of thing is much easier in the more relaxed and reflective culture of, say, a stroke unit than a medical admissions unit.

  12. I disagree that observation is not legitimate peripheral participation, especially early in the course or placement. When students come on primary care placements we work hard at thus in the first few weeks. You're right that different settings will allow for different forms of participation. But I suppose key will be helping students and staff to negotiate what is appropriate and when.
    This is a great paper:

  13. As a student myself I really like the idea of having a clear and dynamic 'family tree' of who's who and staff currently on duty with bleep numbers etc that could be accessed remotely - say an app on a phone as suggested above. That would be VERY useful, because it can take a while to figure that out.

    It would certainly help to make students feel more welcome if there were slots for 'medical students' too.

    Having access to information about what is going on around the ward - meetings etc - would be invaluable. Even if it just so students can track down where their mentors are scheduled to be.

    However, I think what is needed more than this is a change of attitude from both staff and students. It doesn't take much effort for a staff member to introduce themselves and find out who you are. All too often a lot of the staff are completely oblivious, disinterested or just too busy to make much of an effort and that can lead to lack of enthusiasm from students.

    The best placements I've experienced have been the ones where the staff take the time to get to know the students and introduce everyone on the team properly at the beginning. When things are clear from the outset the placement runs much more smoothly and the learning opportunities seem to spring out of nowhere. If the team know who the students are they can trust them to carry out small tasks - taking bloods, filling out forms, running errands etc - all of which can add to a students learning experience and make them feel more involved, more useful and at ease to ask questions. On placements where students are directed to an anonymous ward it can be confusing and the placement disjointed. I appreciate that time constraints mean this is not always possible - and perhaps a system such as you suggest would be a good resource and a good safety net.

  14. Excellent post, Anne Marie.

    You've prompted me to write a full-blown blog post of my own:

    While I usually focus on my own sector (corporate), I've found it enlightening to combine my ideas with yours and apply them to the medical sector - no doubt somewhat naively!

    May I also say I totally agree with Natalie's comment above regarding attitude. While technology can be powerful, it is no substitute for culture.

  15. I thought you may be interested in some work I have recently completed for the NHS - a project looking at the feasibility of mobile learning which could apply to both students and also practitioners. The research involved more than 170 staff across a variety of job roles, and was peer reviewed by Dr Chris Davies, Head of E-learning Research Group at Oxford University, and also Professor John Traxler, the UK's only Professor of mobile learning. You can read a summary here: (You can also view 2 apps we’ve produced for the NHS as ‘proof-of-concept’ at and – also available as iPad versions).
    Dr Naomi Norman, Director of Learning, Epic


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