Pre-print to appear: Fawns, T., Markauskaite, L., Carvalho, L., & Goodyear, P. (forthcoming). H2m pedagogy:
Designing for hybrid learning in medical education. In E. Gil, Y. Mor, Y. Dimitriadis, & C. Köppe
(Eds). Hybrid learning spaces. Cham: Springer.
H2m Pedagogy: Designing for Hybrid Learning in Medical Education
Tim Fawnsa, Lina Markauskaiteb, Lucila Carvalhoc, Peter Goodyearb
a Medical Education, Edinburgh Medical School, University of Edinburgh, Edinburgh, United Kingdom
b Centre for Research on Learning and Innovation, Sydney School of Education and Social Work, The University
of Sydney, Sydney, Australia
c Institute of Education, Massey University, Auckland, New Zealand
In May 2020, the University of Edinburgh announced the September launch of a hybrid model for all on-
campus programmes. Teaching would be neither fully online nor fully on-campus, but able to take place in either
or both modalities (e.g. remote and on-campus students learning together), and change location without major
disruption to its design. The significant pedagogical challenges were most keenly felt in professional education,
where learning practical skills through engagement in complex practice is crucial. Focusing on examples from
medicine, we begin by discussing hybrid learning in a 2-metre world (i.e. where physical distancing requires a 2-
metre separation between people), or “H2m”. Our “chemistry” notation indicates the influence of the 2m
requirement on the structural composition of the hybrid model (H). At the same time, we argue that, as unusual
as the conditions are, they do not call for fundamentally different design principles and processes (the “how” of
design). Design for H2m learning requires flexible design tools that help teachers see and focus attention on
relationships between a priori design decisions and the wider, distributed environments and emergent activity that
are co-assembled in situ with students at “learntime”. Drawing on insights from a professional development course
to help clinical educators redesign their own courses for H2m learning, we show how such relational design tools
facilitated the creation of different design outputs (the “what” of designs), better attuned to situational affordances.
Among other things, these design outputs foreground: ways of encouraging student co-design of learning
environments; explicit consideration of diversity among students; and reflection on the relationships between what
students bring to the learning space, their emergent learning experiences, and what they must yet learn for
professional practice. We also argue that in order to deal with the complexity of designing for H2m, teacher-
designers need a good appreciation of the relationships between designable structures and student agency.
Keywords: hybrid education; physical distancing; clinical skills; professional practice education; medical
education; design for learning; design templates; teachers as designers; student agency.
This chapter falls into five main sections. In the first, we introduce the practical context—set by a university’s
urgently-formulated strategies for dealing with the uncertainties of teaching during the COVID-19 pandemic: a
‘digital first’ model for hybrid learning. In the second section, we analyse some core challenges this strategic
change presents for those staff whose responsibility it is to strengthen educational design capabilities within the
university, looking specifically at challenges in medical education. We express this in terms of H2m pedagogy,
set within the broader context of design for learning. Our “chemistry” notation indicates the influence of the 2-
metre requirements on the structural composition of the hybrid model (H). The third and fourth sections present
and reflect on a course created to strengthen university teachers’ design capabilities. Insights gained from the first
run of this course help illustrate some design principles and sensitivities for H2m learning that we summarise in
the last main section.
Practical Background: An Institutional Strategy for Hybrid Learning
In May 2020, in response to the COVID-19 pandemic, the University of Edinburgh announced the September
launch of a hybrid model for all on-campus programmes (University of Edinburgh, 2020). Teaching would be
neither fully online nor fully on-campus, but able to take place in either or both modes, with remote and on-
campus learning taking place together, and with a possibility to change mode and location quickly and without
major disruption. Buildings would operate at a maximum of 30% capacity, and restrictions to lecture theatres,
labs and other teaching spaces might be in place for some time. Further, there was a need to account for potential
recurrent outbreaks of COVID-19, which meant that students and staff might have to self-isolate at short notice.
This, in combination with the uncertainty of ever-changing national and institutional guidance, meant that a
“digital-first approach” was advocated, where most learning would be online. The university’s aim was to protect
the ability of students to continue learning while also being mindful of students’—and teachers’—sometimes
precarious physical circumstances and fragile wellbeing. The university’s guidance acknowledged that homes can
be difficult workplaces and that not everyone has good access to computers and the Internet.
