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Purpose: In order to foster positive student experiences in the clinical learning environment, we wanted to better understand which teaching practices they regard highly. Methods: In 2016, the authors undertook a paper 'exemplar' survey (ES) of all fifth year medical students at one tertiary teaching site. Students had experienced all assigned clinical rotations over a two year period. Following a 66% response rate, we identified two clear exemplar clinical areas (ECAs). Over 2016-7, six focus groups with multidisciplinary staff members from these clinical areas were held, with the aim to identify, discuss and understand their specific teaching practices in more detail. Results: The authors present descriptions of positive student experiences and related staff practices, in five themes. Themes emerged around foundational logistic and personal factors: central to student and staff data is that 'welcome' on a daily, and ongoing basis, can be foundational to learning. Central to ECA staff data are universal practices by which all staff purposefully work to develop a functional staff-student relationship and play a part in organising/teaching students. Students and ECA staff groups both understood teacher values to be central to student learning and that cultivating a student's values is one of their major educational tasks. Conclusions: The framework formed by this thematic analysis is useful, clear and transferrable to other clinical teaching contexts. It also aligns with current thinking about best supporting student learning and cultivating student values as part of developing professionalism. Instigating such practices might help to optimise clinical teaching. We also tentatively suggest that such practices might help where resources are scarce, and perhaps also help ameliorate student bullying.
R E S E A R C H A R T I C L E Open Access
They cared about us students:learning
from exemplar clinical teaching
Althea Gamble Blakey
, Kelby Smith-Han
, Lynley Anderson
, Emma Collins
, Elizabeth Berryman
and Tim Wilkinson
Purpose: In order to foster positive student experiences in the clinical learning environment, we wanted to better
understand which teaching practices they regard highly.
Methods: In 2016, the authors undertook a paper exemplarsurvey (ES) of all fifth year medical students at one
tertiary teaching site. Students had experienced all assigned clinical rotations over a two year period. Following a
66% response rate, we identified two clear exemplar clinical areas (ECAs). Over 20167, six focus groups with
multidisciplinary staff members from these clinical areas were held, with the aim to identify, discuss and understand
their specific teaching practices in more detail.
Results: The authors present descriptions of positive student experiences and related staff practices, in five themes.
Themes emerged around foundational logistic and personal factors: central to student and staff data is that
welcomeon a daily, and ongoing basis, can be foundational to learning. Central to ECA staff data are universal
practices by which all staff purposefully work to develop a functional staff-student relationship and play a part in
organising/teaching students. Students and ECA staff groups both understood teacher values to be central to
student learning and that cultivating a students values is one of their major educational tasks.
Conclusions: The framework formed by this thematic analysis is useful, clear and transferrable to other clinical
teaching contexts. It also aligns with current thinking about best supporting student learning and cultivating
student values as part of developing professionalism. Instigating such practices might help to optimise clinical
teaching. We also tentatively suggest that such practices might help where resources are scarce, and perhaps also
help ameliorate student bullying.
Get the learning environment right, and the learning will
look after itself (Alan Clarke, in [1], p. 85). Medical stu-
dent experiences in the clinical environment are crucial
to their learning; what they are formally taught, see and
do shapes their development as a practitioner [2,3].
Positive experiences might result from a teacher taking
time to discuss a clinical case in detail, negative from a
teacher asking the student questions which are know-
ingly too hard for them to answer, with the aim to
embarrass or belittle. While the former experience might
enhance student learning and development, the latter
will almost certainly impede it [4,5].
Currently, it is understood that a students negative ex-
periences in the clinical environment will likely include
bullying (mistreatment, harassment, etc. [69] as defined
by Mavis [6]). Notable cases of bullying feature in recent
Australasian media and publications from professional
bodies [10,11]. Together with the current academic lit-
erature, these documents indicate that student bullying
is a significant, persistent and worldwide phenomenon
[79]. As a result, the bullied student can suffer negative
effects on learning, academic achievement and clinical
performance [12], acute and ongoing mental health is-
sues [13] and an overall impeded professional
© The Author(s). 2019 Open Access This article is distributed under the terms of the Creative Commons Attribution 4.0
International License (, which permits unrestricted use, distribution, and
reproduction in any medium, provided you give appropriate credit to the original author(s) and the source, provide a link to
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( applies to the data made available in this article, unless otherwise stated.
* Correspondence:
Otago School of Medicine, University of Otago, Dunedin, NZ, New Zealand
Department, Bioethics Centre, University of Otago, 71 Frederick St, PO Box
56, Dunedin, NZ 9054, New Zealand
Full list of author information is available at the end of the article
Gamble Blakey et al. BMC Medical Education (2019) 19:119
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development [14]. These effects can persist over a vic-
tims entire career [15].
In this article, we describe practices perceived as posi-
tive learning experiences by a cohort of medical students
and staff from two exemplar clinical teaching areas voted
the best by students. We present these practices on their
own merits, as such information can offer helpful in-
sights for any clinical teacher in the clinical workforce
[16]. We also present these practices because they po-
tentially represent a useful foundational approach to
clinical areas suffering resource scarcity, and because of
a potential link between these teaching practices and a
marked lack of reports about bullying in our exemplar
departments. We also report about these teaching prac-
tices because of the growing interest in the extent of
healthcare managements duty of care for all employees,
now articulated in current NZ workplace health and
safety legislation [1719] which stipulates managements
responsibility to effectively tackle workplace bullying.
