Novice students navigating the clinical environment in an early medical clerkship.

CONTEXT: The black box that is student learning in clinical environments is an ongoing research project. Our previous research showed that despite the time that students are given to learn with, about and from patients, some lack confidence for those encounters and see few patients. The study reported here investigated individual and environmental factors affecting medical students' self-directed learning time in hospital.

METHODS: We studied second year students in the four-year postgraduate Melbourne Medical School programme as they undertook the first of their four 9-week hospital placements in medical wards. Each week approximately 10 hours of structured teaching is offered; the remaining time is spent in self-directed learning. Over six weeks, we observed 31 medical students and interviewed 17 of them. The interviews were subjected to content analysis procedures and the observation notes added contextual information to what was said in interviews. We considered the findings through the Experience-based Learning framework.

RESULTS: We found four main themes in the data: finding and contacting patients challenges all students and overwhelms some; the educational design of the placement is a flawed navigational device providing inadequate clarity and security; the physical and social terrain of a large tertiary hospital is replete with obstacles making it easy for some students to stumble and retreat; finally, any positive connection with peers, staff and patients is empowering.

CONCLUSIONS: This study throws light on to the uncertain path of the novice clinical learner illuminating both the intractable aspects of hospital environments and opportunities for pedagogical and affective supports that can compensate. The processes and conditions for self-directed learning time need attention in order to provide for a safe, efficient or successful clerkship experience for all students. Particular effort is needed to sensitively identify those individuals who struggle and suffer on the journey, and provide appropriate support.