There were significant challenges in changing from a predominantly on-campus educational model to a hybrid
one within a very short timeframe. However, the university characterised these challenges as also being
opportunities for pedagogical innovation: to “build new approaches which not only mitigate the immediate
COVID-19 crisis but which build our capacity for creative, resilient and future-facing pedagogy longer-term”
(University of Edinburgh, 2020). This was not an unexpected rhetorical move; in fact, the hybrid model was
already under development before COVID-19, created by the Edinburgh Futures Institute (EFI) as a part of the
university’s effort to contribute to tackling complex social and global challenges. The EFI’s hybrid model
focussed on innovative combinations of online and offline learning to bring a greater sense of reach to the physical
campus, irrespective of the mode of learning. The endorsement of hybrid pedagogy therefore was both an adoption
of a plan “B”—to be used when on-campus education is impossible—and an acknowledgement of the creative
pedagogical, cultural, emotional and strategic value in combining on-campus and online educational practices
(Bayne et al., 2020).
Core Challenges: Sharpening Design Capabilities
With extensive IT and digital education support structures, it might appear that the university already had the
necessary infrastructure for a fast transition to hybrid learning. However, digital education specialists (e.g.
learning technologists) were either based in discipline-specific academic teams, or provided general support but
were not resourced to work with teachers on their discipline- or context-specific challenges. Design patterns,
principles and other kinds of general design knowledge could help teachers (Cremers et al., 2017), but teachers’
full reliance on the design knowledge of others is unlikely to be sustainable as generic design principles need to
be resituated and enacted in a specific context. Thus, design is inseparable from other daily tasks, roles and
expertise of the teacher (Goodyear, 2015). This entwinement is particularly pronounced in professional disciplines
with specialised physical environments and situated practices, such as in clinical education.
The hybrid model brings the physical (material and digital) environment into sharper focus. It can be hard to
notice how physical conditions shape knowledge practices and learning in routine situations (Knorr-Cetina, 1999;
Markauskaite & Goodyear, 2017a), but this becomes more visible when things cease to work well. Coping with
restricted availability, absence, or change relating to material elements can necessitate major reconfigurations of
course design. In particular, 2m requirements created significant challenges (and opportunities for ingenuity) for
clinical programmes that depend on specialist equipment, purpose-designed (learning) spaces and specialised
interactions with other people—not just students and teachers, but also professional practitioners and clients.
While there were exceptions to the 2-metre physical distancing rule (e.g. examination of patients during clinical
placements), we use ‘2m’ as a shorthand for the related set of restrictions, regulations and policies that influenced
operation within shared physical spaces.
In Medicine, the development of professional expertise normally relies on access to some specially-configured
social and physical environments (clinics, wards, etc.), and the 2m restrictions required significant design changes.
For example, the need to control numbers of people in a room and to clean equipment between uses meant that
there was less time available for learning to use specialist devices, such as ECG machines. Reduced access needed
to be complemented with off-site preparation and follow-up tasks. A number of other pedagogical challenges
arose from the need for medical students to engage in complex working practices, through interaction with
qualified healthcare practitioners and patients in authentic environments. An example, which we examine later in
the chapter, was learning to act capably in Emergency departments.
That material environments are deeply embedded in professional knowledge practices and cultures, yet barely
visible to many educators—and almost absent in educational theory—presents particular challenges. As Yeoman
and Carvalho (2019) note, “educators are seldom trained to understand how their epistemology or conceptual
structure of learning relates to the material structures of learning” (p. 64). The complexity of hybrid education
“creates a need for design-oriented skills in those engaged in designing for learning” (p. 65).
Design frameworks for hybrid learning, and examples of past hybrid design practices from which to learn, are
still scarce. Fortunately, there are some theoretical perspectives where the emphasis is not so much on media,
instruction or content, but on the conceptual, social and material assemblages needed to support students’ learning
activity. From such perspectives, design for hybrid learning is not so different from design for on-campus or
online learning in terms of how design is done. Instead, the differences relate to the (re)combination of different
design elements and understanding of their affordances: what is fixed, what can be designed in advance, and what
needs to be left to teachers and students at “learntime”. Mixing different ways of learning (direct teaching,
individual practice, collaborative discovery, etc.), different media and tools (material, digital), different spaces
(on-campus, off-campus, etc.), and different aspects of learning (conceptual, social, material, etc.) is familiar to
those who study and design such assemblages.