The exemplar survey (ES, see Additional file 1for fur-
ther information) we describe in this article was under-
taken prior to, and informed the administration of, a
wider action research project called Creating A Positive
Learning Environment (CAPLE). This project entailed
the development and implementation of an intervention
in response to general concerns of medical student
bullying in clinical work environments in Australasia.
Explicating clinical teaching and learning
While an in-depth discussion about the definition of
teaching and learning is outside the scope of this article,
we still need to explicate what we mean by teaching and
learning in the clinical environment (Table 1). This is
because sources of learning in clinical practice are di-
verse, to include many interrelated and contextual prac-
tices. We understand that students are taught and learn
both explicitly and implicitly from: formal instruction,
e.g. a presentation about a clinical case, from observing
or participating in activity or process, the use of written
materials, and the language, behaviour and actions of
clinical staff and patients [3].
The ES was administered to all 80 fifth year medical stu-
dents who had completed every training runat offered
at one tertiary site in Australasia. Student data recorded
which departments were the best for their positive learn-
ing experiences, and why. Data were also gathered from
focus groups held in the two clinical areas voted as the
topexemplars. The latter data included detailed verbal
accounts of teaching practices the exemplar clinical area
(ECA) teachers used, and that they considered excellent
teaching practices. Data were taken from a total of six
focus groups and 15 multidisciplinary staff members.
Stage 1: exemplar survey
The ES had several goals, two of which are important to
the current article:
1. To gain information about which departments in
one teaching site offered the best and worst student
learning experiences;
2. To allow researchers to hold focus groups with staff
of the ECAs, and gain a detailed understanding of their
excellent teaching practices.
The ES was a paper-based four-question survey, ad-
ministered during a whole-class lecture. Questions were:
1. Identify the clinical areas/teams that you felt offered
you the most support for your learning as a medical
2. Please identify the actions or behaviours that you
felt made these areas/teams stand out as
supportive for your learning.
3. Identify the clinical areas/teams that you felt offered
you the least support for your learning as a medical
4. Please identify the actions or behaviours that you
felt made these areas/teams stand out as least
supportive for your learning.
Two researchers (EB) and (AGB) collated data from
questions one & three and recorded each under depart-
ment/or clinical area. The two with the most votesbe-
came known as our ECAs, and detailed reports from
questions two and four informed the thematic analysis
we report here.
Table 1 Key points for exemplar teaching practice in the
clinical learning environment. On the basis of our findings, we
suggest the following
1 Staff in each clinical environment assign time and resources to
deliberately make provision for studentsarrival.
Provision of a daily deliberate welcome to student into each clinical
environment, e.g. by introducing everyone by name in the operating
theatre/clinic and briefly explaining the studentsrole and current
learning aims.
2 That responsibility for teaching is shared between multidisciplinary
and support staff, who understand how to develop and use
opportunities for teaching, e.g. teachable moments.
Skills in teaching should be a priority focus of staff development.
3 Teachers create opportunities to develop a healthy relationship with
their students, sufficient to enhance their understanding of each
studentsspecific learning needs.
4 The potential power of teacher values on student learning (e.g. caring,
respect) be understood by staff and be a focus of staff development.
Similarly, how a students work might be explicitly valued as part of
clinical practice.
5 Teachers understand that cultivating students values, can, and should
be done in clinical practice. Specific skills to do this would be a further
important focus for staff development.
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Stage 2: exemplar clinical area (ECA) focus groups
Following the collation of student survey results (2016),
two researchers (AGB and KSH) undertook three
one-hour focus group interviews with staff from the first
exemplar clinical area (time and place as convenient to
staff). Staff of the ECA who had a significant role in
organising/teaching medical students were invited to
take part and included nursing, medical and administra-
tive staff. Researchers opened focus group discussions
with the broad question: Can you tell me why you think
your department was voted the bestfor supportive
teaching practices in this student survey?In 2017, we
approached the second exemplar department staff in the
same way, and undertook three more focus groups. We
did this specifically to seek triangulation between the
two ECA departments and strengthen our conclusions.
Data analysis and representation
We report responses from student ES questions two and
four along with data from ECA groups, all of which in-
formed our thematic analysis.
All participant responses were recorded, transcribed
and analysed using a general inductive approach [20]. EB
and AGB created themes related to medical students
positive and negative experiences, and ECA staff sup-
portive teaching practices. Each theme was chosen to be
representative of a data segment, and each theme was
also reviewed and discussed with the wider author
group, together with raw data, to evaluate each as a way
to clearly explain findings. This process was continued
until consensus was reached about each theme and its
meaning and at the point that no further categories
arose and data were exhausted - the point of data satur-
ation [21]. Methodology was thus emergent and in line
with a constructivist epistemology [22,23]; we sought
answers to a research question with little initial idea of
what data might reveal.
We present data in themes and summaries to commu-
nicate student experiences or ECA staff group consensus
and also using quotations, which are verbatim from sur-
vey/focus group transcriptions. Some data are edited to
preserve participant confidentiality, in which case we to
care to preserve meaning by checking edits with the par-
ticipant concerned. For some data in this study, we have
to be exceptionally strict around issues of confidentiality
due to concerns that staff and workplaces can be identi-
fied easily from what might seem ordinary information.
Exemplar survey (ES)
The ES of medical students had a response rate of 66%
(54/80 students). Results strongly suggested that stu-
dents had vastly different experiences in the clinical en-
vironments in question. Two clinical areas (ECA 1 & 2)
emerged clearly as exemplars, one with 48% of all votes
(26/54), out of 22 departments, and a corresponding
near-absence (one vote) for this department in terms of
unsupportive practices. In contrast, the department
voted most unsupportive received 12 votes (22%) with
two reports of supportive practices.
