1. Rural longitudinal integrated
placements – how do they work?
A social learning systems perspective
SYDNEY MEDICAL SCHOOL
Michele Daly
Chris Roberts
Malcolm Moore
Broken Hill University Department of Rural Health
3. Aims
The…WHAT of longitudinal placements
The…WHY of longitudinal placements
The aim of this research was to understand HOW
medical student clinical placements, delivered in rural and
remote community-engaged settings, work from a social
learning system perspective.
4. Photo: MDaly:
The Broken Hill Extended Clinical Placement
(BHECPP) Program
Longitudinal
“Integrated community-based education”
Hospital: 80+ beds;
dependence on FIFO doctors
5. The BHECPP Education Model
• Integrated community-based education model
• GP supervisor for 4 sessions per
week (Host)
• Range of clinical contexts
• Hospital,
• Remote healthcare teams
• RFDS
• Interprofessional Learning
• ENRICH program
6. Research Study Participant Details
Table 1. Participant Details (n=34)
General
Practitioners
n=8 Four of whom were GP supervisors
Health
Clinicians
n=10 Seven doctors working in the hospital and three
community health nurses
Medical
Students^
n=16 University n Student Entry Gender Age
Sydney 6 Graduate 10 female
plus 6
male
21-30
years*
Wollongong 6 Graduate
Adelaide 4 Undergraduate
^All medical students were in their final1-2 years prior to internship
*except one
7. Data Collection and Analysis
Data Collection (2010 – 2012)
34 Semi-structured interviews (GP/HC/MS)
• Perceptions and experiences of activities and
interactions within and outside the clinical
learning environment, including sources of support,
personal and professional growth, perceived
preparedness for living and working in a rural location
8. Developing a
thematic
framework
Code
discussion and
negotiation
Independent
analysis of
transcripts
Familiarisation
with data
8
Framework Analysis (Ritchie and Spencer 1994)
Data Analysis
Wenger’s Social Learning Theory
(http://pagi.wikidot.com/wenger-social-theory-learning)
Data interpretation
informed by...
9. RESULTS
Three main themes were identified in relation to impact on
student learning in the context of the BHECPP
›Geography of Place
›Learning Spaces
›Connectivity
10. Geography of Place
“...once you get past the regeneration area
that borders the town, you’re literally into the
back of beyond, and there is nothing”
11. Geography of Place
› Broken Hill, has its own ‘geography of place’ with its own unique location,
locale and sense of belonging
Location
• Physical and
Social Isolation
Locale
• Rural
&Remote
Issues
Sense of
Belonging
Geography
of Place
•Camaraderie & Rural
“...it was a lifesaving experience for Intimacy
that driver, and I had to crawl inside the
wreckage and give him morphine” [S12 Ext]
12. Learning Spaces
Formal (GP, Wards, ED, Remote Communities)
we’ve been able to practice our clinical skills in areas
that we will most likely have to demonstrate when we
are interns S
Informal (Everything else !)
12
13. Informal Learning – Clinical Environment
•Adhoc learning …
•Inter-professional teamwork and
collaboration opportunities…
•Role modelling and mentoring …
Informal
Learning
Opportunities
“today for instance there’s no
surgical registrar so I had no
choice but to assist the
surgeon, so they have to use
their medical students, ‘cause
that’s all they’ve got” S
14. Informal Learning - through Community Service
Participants talked about the value of experiences outside the formal
learning environment, such as by offering to provide community service.