The following exploration focuses on how these ways of framing and supporting design can help clinical
educators embrace the challenges and affordances of design for hybrid learning in a 2m world, or “H2m design”.
At the same time, we argue that, as unusual as the conditions are, they do not call for fundamentally different
design principles and processes.
The Response: Framing and Supporting Design for Learning
To assist teachers to transition to hybrid learning, a team in the Medical Education department offered a
professional development course called “Agile Course Design for Professional Education” (ACDPE). The rest of
this chapter is based on our experiences designing, facilitating and reflecting on this course.
Our description is inherently recursive: designing a course to help other people design courses; teaching
teachers to teach students in more flexible ways, and so on. We start with a clarification of roles—see Table 4.1.
The four of us writing this paper—whose discussions also helped shape the design
of the ACDPE course.
Course team or
The team of three people at the University of Edinburgh who led and facilitated the
ACDPE course. The lead author of this paper (TF) was a member of this team, along
with Derek Jones and Gill Aitken.
University of Edinburgh academic staff in the College of Medicine and Veterinary
Medicine who took the ACDPE course in 2020. We use the phrase teacher-designers
to foreground designerly activities within teachers’ work.
Students for whom the teachers participating in the ACDPE course were designing.
Table 4.1: Designing to strengthen design capabilities in clinical education: the main roles
ACDPE was a fully online pilot course that brought together 20 clinical educators for a period of 6 weeks (July
to August 2020). The course focused on building teachers’ capability to design courses responsive to the dynamic
H2m context, acknowledging the importance of preparing students and teachers to negotiate the uncertainty and
complexity of the future in connection with COVID-19. ACDPE asked for teachers’ willingness to experiment
with constructing and deconstructing their designs-in-progress, helping their peers, sharing ideas, and debating
the needs of future students.
Most participants had also previously completed a 5-week course on online teaching. Data from this first course
provided contextual information for the design of ACDPE (e.g. teachers’ perceptions of students’ studying
conditions, learning needs and benefits of on-campus and online modalities for their disciplines). These insights
contributed to our conception of tools to support H2m design.
ACDPE included three main kinds of activities:
• Week 1—teacher-designers worked in groups of 4-5 to design a single task for their students under the
design brief of “How to make the most of studying in lockdown”. The ACDPE task asked teachers to
consider how to help their students to be more productive, within constrained learning conditions. The
task had a dual purpose. It was an authentic challenge, intended to help teachers think through their
students’ needs and circumstances. It also familiarised participants with the ACDPE course structure.
• Week 2—each teacher-designer compared their group’s design with those produced by other groups.
During this week, they also shared the first iteration of their individual design, using customised templates
(in which each teacher-designer would continue to develop their course designs) with the ACDPE cohort.
• Week 3-6—teacher-designers completed two additional cycles of comparison and revision of individual
course design work, which included their insights from comparisons with the work of peers to improve
Some key features of ACDPE’s design were:
• A framework for analysis and design that alerted teacher-designers to the main areas on which they needed
to focus: the ACAD framework coupled with H2m pedagogy.
• A new template intended to scaffold the work of teacher-designers. The template embodied some of the
core ACAD and H2m ideas, including requiring teacher-designers to make their design rationales explicit,
in order to help students complete or co-configure those designs.
• A process for supporting the development of the teachers’ design work, based on Nicol’s (2020)
ACAD framework and H2m design
ACAD, the Activity-Centred Analysis and Design framework (Goodyear & Carvalho, 2014; Goodyear, Carvalho
& Yeoman, 2021), treats learning activity as an emergent phenomenon. It cannot be entirely predicted in advance.
While it acknowledges that learning activity can be influenced and shaped by a number of design choices made
in advance—tools, tasks and social arrangements—the ability to distinguish between such ‘designable
components’ and ‘emergent learning activity’ is crucial.