One main focus for this paper is ES question two,
about supportive teaching practices. This question
yielded 155 comments, several of which were general de-
scriptions, without detail to indicate the practice could
be easily taken up and used, e.g. clear teaching.For
this article, we report on ES data which was more spe-
cific and could more easily guide practice. Our second
main focus is data from the six ECA focus groups.
Student experiences of unsupportive teaching
While data about unsupportive teaching experiences are
not the focus of this article, this information can set the
scene for the discussion of results about supportive prac-
tice. For example, data from survey question four indi-
cate the existence of generally ineffective teaching
practices, such as students being told abouta topic, but
being offered little opportunity to apply and consolidate
knowledge in a clinical context. A significant proportion
of comments (19/91 = 21%) could also be confidently
identified as bullying, e.g. verbal abuse: I was told I
should go back to med school and ask for a refund be-
cause I obviously didnt learn anything.
Student experiences of supportive teaching
We present teaching practices in five themes, the first
two of which emerged from the ES and ECA focus
groups; the last three, from ECA staff focus groups.
Theme 1. ongoing welcome
Welcome practices we describe here were reported by
students in the survey and staff in ECA focus groups.
Students indicated that they valued acts that helped
them feel welcomeon first arrival in a department and
on an ongoing daily basis. Specifically, responses indi-
cated that students felt welcomed because staff seemed
to expect them, had learned their names, prepared for
their arrival and taken care to ensure each student
understood what to do about practical things like stor-
age of their belongings, making hot drinks and where/
when to take a break.
Ongoing welcome was created by staff carrying out
welcoming practices over the studentsentire time in the
department, but also by staff asking each student about
what they wanted or needed to do to meet specified
learning objectives throughout. Similarly, at times that a
student took part in a clinical procedure, staff would dis-
cuss which part of the procedure the student was inter-
ested in or needed to see or practice (31 comments).
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Some further examples of welcome were given by five
different students in the ES:
The doctors actually knew our names.
Friendly and welcoming.
Actually acknowledging usSaying good morning.
Inviting us to participate.
“…asking us what we needed to learn.
Feeling accepted as part of a clinical team.
ECA staff reported understanding that initial and ongoing
welcome had a foundational role in student learning,
which was why they prioritised it. Here, one staff member
makes reference to how welcome might help learning by
enhancing student engagement, and another talks about
how welcome might impact a studentsoveralllearning:
“…if you dont welcome them, they wontwantto
engage, especially because they are at a disadvantage
being a learner. Especially at the start where its all
I learn their names just as fast as I possibly can.
If you dont welcome them, there is a possibility that
their learning just wont begin and they will miss out.
It might be gone forever.(2 different staff, ECA 1)
Staff also reported that welcome could be created with
seemingly small, simple, but nevertheless important,
displaying student ID photos before arrival;
introducing students to all staff on day one;
ensuring students physically are orientated to the
department, including videos of hard to access(e.g.
high dependency) areas;
introducing students to staff in each clinical area,
daily (e.g. clinic staff ) and for each procedure if
appropriate (e.g. in operating theatre);
having a daily focus on which student does whatto
ensure students knew when and where, each
procedure (etc.) was to take place, and who was
responsible for them.
“…we ask them about what they are hoping to get out
of the run, on their first session, and we try to tie
things back to what we have arranged already, and
the other students. We let them know that we put
together a runwith their specific expectations in
“…its a very clear introductory session that sets the
scene for the students learning with us.
(Two different staff, ECA 1)
Theme 2. collective responsibility
Practices reported under this theme were emphasised
universally by all staff from ECA departments. Specific-
ally, staff reported that they all had a role in organising/
teaching medical students, to include administration
staff. Responsibility for student teaching was therefore
[admin staff are]just great. We couldnt do any of it
without them.(Staff, ECA 1)
“…well Im just the organiser, but I know its important
to them to feel a part if the place, and that we are on
their side.(Administrator, ECA 1)
If Im busy I know that others can, and will, keep the
students involved. They dont just sit around feeling
awkward then.(Staff ECA 2).
Staff shared out the following tasks:
organising studentsrosters;
supervising students doing tasks;
having students shadow them at the outset of a
giving tutorials about specific cases, skills and topics;
helping students understand their role, e.g. what
they were allowed to do;
reassuring students that they could seek assistance
from any staff member;
attending to acute problems (e.g. a student missing
out on an important experience).
One staff member summarised what collective respon-
sibility aimed for, and contrasted their aims with experi-
ences of other (non-exemplar) departments:
Staff: There should be nothing that they dont know
about, that we havent addressed, or that they dont get
to do.
Researcher: I guess if you didnt do that, given their
position as students, youd be setting them up to fail,
Staff: It wouldnt occur to me to not do it, but I see
that would happen. In fact Ive seen it happen other
places, and lots.(Staff, ECA 1)
Theme 3. relationship
This theme comprises several related practices which
overall seemed to ensure an ongoing functional
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staff-student relationship, possibly as an extension of
welcome. Examples included staff:
enquiring about, and communicating with each
other about a studentsleveland specific needs/
limitations, to ensure appropriate involvement in
enquiring about a students background, which
might indicate possible learning needs (e.g. ethnicity,
cultural background, language skills, past learning
experiences or qualifications);
assigning an overall mentor to engage with and
discuss progress with a student, deal with
outstanding/problematic issues and plan ahead;
ensuring the mentor remained the same if the
student were rostered to the department again.