“we went to a bush gymkhana …
wore the ambulance vest and we
were the ambos for the day, so
we followed the horse races and
picked up people who fell off and
looked after them, did a bit of
basic life support for the staff
and that was really good” (S01)
Fb:stpatricksbh
fb:stpatricksbh
15. Student learning through Connectivity
•Relationships/Interactions with the
• Patient Community
• Broader Community
• Professional Community
Connectivity
Community Connection
“...cause everyone’s
connected you just branch out
and meet people and it’s very
easy” SO8Ext
Reciprocal connectivity
“...because you’re helping
them out they want to
teach you more as well so
it works both ways” SO2Ent
16. Broken Hill as a Social Learning System
Geography
of Place
Hospital
Ward
Preparedness for practice
Mediated by the
process of
Connectivity
Remote
Care
Setting
Learning
Spaces
informal
Learning
Spaces
formal
GP
17. So how could this model be enhanced?
› Promoting T& L activities , authentic contextual
setting
›Exercise Green Desert...
18. Conclusion
Conceptualising a LIP as a SLS is a valuable
way of promoting student learning
› Medical educators and curriculum developers can
encourage :
- flexibility within the formal and informal curriculum
- role modelling/mentoring opportunities
- active student participation and engagement
(i.e. coach students to recognise social network opportunities within
the various learning spaces and then take advantage of the learning
opportunities they bring).
19. Acknowledgements
Prof David Garne
Dr Koshila Kumar
Prof David Perkins
....and of course... all the participants who gave up
their valued time to be part of this research
20. For More Information
SYDNEY MEDICAL SCHOOL
Michele Daly
michele.daly@sydney.edu.au
Twitter: @michele_daly
Daly, M., Roberts, C., Kumar,
K., & Perkins, D. (2013).
Longitudinal integrated
rural placements: a social
learning systems
perspective. Medical
Education, 47(4), 352-361
21. Geography of Place
I got to go out with an ambulance crew to a very
remote location where a car had rolled over and the
driver was trapped inside, there was no doctors,
there were a couple of nurses, and that was a learning
experience, but it was also a lifesaving experience
for that driver, and I had to crawl inside the
wreckage and give him morphine [S12 Ext]
21
Location
Opportunity
to “Act Up”
Locale
Socio-economic
insights
Sense of Belonging
Opportunity to build rapport
and develop clinical
confidence
22. 22
GP
Hospital
Remote
Care
Formal Learning Communities
Spaces
Informal Learning
Spaces
Preparedness for Practice
Informal team
membership
“extra pair of hands”
Practice
Team
Mountain bike club
with hospital
clinicians
Service learning
opportunities in
the wider
community
(Health Academy,
Ambulance
retrieval)
Within this unique Geography of Place
23. Potential barriers
› Geographical and academic isolation
“Out here if your tutor doesn’t teach you nobody else is going to because
there’s nobody else around”
› Students need to be proactive
“There was definitely more opportunity if I wanted... looking back I probably
still could have done more”
Editor's Notes
Today I am going to share some research relating to rural longitudinal integrated placements and how they maybe akin to a social learning system.
The fact we are all here today from places far across the globe, shows just how much international interest there is in community engaged medical education. Today I am going to share some research relating to rural longitudinal integrated placements.
Longitudinal placements – we have an idea what they are and why they were set up (rural career intention, accomodate increasing student numbers coming through the training system) but we wanted to explore HOW these type of medical student clinical placements in community engeged settings , worked from a social learning system perspective
The Broken Hill Extended Placement Program (BHEPP), is located in a rural and remote desert scrub setting, 1300km West of Sydney and 500km from the nearest city.
It is an innovative, multi-university, rural and remote, extended placement initiative. It is run as a collaboration by three universities, and is hosted and managed by the University of Sydney’s Department of Rural Health in Broken Hill. Student placements vary from six to twelve months. Itis a longitudinal integrated rural and remote clinical placement . It is community engaged, integrating community and hospital-based activities, structured learning, and inter-professional focus and independent study allow students to follow the patient journey.
There are three distinct clinical practice communities: general practice; hospital; and remote community care, each characterised by different learning opportunities and experiences such as parallel in general practice and team collaboration in the hospital setting. The students are hosted by a general practice and spend two to four half-day sessions there each week, with the rest of the time spent in the base hospital, as well as four weeks on remote placement.