ACAD draws attention to three structural dimensions of design: set design, epistemic design and social design
(Figure 1). These situate emergent co-configuration and co-creation activity at learntime. Structural elements
related to the material and digital tools and resources, including furnishings and spatial arrangements, are framed
as part of set design. Tasks and other suggestions of things for learners to do are part of epistemic design. The
social organization of learning—groupings, divisions of labour, roles, etc.—is part of social design.
Figure 1: ACAD framework (adapted from Goodyear & Carvalho, 2014, p.59)
Our H2m design framework is based on ACAD, with a particular emphasis on flexibility and adaptability, and
an openness to imperfection, messiness, and unpredictability. Thus, two main features of the ACAD
conceptualisation of the design problem space are helpful with respect to H2m. Firstly, ACAD emphasises the
proactive role of students in interpreting, customizing and fine-tuning what has been designed for them. University
students routinely reconfigure the tasks that have been set, the spaces in which they work, and the roles and
divisions of labour suggested to them by teacher-designers (Goodyear, 2015; Sun & Goodyear, 2019). So learning
situations are not predetermined by design; they emerge from embodied learner interaction with a task in the
world – rather in the way that Dourish (2004) conceives of emergent ‘contexts’ in HCI. Students play a key part
in completing designs. This has several implications. They need to understand the logic of what has been designed
for them, in order to complete the designs in productive ways. They need to understand how to make productive
adaptations quickly, when circumstances change (e.g. when moving activities from hospital to home, because of
a lockdown). Indeed, knowing how to create productive learning environments—how to reconfigure congenial
hybrid learning spaces—is an important but rarely acknowledged component of becoming an autonomous learner
(Trede et al., 2019). In other words, ACAD draws teacher-designers’ attention to the breadth and importance of
student agency, and this is particularly important in the diverse and unstable study settings of students during the
Secondly, ACAD distinguishes between epistemic (task), physical and social design components to make it
easier for teacher-designers to focus on each of these in turn, when possible, while not losing sight of the fact that
they become entangled (and hard to separate) at learntime. Thus, when an on-campus learning activity has to be
redesigned for H2m, ACAD makes it easier, at design-time, to think through the implications for changes in each
of the three kinds of design components. A change to the nature of a task may have implications for physical
design and vice versa. The loss of an element of the social design may be compensated by a tweak to the task
design, etc. Of course, it may not always be possible, during design, to separate the epistemic component from
physical or social components (e.g. a learning task for using an ECG machine cannot be designed without
considering features of an ECG machine), but this does not reduce the usefulness of the analytical activity. Rather,
it helps identify those aspects of design where change in one component (e.g., physical space or equipment) can
be consequential for learning. The challenges of H2m caused by the need to distance physically do increase the
importance of examining the limitations of any given learning situation.
Both the template and the design of ACDPE itself were underpinned by these considerations.
Templates have a long history in professional work: providing scaffolding that enables novices to accomplish
complex tasks that they do not yet have the skills and understanding to complete autonomously (Markauskaite &
Goodyear, 2017a; Turnbull, 1993). The teacher-designers were supported by a customised template in which they
articulated the learning tasks and rationales for their courses, and which made the design thinking process more
visible and tangible (Markauskaite & Goodyear, 2017a). The template foregrounded core design elements, and
reminded teacher-designers about the need to consider relationships between those elements. It incorporated the
ACAD dimensions and H2m sensitivities as highlighted above, and invited teacher-designers to reflect on issues
that are deeply entangled in design for learning but often left implicit (e.g. values, knowledge and background of
the learners, the pace of engagement in activities). It also prompted teachers to think about how to foster robust
connections between what students are learning and doing, and their future professional activities and experiences
(Markauskaite & Goodyear, 2017b).
The first part of the template scaffolded overarching ideas that would inform each course and help situate the
design within a particular context (Table 4.2).
50-150 words about the course.
Purpose & Aims
What is the point of the course, what should it achieve?
Who are the learners, how many, what are the expected challenges?
Beliefs about what is important and how learners best learn.
How long is the course, how is it structured?
How are knowledge and performance connected to outcomes and values?