Here, an administrator notes how this relationship is
developed and maintained:
We have photo sheets and we keep notes on the
person and where they are from and what they are
known as rather than lumping them as the students
to be processed en masse.(Administrator, ECA 1)
Theme 4. teacher values supporting student learning
Approximately half of ES supportive comments from
students were about a teachers values, and related
Being friendly.
Consultants being kind on ward round.
Great lovely people with empathy.(Three different ES
Other supportive teacher values reported by students
included: being sociable, thoughtful, inclusive, and con-
cerned about student welfare. A specific example of the
latter was given by a student who reported being kindly
asked about their health and wellbeing following an ab-
sence. Teacher values and learning also featured signifi-
cantly in data from ECA staff:
I treat them with respect, and I expect them to treat
me with respect.
It doesnt preclude me from teasing the heck out of
themthey rib me back, and thats fine, we dontgo
over the linebut it makes them feel part of the place
and helps them learn.(Staff member, ECA 2)
ECA staff reported that they consciously enacted cer-
tain values when teaching, in order to help their stu-
dents learn. In the following quote, a doctor observes a
peer caring and notes how they saw students perceive
this caring, and grow in confidence and learn as a result:
The sense that I always get from the consultants
involved with teaching is that they really care about
the teaching and the students. But when they
[students] get it [understand that the consultants care]
itsatickof being accepted and then they tend not to
be so shy and then can do more things. Its vital to
their learning sometimes. I know they do it on purpose,
because Ive complimented them [the peer] on it
before.(Doctor, ECA 1)
One specific value that was reported as supportive to
student learning was being keen on, or interested in
teaching. This theme featured significantly in the survey
(12 comments) as a practice supportive for student
learning. ECA staff also understood the need for the stu-
dents to perceive that their teachers are interested in
teaching and that this perception would help them learn.
Staff also noted a similar effect on learning with valuing
a students work:
When their contribution is valued, by the staff and by
the patients, this positive feedback makes them grow...
(Doctor, ECA 1).
Staff talked about efforts they made to get students
doing things in the department with a specific aim to
show students that their contribution was valued. Staff
also wanted students to understand that they:
“… add value to a departmentthat we go out of the
way to include the student, especially if we feel they
are a bit shy. They appreciate it and grow and learn
from knowing that...(Doctor, ECA 1).
Theme 5. teaching studentsvalues for professional
This theme was specific to ECA staff, and was about
values staff aimed for their students to develop. Specific-
ally, how students might learn values from a teachers
Its not [teaching isnt only] what you know, because
you can find that out from a book, but its about how
you deal with them [the students] and your patients
and your colleagues. Thatshow they learn to be a
good physician [their emphasis]
Teachers also explained why they would necessarily
address persistent behavioural issues they understood to
be related to studentsvalues:
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“…if they [the student] are repeating the same [bad/
inappropriate] behaviour over and overwe bring it
up, and talk about it, help the end of the
roster they will be a lot betterIts about educating the
whole person as a doctorthey might end up treating
us, or our children!’… ‘Its future- proofing in a way
they are going to run into problems later in their
career if we dontwe have to teach them values
[their emphasis].
ECA also staff talked about how they needed to teach
positive, requisite values implicitly, by modelling being a
good person.A specific example of this was given by a
doctor who had witnessed a students distress when
by another staff member. This staff member,
according to this doctor, was not showing the values
that we would like a student to learn.In response, the
doctor took time to ask the student how they were and
to explain how the other staff member had acted poorly.
This doctor indicated that his purpose in doing so was
to make sure that they are OKbut also specifically to
indicate that caring is what we do here.This is what
they [students] need to learn.In other words, this doc-
tor deliberately acted in a way that aimed to cultivate
the students values desirable for clinical practice, instead
of the undesirable that are likely from such an incident.
We wanted to understand what exemplar clinical depart-
ments did for student teaching and learning in one
teaching hospital. The two departments voted exemplars
offered a significantly more positive experience for stu-
dents than most others, complemented by a deficit of re-
ports of student bullying incidents.
We supplement our discussion of each theme we iden-
tified in data with examples of what might happen to
student learning if the practice was not employed. Some
examples form part of the unsupportive ES data, others
are summarised from discussions with focus group par-
ticipants or between our researchers. Our themes for ex-
emplar student teaching are:
1. Ongoing welcome
2. Relationship
3. Collective responsibility
4. Teacher values supporting student learning
5. Teaching students values for professional practice
One important overall observation about our findings
was their surprising simplicity. Exemplary teaching was
created and supported by a combination of fundamen-
tally logistic and personal factors; specific pedagogic
method or theoretical standpoints were not reported as
important to student learning. This result is consistent
with literature [24,25] in which logistic and personal
practices are confirmed as foundational to much of stu-
dent learning in the clinical environment, and that the
attitudes of clinical teachers can have a positive influ-
ence on personal development [14]. We thus find a con-
firmation that practices reported here should be our
main aims in the clinical environment and perhaps a re-
assuring focus where resources are in demand.
Ongoing welcome
Our first theme, about ongoing welcome, is well sup-
ported by the literature, in which reports indicate that
practices related to student welcomeare essential for
some student learning. For example, that welcoming a
student at the outset of, and throughout a students clin-
ical placement, can be likened to their introduction to
and progressive legitimate peripheral participation (LPP)
in the workplace, as described by Lave and Wenger [26].