The BHEPP model uses an integrated curriculum rather than the silo learning which is common practice in urban tertiary education where separate learning blocks are undertaken sequentially
We interviewed a range of stakeholders exploring “perceptions of....
Familiarisation with data
Independent analysis of transcripts
Code discussion and negotiation
Developing a thematic framework
Framework analysis was used and in conjunction with this, Data interpretation was informed by Wenger’s social learning theory
and examined the structure and operation of learning spaces and the nature of formal and
informal curriculum.
In a LIP students participate in a SLS with distinct learning spaces situated within a unique GoP, with connectivity aiding access and boundary crossing between learning spaces
Broken Hill, has its own ‘geography of place’ with its own unique location, locale and sense of belonging
Social and physical isolation is a major aspect of the geography of place. Loss of social network, adverse weather conditions, access and transport issues all contribute to a differing sense of place, for different people. The sheer physical isolation can be overwhelming however it can also provide other opportunities... Acting up
Locale Socioeconomic issues (gain better insight)
High Unemployment , Poor educational outcomes
Poor health access, Higher mortality rate
Sense of belonging Opportunities to develop relationships with colleagues and patients (Confidence and rapport building).
“the population in the areas like ours welcome people much more than…in the urban areas”GP
“Adhoc learning opportunities…Extra pair of hands surgical team,
Enhanced inter-professional teamwork and collaboration…Extra pair of hands for RFDS retrieval
Role modelling and mentoring Opportunities…Bike riding with senior docs
...we’ve got all these amazing role models who love their medicine and are passionate about their medicine but also have a great cultural and social life”HC
Connectivity aided access to different learning spaces but also boundary crossing between learning spaces (Identify, negotiate, cross)
Connection with the Broader Community
Pt Interaction
Social Inclusion
Connection with the Professional Community
Rapid integration (through shadowing and modelling)
Reciprocal Connectivity
In a LIP students participate in a SLS with distinct learning spaces situated within a unique GoP, with connectivity aiding access and boundary crossing between learning spaces.
An example of the formal learning spaces is the rural and remote community care component (spending a month out at Wilcannia) and
an informal learning space could be a student volunteering to be part of a health academy or go out on an ambulance retrieval in that setting. Alternatively an informal learning space could be as simple as belonging to the hospital clinician mountain bike riding club.
Informal service learning opportunities e.g. volunteeringhealth academy
It would appear that this type of social learning may promote preparedness for future practice
This social learning model could be enhamced by promoting T& L activities that make the most out of the authentic contextual setting
By actively encouraging medical educators and curriculum developers
To promote role modelling/mentoring opportunities in this unique geography of place
To promote connectivity opportunities (e.g.Interprofessional) E.g. Exercise Green Desert, Broken Hill, May 2011
To encourage flexibility within the formal and informal curriculum, through incorporating a mix of formal and informal learning spaces
So how could this model be improved?
Conceptualizing a longitudinal clinical placement as a social learning system is a valuable way of promoting student learning.
We can encourage
Medical educators
-to promote flexibility within the formal and informal curriculum through various types of learning spaces,
-encourage role modelling and mentoring opportunities
-and finally promote active student engagement and participation in the various learning spaces that make up a particular geography of place. i.e.
Coaching newly arrived students is importanted to recognise the embedded communities of practice and social networks within the various spaces so that they can then take advantage of the learning opportunities they bring.
Remote location: student had to “act up” as a pseudo doctor under the supervision of senior nurses
No doctors : Insight into lack of health access
Sense of belonging within the community: Building rapport and developing clinical confidence
Our findings show that within a unique geography of place, students take part in a number of distinct learning spaces characterized by different degrees of formality, membership and interactions, as well as different learning opportunities and experiences. The notion of “connectivity” helps explain how students access and cross the boundaries between these learning spaces and communities, and how they may develop a more complex sense of rural professional identity.