Table 4.2: Template section 1—overarching ideas
The second part of the template invited teachers to focus on the design of learning tasks (Table 4.3). Again,
scaffolds were provided to break down complexity and guide teacher-designers in considering multiple,
overlapping design elements.
Task instructions (epistemic design)
How students should do the proposed task
Prompts to consider digital and material resources
Prompts to consider social arrangements (e.g. pairs, groups, scripted
When this task would run, how many hours of learner’s time, how
would they pace themselves.
Learning before/ during/ after
Prompts to think beyond the direct learning from the immediate task,
by also asking what students would need to know beforehand to
succeed at the task, and what they would need to do afterwards to
consolidate that learning.
A reflective prompt asking why the task was designed in this
How the teacher would ascertain how well the chosen design worked.
Table 4.3: Template section 2—details of design elements
The third part of the template invited teacher-designers to engage with design at a higher level of abstraction.
Teachers were prompted to attend to significant relationships, such as alignment between tasks, assessments and
intended course outcomes, and to write an overarching rationale stating how they saw design elements combining
into a coherent whole in ways that enacted their values. The last prompt asked teacher-designers to reflect on how
their design would help students to understand what they had learned and what they would still need to learn in
future (before and during qualified professional practice). We saw this as a particularly important aspect of H2m,
where circumstances might make it impossible to meet the original intended outcomes of the course.
Comparison and dialogue
The ACDPE course followed a “design and compare” process, based on David Nicol’s model of self-generated
or “internal” feedback (Nicol, 2020) which advocates asking learners to explicitly compare their own work with
that of others. Teacher-designers produced design work (scaffolded by the template) and then compared their
designs with the work of their peers. The aim was to create opportunities for them to progressively draw out
principles and parameters of good course design (e.g. by pointing out differences and discussing why these
matter). Resources (e.g. journal articles, blog posts, Twitter conversations, infographics or videos) were also used
as comparators with the teacher-designers’ own understandings, principles and designs. A separate template
scaffolded the comparison process.
Part of the rationale for using Nicol’s (2020) comparison model was that educating professionals can be a
complex enterprise, where one size does not fit all. The structured moments of comparison reduced reliance on
expert-designers as sources of wisdom, and created possibilities for teacher-designers to generate their own
meaningful connections, insights, and sustainable design principles.
Details of the design and comparison templates, the course structure, and the task instructions are available in
our open educational resource workbook (https://open.ed.ac.uk/agile-course-design-for-professional-education/).
Lessons Learned: Case Example
We used a case study approach (Yin, 2003) to draw out some challenges and contextual considerations of H2m
design for complex medical practice. For this chapter, we have selected the case of participant Morag
(pseudonym), who, for the ACDPE course, designed a 3-week module in Emergency Medicine to help 30 final
(6th) year undergraduate medical students learn to work “as a core part of a clinical team, seeing patients,
practising clinical skills.” Morag is a Consultant in the Emergency Department (ED). She is highly experienced
as both clinical practitioner and educator but has had very little experience with online or hybrid education (though
she had recently taken the online teaching course). She has a diverse group of UK-based and international students
with some professional placement experience but her students usually have had little experience of seeing patients
independently, making clinical decisions and seeing “the spectrum of sick patients that present to the ED.” Morag
identified some common challenges for her students: “Navigating the busy (at times chaotic) environment of the
ED without feeling lost; some need more guidance than others to get ‘hands on’.”
Morag’s case is instructive because it emphasises the importance of compassion, collaboration, and a safe and
supportive learning community, while dealing with complex practical and logistical challenges. For example,
across the practical modules of the undergraduate medical programme, part of Morag’s role involved coordinating
a large number of clinical teaching staff working in unfamiliar conditions (“We've got 40 tutors who are doing
online learning for the first time”).
Below, we briefly describe three tasks designed by Morag for her students before considering how her proposed
designs address some important themes of H2m. Excerpts are taken, with Morag’s consent, from discussion
forums, tutorials (voice and text chat), and completed design and comparison templates. Ethical approval for the
research was given by the Edinburgh Medical School ethics committee.