This well-accepted theory enables us to explain how a
learner can be effectively and progressively inculcated
into workplace practice, in parallel with learning, to pro-
gress from newcomer to experienced. Overall, this grad-
ual exposure to the tasks, vocabulary and organisation of
a workplace community can support and integrate the
student and their learning in a workplace within a spe-
cific, perhaps complex, context.
Lave and Wengers[26] theory of LPP also helps ex-
plain how a learner who becomes separated from a
learning community can experience substantially limited
learning and professional growth. This view is confirmed
by others (e.g. Sheehan, et al., [24]) who describe how a
lack of welcome can decrease learner engagement to an
extent that some students question their current career
choice. Whilst damaging to learning in itself, a student
who questions their career choice can also have an im-
pact on patient care, e.g. by unwittingly displaying their
unhappiness in body language which is negative or in-
appropriate. We also understand that neglecting to
welcome a learner might also preclude them from:
understanding the expectations of their new role;
opportunities for learning at all levels
clinical discussions and associated learning;
practicing knowledge application;
developing skills to a competent level;
growing confidence in clinical and interpersonal
feelings of belonging and associated positive
emotions [3].
Again, the theme about relationship is not about a spe-
cific teaching method, rather a fundamental and founda-
tional basis for all teaching practice, and once more
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supported by the literature. For example, that such a re-
lationship supports learning by allowing a teacher to
understand student-specific learning needs and issues
which require attention (e.g. fear of talking to patients)
[2731]. It is also suggested that relationship can be a
principal mediating factor in how a student learns from
the hidden curriculum [32], and as such, relationship
could also be important to learning the fundamental
premises of best practice in a personal sense. For example,
relationship can mediate a students learning about inter-
acting with others as an essential skill for good practice:
The relationship between teachers and learners can be
viewed as a set of filters, interpretive screens, or
expectations that determine the effectiveness of
interaction between teacher and student . . .within
[effective] relationships, learners are willing to
disclose their lack of understanding rather than hide it
from their teachers; learners are more attentive, ask
more questions, are more actively engaged . . .
learning is contextual, and one of the most important
contexts for human beings is other people[33].
Similarly, Telio et al., [34] discuss teacher-student rela-
tionship in terms of creating an educational alliance with
a student, and how the resultant relationship can better
enable honest, helpful feedback, which a learner takes
seriously and puts into action. Importantly, it has also
been shown that a student in such a relationship can go
on to develop a sense that their teacher is credible and
therefore of value to their learning. Again, we see the de-
velopment of relationship between student and teacher
offering several benefits to learning, but also to a stu-
dents personal development.
When we examine teacher-student relationships (how-
ever defined) that are wrong,’‘negativeor even
non-existent, we gain further insight into how relationship
is important to learning and personal development, but
also to the work environment in a general sense. Specific-
ally, that failure to establish a positive teacher-student re-
lationship may preclude a student from:
having their specific learning needs understood and
receiving accurate feedback in a manner that is
helpful to learning;
learning effective communication skills by
interacting with the teacher;
experiencing a sense of belonging in the workplace
and its related positive emotions;
communicating an acute worry to their teacher, say,
about a patients condition, which can lead to a
student becoming implicated in inefficiency, error,
or negative clinical outcomes [3].
Collective responsibility
Collective responsibility for student teaching again in-
cluded practices which supported student learning in a
practical sense, e.g. by enhancing access to learning op-
portunities, teaching staff, chances to learn from a multi-
disciplinary team [35] and for teachable momentsto be
used as a way to optimise teaching in a time-poor or un-
predictable environment [35]. Pratt, et al. [36] specific-
ally recommend such an approach to teaching; that a
focus on teaching and learning should extend beyond
the singular use of one attending physician or preceptor,
and argue that student learning should be a product of
the broader context of learning: the cultural arena
within which engagement is invited and supported, or
denied.(p. 136, see also [37]). Interestingly, data we de-
scribe under this theme had a comparative lack of stu-
dent data. We ascribe this lack to the relatively invisible
or background involvement of much of the work done
by staff (behind the scenes). As such, we understand
that an appreciation of collective responsibility for teach-
ing may well be expressed by students as part of com-
ments about the generally supportive environment and
provision of learning opportunities. If responsibility for
student learning is not undertaken as a collective, we
understand that:
1. student teaching workload would be shared
between fewer staff, who might therefore
experience relatively more teaching-related stress;
2. students would likely have limited contact with
teachersvarious teaching methods and knowledge,
and experience more limited overall learning;
3. teaching and its administration (e.g. filling out
feedback forms) might need to be neglected to meet
patient demands;
4. teaching might not happen if a staff member is on
leave, busy with their own study or in an acute
patient situation;
5. staff with appropriate expertise might not have a
chance to divest this to student, e.g. a midwife will
have expertise appropriate for medical student
learning [3].
Teacher values supporting student learning
Teacher values in learning is also a topic which has be-
come established in the literature, and one which is enjoy-
ing somewhat of a resurgence [44]. ECA staff seemed
aware that their values could be perceived by their stu-
dents, and that some values can help student learning.