“Design your lockdown workspace”
In Week 1, Morag’s group designed a task aimed at helping students to plan a “study space that works for each
individual [student] specific to their circumstances”. It involved students evaluating their current study space,
researching attributes of productive learning environments, and then drawing an achievable, improved study
space. This drawing would be shared with student peers for discussion and comparison. The aim was not only
that students would end up with improved studying conditions, but that they would learn valuable things about
how they study, and also share something of themselves with peers and tutors, thus contributing to the building
of trust and community. In learning about how others were adapting their own spaces, students would develop a
richer collection of strategies, which ultimately could help them cope with constraints imposed by the H2m mode.
In the first individual design cycle, Morag developed an “empathy task” aimed at increasing students’
understandings of what it is like to be a patient. In pairs, students would identify an appropriately complex case,
and then, having obtained the consent of the patient and the other staff, would “shadow” them for a week. From
this, each pair would produce an infographic related to the patient’s, relatives’ and carers’ experiences, and the
students’ reflections on these. The infographics would then be shared with the wider class for discussion. The
shadowing under H2m mode required rethinking social design, as these practical placements were organised in
hospital wards that students could visit in lower numbers than normal, using a tightly-organised schedule.
“The resus case”
In the second individual design cycle, Morag added a task in which students would write a 500-word reflective
account of a real “resus” (resuscitation) case they had seen in the previous two weeks. She explained: “Emergency
Department resus rooms are where the sickest, most time critical patients are treated… Most often errors are
caused by a failure of non-technical skills, rather than a lack of knowledge.” The task built on a tactical decision-
making session that the students would have done in a previous year, with the purpose of helping them to
understand the contribution of “human factors” to clinical errors (e.g. “being HALT (hungry, angry, late, tired),
feeling cognitively overwhelmed and the impact of our emotions”). These accounts would be shared via the
discussion board, with a follow-up task to explicitly compare their account with those of others. This task relied
on learning and sharing strategies about tactical decision-making, and could be quickly adapted and conducted
remotely under an H2m mode.
While there are many facets of Morag’s experience that could be usefully examined, we focus on themes
around: assumptions and inclusivity; structure, flexibility and mess; and future-oriented design.
Theme 1: Assumptions and inclusivity
The “design your lockdown workspace” task recognised that, in an H2m context, supporting students to
configure their own learning environments is important. However, comparison with the designs of other groups
helped Morag to think differently about agency and inclusivity:
“All of these courses will have a wide variety of students who will have different constraints placed on them
during lockdown. Not everyone will have the ability to create an ‘ideal’ study space… asking students to design
a workspace and submit anonymously might help, or could they design their ‘ideal’ workspace and describe three
aspects that they could actually apply to their own workspace…?”.
This insight prompted Morag to turn to research on the current study conditions of university students, which
reminded her that “we need to design learning activities that will not inadvertently contribute towards ‘otherness’
in online learning.” In other words, designers need to be careful not to base designs around unreliable assumptions
about who students are and what their conditions are like. Similarly, following a comparison of her individual
design with Hager and Hodgkinson’s (2009) “Moving beyond the metaphor of transfer of learning” in Week 5,
Morag wrote the following about being mindful of different individual needs when designing tasks like the
“patient journey”, set in complex environments:
“If I designed my course solely around participation in context I may fail to account for the variation between
my learners. If as a student you quickly and easily demonstrate the ED ‘identity’ then you will fit into the ‘social
context’ more easily and be offered more opportunities for participation, than say the quieter student who may
‘get lost’ in the environment of the ED.”
Therefore, scaffolding to help quiet students avoid “getting lost” in clinical settings might usefully focus on
supporting a gradual increase in participation in context.
Theme 2: Structure, flexibility and mess
It was apparent from the teacher-designers’ discussions across the ACDPE course that there was no “correct”
design for complex situations such as H2m. Design required a balance between what needed to be learned, what
the teacher believed in and was comfortable and confident doing, perceptions about the students’ particular needs,
preferences and circumstances, and the available resources. In describing previous versions of her course, Morag
noted that it could be “…very prescriptive about: ‘this is leadership... this is calling for help, this is team
working’…”. She contrasted this approach with results from her colleague’s research, which showed that
“you ask junior doctors what they found stressful about looking after acutely unwell patients… and actually
it's so much more deep and complex. We say to students ‘call for help,’ but actually there are a hundred million
levels under that of who, when, why, my competence, my role, my hierarchy… we've been guilty, probably for 15
years, of oversimplifying human factors.”
Morag’s ACDPE designs featured some careful scaffolding of complexity, with prompts to help students make
sense of dynamic and complex experiences.
“…any tasks that help them structure patient learning opportunities should be beneficial. Without tasks such
as this they run the risk of being passive observers, with limited meaningful learning.”
Morag’s tasks combined structured activities (e.g. brainstorming or reflecting on previous learning and possible
future learning) with scaffolded social interactions aimed at building community and creating opportunities for
peer review and dialogue. Morag also proposed ongoing, informal conversations as an important aspect of the
evaluation of her approach, rather than only evaluating at the end. In this, Morag displayed a developing
understanding of the need to balance preparation, forethought and structure with flexibility. This was particularly
important in the context of H2m, so that teaching practices could be adapted to the particular needs of students on
her course that year, or to other emerging constraints. This was coupled with a growing sense of the impossibility
of controlling “the student experience”, particularly where teaching was done by many different contributors.
“…we're obsessed by trying to deliver the same product to everyone… but over the last week, I've been thinking,
does it actually matter? What they're getting from people delivering what they're good at and what they want to
do is actually better than what we want them to deliver… It doesn't matter what we do, they’re never gonna have
the same experience.”
For Morag, letting go of the perceived need to standardise teaching could free teachers up to teach in ways that
suited and motivated them, and this should have a number of benefits, including a greater capacity to adapt in the
situation. Morag was able to see that what has been designed in advance is actually not static. Rather, design often
evolves through tweaks and adjustments at learntime, and also as students co-configure what has been set in place.
In her design process and in her students’ work in the H2m context, she recognised the importance of avoiding
perfectionism, and the benefit of sharing and discussing early work and thinking in progress. In conversation with
others, she came to the position that for this flexible and adaptive model of teaching, the teacher needs a strong
foundation of relevant knowledge, and sufficient preparation to be able to act spontaneously. She suggested that
others with less confidence might be supported by teaching alongside a more experienced teacher.
“I've kind of decided the only way to do it... it's a massive investment of time but for the first 5 week block I'm
pretty much going to double up with all the tutors just to help that process… So there's someone there who's got
a wee bit more confidence… one of the things with online teaching is, people need support.”
This onerous approach demonstrates that loose design does not mean less effortful design. Morag’s recognition
of the need to balance structure and flexibility within teaching mirrored her design intentions, which were about
scaffolding students to recognise and explore complexity within a high-pressure environment.
Theme 3: Future-oriented design
The H2m context highlighted a principle that we see as relevant to any professional programme: it is not
possible to learn everything that is necessary for future practice. Morag noted that, even outside of an H2m context,
“in reality maybe we have to challenge our belief that graduates are ready for practice and accept that a huge
amount of learning required for this ‘boundary transfer’ will take place after rather than before.” This shows a
shift in Morag’s focus towards helping students to develop a greater awareness of what they actually learn (which
cannot be assumed to mirror the stated learning outcomes), and how this relates to what they will need to learn in
the future—to learn how to learn. It calls for a reorientation of what should be learned in medical school and how
such learning might support what is still to be learned after graduation, which would then form a basis for action,
during and after a course, led by the students themselves. In other words, teacher-designers might recognise the
limits of their control and responsibility, and design for sustainable learning in which the primary aim is not to
produce guaranteed skills or knowledge in their students, but to cultivate the capacity for their students to continue
to develop such skills and knowledge in the future.
Of course, discipline-relevant skills and knowledge will be an important element of this capacity. However,
these should not be seen simply as acquired by and residing within the individual student, but as emergent in
activity in complex settings. In Morag’s regret that previous courses had “oversimplified human factors”, we hear
a call for foregrounding materials, emotions, and embodied experiences within design tasks for medical education.
Our proposed H2m pedagogy advocates making the rationale for this explicit so that students not only complete
the designed tasks in appropriate and meaningful ways, but learn to appreciate these often invisible aspects of the
patterns of professional practice (Markauskaite & Goodyear, 2017a).