This view is strongly supported by Palmer [39] who speci-
fies that values such as caringcan help studentslearning
by ameliorating anxiety or fear, and thus enhancing en-
gagement [30,31,3941]. Tanner [41] explains the rela-
tive importance of teacher values in learning, and that:
Gamble Blakey et al. BMC Medical Education (2019) 19:119 Page 7 of 10
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“…how little great teaching has to do with technique
and how much it has to do with the teacher as a
ECA data also make specific reference to valuing teach-
ingas being supportive for student learning. While such
a finding seems self-evident - that someone who values
teaching would likely enjoy it, and this would probably
positively affect learning - the appearance of valuing
teaching in this study was notable, and is a phenomenon
rarely explicitly mentioned in other literature. This find-
ing thus offers us an additional understanding of how
particular teachers can help students learn better as well
as adding weight to more general reports [42] about
values supporting teaching. That is, a focus on teaching
the teachersabout teaching & learning and therefore
encouraging their valuing of itwould be an excellent
focus point for staff development.
ECA staff also reported valuing studentswork as im-
portant to student learning. This value is again seldom
seen reported in literature. In the case of this study, we
found it tempting to dismiss this value as a practice that
simply helped overcome effects of resource constraints.
After all, teachers described how students would make a
specific practical contribution to the running of the clin-
ical workplace, e.g. by teaching students to be very
confident with cannulation and getting them to do ten
cannulations on surgery day, to help with student learn-
ing but also helping to keep surgeries on schedule. How-
ever, we detected something more to the valuingof
student learning than a practical solution; staff indicated
that this positiveperception of the student offered the
student confidence in the workplace, perhaps to progress
in ways suggested by Lave and Wengers theoretical
Again, examining what might happen if a students
work is not valuedoffers insight. Failing to value stu-
dents work might preclude them from:
Feeling part of a workplace and experiencing the
positive emotions as a result of this;
Feeling that they have progressed or can contribute
meaningfully to patient care;
Being allowed to undertake new procedures or tasks,
or practicing to a competent level [3].
Teaching students values for professional practice
Cultivating studentsvalues is another well-established
topic in the literature which has now begun to reveal
some ways to foster an effective discourse for doing so
[30,38,39]. This literature supports our staff participants
understanding that cultivating studentsvalues can [42]
and should [43] be developed as part of their clinical edu-
cation, and as an important part of developing students
professionalism [14,44]. Our ECA teachers also reported
that values can be challenging to teach in an explicit sense,
but also that values could be taught by acting according to
these values, viz., by more than modelling [45], but simply
being.Some call this teaching by default[46,47], and
also note that this approach to teaching and learning is
likely to be a pervasive practice:
Observing role models to help us imagine, define, and
practice the kinds of behaviours we would like to
exhibit in our own lives is one of the most common
means by which we learn [46].
Evidence of teaching and learning by default was also,
sadly, found in comments we gathered from the question
about unsupportive teaching practicesin our ES. To
summarise some of these, and our own thinking, failure to
teach values, even if by simply not modelling or beinga
positive value, might mean a student is precluded from:
developing some values necessary for best practice;
learning to express these values and behave in ways
acceptable to quality practice;
developing values which are (perhaps unwittingly)
modelled to them, such as those unconducive to
good practice, e.g. impatience.
Strengths and weaknesses of our study
Data in the current study contain reports of teaching
practices by proxy, i.e. reported through students and
not observed first hand. Such reports might be suscep-
tible to a degree of personal interpretation; our under-
standing of actual teaching practices would be enhanced
by direct observation. However, our aim was to deter-
mine studentsexperiences, and thus we suggest this po-
tential limitation has little impact on our conclusions.
Reassuringly, we find confidence in our interpretation as
meaningful, as data triangulate well between students
and staff, and the two clinical areas approached as part
of this study.
We also acknowledge that we make an assumption
about supportive experiences of teaching: that support-
ivemeans helpful for student learning. For example, a
student might perceive a practice by which a teacher
gives them all the answers as supportive. However, such
a practice might be one which does not help the student
to reason answers for themselves (see Delany & Golding
[48]), which might be what they need to take their learn-
ing further. Survey data do not allow us to further tease
out distinguish such detail from these reports.
Further research
Of note in the ES was the near-absence of survey reports
about bullying in the ECAs. This absence may be
Gamble Blakey et al. BMC Medical Education (2019) 19:119 Page 8 of 10
Content courtesy of Springer Nature, terms of use apply. Rights reserved.
attributable to factors such as an absence of staff with pre-
disposing personal characteristics [4]. Further investiga-
tion is required to determine whether the instigation of
specific teaching practices may also be responsible for the
apparent absence of bullying behaviours. We suggest this
be done by measuring change in bullying incidence in a
department that adopts the framework of clinical teaching
methods reported here. We might also consider including
an approach specifically aimed to enhance teaching and
learning of values, within such a framework [38].
A more detailed understanding of how valuing a stu-
dents work might translate into better learning in prac-
tice is also required. Such an understanding offers an
opportunity to further hone a more detailed strategy for
foundational learning in the clinical workplace.
Reports of teaching practices from our ES indicate that,
in two specific departments, students experienced teach-
ing practices that were considerably more supportive to
student learning than in some other departments in the
same hospital. Together, data from the ES and the ECA
focus group indicate foundational practices to support
the cultivation of skills of practice, knowledge and the
values required for excellent clinical practice. Specific-
ally, we find that valuing the work our students do in
the clinical workplace, and valuing teaching, might fur-
ther positively influence learning. Teaching practices re-
ported here are supported by the current literature, to
also include very recent literature about teaching stu-
dents values as a specific, important aim.
We see staff respond to the challenges of practice and
teaching with a unified, feasible, pragmatic and effective
strategic plan for optimising clinical teaching in a busy
and unpredictable environment. While some of the more
humanelements of our findings might be harder to ma-
nipulate, as Clarke (see [1]) indicates, it might be that if
we look after the learning environment, learning might
indeed more easily look after itself.