Discussion: Designing for H2m learning
ACAD worked well in supporting the design of ACDPE and the teacher-designers. Its use also allowed us to see
that H2m design calls for particular sensitivities. Amongst the main lessons for the teacher-designers were the
need to avoid perfectionism and embrace design messiness. Designers often deal with complex problems to which
there are multiple potential solutions, and teachers cannot entirely predict or control what will happen at learntime.
The H2m context, however, seemed to heighten this unpredictability, calling for flexibility and adaptability.
Teacher-designers also realised that not everything can (ever) be learned, particularly where specialised
physical elements and complex practice are concerned. Designs may have to compensate for unexpected changes
in the physical or social situation, but also for the unavoidable limitations of any educational programme that aims
to prepare students for professional practice.
Teachers constantly zoomed in and out, thinking about individual elements, the relationships between these
elements, and how “design parts” relate to the “learning whole”. Morag’s case demonstrated some central
relations—or dimensions of hybridity—that matter in designs for professional H2m learning.
• Spatial relations: Designs should focus not only on creating shared environments, but also on helping
students fine-tune their individual learning environments so that a whole H2m assemblage—distributed
across physical and digital spaces—works well for them.
• Structure-activity relations: An important area of design decision-making is the relationship between
what is designed ahead of time and what the teacher leaves to unfold at learntime (when more is known
about context, student needs, etc). There is a fragile balance between (too) loose and (too) tight designs.
Advance knowledge of what the teacher, or their teaching assistants, may be able to improvise at
learntime is a factor here.
• Temporal relations: H2m designs for professional education need to extend over longer time scales—
paying more explicit attention to the relationship between current, non-practice learning tasks and
ongoing learning within future practice settings. Students’ awareness of how their learning extends
across time is an important aspect of H2m learning.
Authentic design tasks, scaffolded by the template, the comparison model, and dialogue with peers, helped
teacher-designers notice these key relations and purposefully design their courses to take account of them. Our
case example has helped us to identify some principles that apply to any domain but are heightened in the H2m
• Inclusivity requires dialogue with students, flexible designs and adaptability at learntime.
• Accept imperfection, mess and incompleteness, and engage in open discussion of the limitations of
the emergent learning activity within the course.
• Discussing these limitations with students can help them prepare for the learning that they need to do
after the course.
This chapter shares some insights drawn from a professional development course to help clinical educators
redesign their courses for a hybrid model, in response to the COVID-19 pandemic and physical distancing
regulations. The course featured a design template underpinned by the Activity-Centred Analysis and Design
(ACAD) framework (Goodyear & Carvalho, 2014; Goodyear, Carvalho & Yeoman, 2021), which provided
adaptable principles that can be applied to hybrid models in dynamic circumstances. The ACAD framework also
illuminated particular sensitivities that are heightened in the context of highly-constrained, unpredictable and
unstable learning conditions. This combination of principles and sensitivities—what we call H2m pedagogy—
encourages teachers to avoid perfectionism and embrace students’ agency, while respecting the need for flexibility
and sensitivity to students’ circumstances and challenges, including scheduling, technology issues, workload and
caring pressures, and mental and physical wellbeing. Thinking about H2m pedagogy and design also helped
recognise and compensate for students’ restricted access to specialised equipment and workspaces, and their
reduced opportunities for participation in complex forms of professional practice. Use of ACAD, the template and
Nicol’s (2020) comparison model helped draw teacher-designers’ attention to the importance of relationships and
dependencies between design components, the relevance of community-building, and the need for richer forms
of student support. These lessons are heightened in H2m, but they apply across a wide range of circumstances.
The authors would like to thank Gill Aitken and Derek Jones for their input into designing and teaching the
ACDPE course and the preceding Online Teaching course; participants in the ACDPE course, especially ‘Morag’;
and David Nicol for his input into and discussion of the design of the comparison tasks.
Peter Goodyear and Lina Markauskaite acknowledge financial support from the Australian Research Council
through grants DP200100376 and DP150104163, which helped fund their contributions.
Ethics approval for this study was given by the Edinburgh Medical School Medical Education ethics
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