Being deliberately humiliated by a teacher asking
questions that are too hard [5].
Additional file
Additional file 1: Exemplar Questions. (DOCX 839 kb)
AGB: Althea Gamble Blakey (researcher and primary author); EB: Elizabeth
Berryman (researcher and co-author); ECA 1 & ECA 2: 1 and 2 are used to
differentiate between the two clinical departments (correspondingly
approached in 2016 & 2017) used for our focus groups about exemplar
clinical areas; ECA: Exemplar Clinical Area a clinical department or ward
voted in the ES to be comparatively better for student learning experiences;
ES: Exemplar survey: A survey of medical students undertaken to understand
which department offered the most and least student learning experiences
in one teaching hospital; KSH: Kelby Smith-Han (researcher and co-author)
We acknowledge and thank all staff and students at the clinical teaching site
with whom we came into contact during each phase of the broader
research project.
The authors wish to thank the Division of Health Sciences at the University
of Otago for funding granted for this research. This funding was provided for
the salary of the primary author of this article and the funding body itself
had no further role in research design, data analysis etc.
Availability of data and materials
We deposit no data in relation to the current article and retain our raw
qualitative data from public access. We do this primarily because this type of
sharing was not stipulated in our ethics approval application and thus we do
not have consent from participants to do so.
Whilst a moot point, we also make this choice on the basis that in
Australasia, medical, clinical and academic communities are exceptionally
close-knit. Qualitative data contain several comments (e.g. some colloquial-
isms) and descriptions (e.g. of a specific staff member) which could be easily
identified and risk compromising the confidentiality of a participant or the
clinical area in question. The authors have spent a considerable amount of
time in interpreting and representing data accurately in the current text, at
the same time as avoiding risk to participant confidentiality.
AGB and KSH collected the data. EB and AGB completed the first analysis of
themes. AGB finalised the analysis, in consultation with KSH, EB, LA, TW and
EC. AGB completed the first draft and responded to iterative comments from
the group. All authors contributed to: The overall design of the broader
research project; Ongoing analysis of emergent themes from data; Redrafting
and earlier iterations of the current article; Development of ideas used in the
discussion section of the current article. All authors agree to be accountable
for all aspects of the current work to include work undertaken to ensure
participant confidentiality yet represent data clearly and accurately. We also
acknowledge responsibility for the investigation of any issue raised about
the integrity or accuracy of the current work. All authors read and approved
the final manuscript.
Ethics approval and consent to participate
Ethical approval was sought and granted for the studies reported in this
article. This was granted by the University of Otago Human Ethics
Committee (Health), reference number H16 091 (both studies).
Written consent was obtained from each participant in this study. Where
participants undertook questionnaires alone, we used a consent process by
which we indicated that filling out and submitting the survey form would
indicate consent to participate and for publication of any data gathered. A
copy of the written consent form/survey is available for review by the Editor
of this journal. We also undertook consultation with Māori for this research.
Consent for publication
Each information sheet clearly indicated that consent for publication was
being sought at the same time as consent for participation.That we sought
consent was also made clear in the pre-consent discussions with the
Competing interests
The authors declare that they have no competing interests.
Springer Nature remains neutral with regard to jurisdictional claims in
published maps and institutional affiliations.
Author details
Otago School of Medicine, University of Otago, Dunedin, NZ, New Zealand.
Department, Bioethics Centre, University of Otago, 71 Frederick St, PO Box
56, Dunedin, NZ 9054, New Zealand.
Otago Polytechnic and Staff Nurse,
Gamble Blakey et al. BMC Medical Education (2019) 19:119 Page 9 of 10
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Southern District Health Board, Dunedin, NZ, New Zealand.
North Shore
Hospital, Waitemata District Health Board, Auckland, NZ, New Zealand.
Received: 8 March 2018 Accepted: 11 April 2019
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... Students are more attentive, ask more questions, and are more actively engaged in such an environment (33). Importantly, it has also been shown that a student in such a relationship can go on to develop a sense that their teacher is credible and, therefore, an invaluable asset to their learning (13,35). Relationships are verily the most vital of determinants in creating an educational climate conducive to learning. ...
To foster a milieu in which student learning can be optimum, teachers need to be aware of the attributes of a safe learning environment. This is the space created in the students' minds to seamlessly promote learning. The 10 maxims, presented in this paper, are the cornerstones, nay, the capstones, for making this happen.
... Answering these questions is key to informing the development of a response to bullying and harassment of health professional students. Furthermore, as effective interventions are developed, for example the Creating a Positive Learning Environment (CAPLE) initiative (Gamble Blakey et al. 2019aBlakey et al. , 2019bBlakey et al. , 2019c), we need reliable and valid measures to determine impact. ...
Full-text available
Background: Instruments that measure exposure to bullying and harassment of students learning in a clinical workplace environment (CWE) that contain validity evidence are scarce. The aim of this study was to develop such a measure and provide some validity evidence for its use. Method: We took an instrument for detecting bullying of employees in the workplace, called the Negative Acts Questionnaire – Revised (NAQ-R). Items on the NAQ-R were adapted to align with our context of health professional students learning in a CWE and added two new factors of sexual and ethnic harassment. This new instrument, named the Clinical Workplace Learning NAQ-R, was distributed to 540 medical and nursing undergraduate students and we undertook a Confirmatory Factor Analysis (CFA) to investigate its construct validity and factorial structure. Results: The results provided support for the construct validity and factorial structure of the new scale comprising five factors: workplace learning-related bullying (WLRB), person-related bullying (PRB), physically intimidating bullying (PIB), sexual harassment (SH), and ethnic harassment (EH). The reliability estimates for all factors ranged from 0.79 to 0.94. Conclusion: This study provides a tool to measure the exposure to bullying and harassment in health professional students learning in a CWE.
Full-text available
Background One aim of medical education is to cultivate student thinking, and specific methods have been developed, implemented, and evaluated for doing this. However, doing so is not as straightforward as simply employing these methods. Methods In a wider year-long participatory action research study about developing student thinking, we interviewed, observed, and video-recorded six medical teacher-participants. Participants also filled out reflective journals and regularly discussed practices as a group. ResultsWe found that teaching methods customarily used to develop student thinking (e.g. reflective thinking, clinical reasoning) sometimes failed. This failure was because students experienced fear as a result of such methods, such as fear of looking stupid in a discussion. Our teacher-participants went on to develop very specific methods for identifying and mitigating fears and better cultivating students’ thinking. They (1) got to know students and understand what they were afraid of, (2) mitigated student fear by talking regularly and ‘normalising’ fear in learning for them, (3) modified teaching methods to make students feel less scared and (4) demonstrated ‘care’ for their students, a value which could increase students’ confidence and help them mitigate fears for themselves. Recommendations and SummaryWe suggest teachers to (1) create opportunities to learn about their students, (2) regularly discuss with their students how fear can be normal in learning, (3) adjust teaching methods to mitigate fear and (4) care and show their care for their students. We also suggest that medical teachers could benefit from staff development about the phenomenon of potential student fear and recommend the pursuit of a better understanding of how ‘caring’ might be identified, nurtured in teachers and usefully expressed in practice.
Full-text available
Failure to reach data saturation has an impact on the quality of the research conducted and hampers content validity. The aim of a study should include what determines when data saturation is achieved, for a small study will reach saturation more rapidly than a larger study. Data saturation is reached when there is enough information to replicate the study when the ability to obtain additional new information has been attained, and when further coding is no longer feasible. The following article critiques two qualitative studies for data saturation: Wolcott (2004) and Landau and Drori (2008). Failure to reach data saturation has a negative impact on the validity on one’s research. The intended audience is novice student researchers. © 2015: Patricia I. Fusch, Lawrence R. Ness, and Nova Southeastern University.
Problem Medical teachers, like many others in higher education, need to help some students cultivate values essential to good practice. However, there is a paucity of evidence-based practical advice about how to exactly do this. While several educational methods are widely accepted as generally useful for such a purpose, specific pedagogical guidance is lacking. Teachers still need to know how to effectively develop values in the classroom. Research Aim As part of an existing curricula with teaching methods already understood to be useful, we pursued the development of specific classroom strategies to more effectively cultivate medical students’ values. Methods We undertook a year-long action research project with six experienced medical teachers. Data included group discussion meetings, semi-structured interviews, observations and interpersonal process recall of each teacher’s classroom practice. Results Participant teachers developed an understanding of values as highly sensitive, in the sense of their relation to an individual’s sense of self. This understanding explained, in part, the challenges teacher participants had experienced in teaching values. From this understanding, participants developed a specific discourse to help one another understand and describe effective values teaching; one of cultivation, placing in sight and of moving a student from where they started to another place. A specific two-part pedagogy was then developed from this discourse: to avoid engendering negative emotion in the student and to implicitly value or ‘believe in’ the student as a person. Conclusions Results have implications for teacher pedagogy and development, and in nominating who might best teach values. Further research should focus on the finer points of language and developing a more specific understanding of how teacher ‘caring’ might help cultivate values.
The complexity of modern healthcare demands that we practice in teams in order to provide high-quality and cost-effective care. Consequently, no matter what their practice site, clinical teachers are more and more likely to intersect with learners from professions other than their own. Clinical teachers must prepare learners from all professions to practice collaboratively. But most physicians haven’t had explicit training in team-based care, leaving many of us uncomfortable with teaching a group of interprofessional learners. This chapter provides strategies for optimizing team-based teaching in settings where trainees in multiple professions work and learn together.
Until recently professionalism was transmitted by respected role models, a method that depended heavily on the presence of a homogeneous society sharing values. This is no longer true, and medical schools and postgraduate training programs in the developed world are now actively teaching professionalism to students and trainees. In addition, licensing and certifying bodies are attempting to assess the professionalism of practicing physicians on an ongoing basis. This is the only book available to provide guidance to those designing and implementing programs on teaching professionalism. It outlines the cognitive base of professionalism, provides a theoretical basis for teaching the subject, gives general principles for establishing programs at various levels (undergraduate, postgraduate, and continuing professional development), and documents the experience of institutions who are leaders in the field. Teaching aids that have been used successfully by contributors are included as an appendix and are available in downloadable form on our website.
This Viewpoint discusses “pimping” as a medical teaching tool in clinical rounds and its future use in relation to increasing awareness of student mistreatment.Medical student harassment and mistreatment have become topics of increasing concern to a wide range of stakeholders in US medical education.1,2 In this context, traditional methods of bedside teaching, particularly the time-honored “pimping” of medical students and house staff,3 have recently come under scrutiny.4 In this Viewpoint, we define pimping, briefly summarize the evidence base for and against pimping, discuss pimping in the context of medical student mistreatment, and outline future directions.