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 Table of Contents  
ORIGINAL RESEARCH ARTICLE
Year : 2014  |  Volume : 27  |  Issue : 1  |  Page : 15-23

Students perceive healthcare as a valuable learning environment when accepted as a part of the workplace community


1 Department of Clinical Science, Division of Cardiovascular Medicine, Danderyd Hospital, Stockholm, Sweden
2 Department of Clinical Science, Intervention and Technology, Karolinska Institute, Stockholm, Sweden

Date of Web Publication11-Jun-2014

Correspondence Address:
Dr. Anna Kiessling
Department of Clinical Sciences, Karolinska Institute, Danderyd Hospital, SE-182 88 Stockholm
Sweden
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/1357-6283.134296

  Abstract 

Background: The healthcare system is complex and the education of medical and nursing students is not always a priority within it. However, education offered at the point of care provides students with opportunities to apply knowledge, and to develop the necessary skills and attitudes needed to practice their future profession. The major objective of this study was to identify students' views of generic aspects of the healthcare environment that influences their progress towards professional competence. Methods: We collected free text answers of 75 medical students and 23 nursing students who had completed an extensive questionnaire concerning their learning in clinical wards. In order to obtain richer data and a deeper understanding, we also interviewed a purposive sample of students. Qualitative content analysis was conducted. Results: We identified three themes: (1) How management, planning and organising for learning enabled content and learning activities to relate to the syllabus and workplace, and how this management influenced space and resources for supervision and learning; (2) Workplace culture elucidated how hierarchies and communication affected student learning and influenced their professional development and (3) Learning a profession illustrated the importance of supervisors' approaches to students, their enthusiasm and ability to build relationships, and their feedback to students on performance. Discussion: From a student perspective, a valuable learning environment is characterised as one where management, planning and organising are aligned and support learning. Students experience a professional growth when the community of practice accepts them, and competent and enthusiastic supervisors give them opportunities to interact with patients and to develop their own responsibilities.

Keywords: Content analysis, community care network, medical education, supervision, workplace


How to cite this article:
Hägg-Martinell A, Hult H, Henriksson P, Kiessling A. Students perceive healthcare as a valuable learning environment when accepted as a part of the workplace community. Educ Health 2014;27:15-23

How to cite this URL:
Hägg-Martinell A, Hult H, Henriksson P, Kiessling A. Students perceive healthcare as a valuable learning environment when accepted as a part of the workplace community. Educ Health [serial online] 2014 [cited 2019 May 20];27:15-23. Available from: http://www.educationforhealth.net/text.asp?2014/27/1/15/134296


  Background Top


Students' professional training takes place in a complex and rapidly changing environment primarily organised to take care of patients. [1] Situated learning in this context offers possibilities to build a professional identity. [2] However, the complexity and lack of time in acute health care hinder teaching of important skills that future professionals need to master. [3]

The teachers' perspectives on learning will affect almost all decisions concerning curricula, instructions and assessments. [2] In the early 1900s, Flexner published a report on medical education that changed the perspectives on learning among teaching staff within the medical profession. Flexner stated that medical education should actively engage students in clinical learning. However, the clinical environment is different today. Irby asserted, on the basis of Flexner's methodology, that clinical education should: Be standardised with regard to learning outcomes, but individualised with regard to learning processes; integrate theoretical knowledge and practical experience; incorporate habits of inquiry and improvement; and, finally, focus the progressive formation of a professional identity. [4] Aristotle asserted that knowledge could be divided into three dimensions. [5],[6],[7] Applied in the context of education, students obtain episteme or theoretical scientific knowledge at university. Practical training adds the opportunity to use this knowledge in practice, and thereby obtain techne and fronesis, that is practical professional knowledge and ethical sensitivity in professional practice. [8]

The healthcare workplace can be denoted as a "community of practice". [9] Communities of practice define competence by combining three elements according to Wenger: [10] A joint enterprise where the members contribute to the community; mutual engagement where members establish norms and relationships; and a shared repertoire of communal resources like shared norms for collaboration and problem-solving, language, tools and routines. Accepted members of a community share its goals, methods and values, and are expected to contribute to its development. Every community of practice has boundaries. Students' participation in, for instance, a ward community can be described as legitimate peripherals. It is accepted that the students will be in the community for some days, weeks or months. However, are they just "guests" who are there to learn or are they expected to contribute to the development of this community? [11],[12]

Several models of how people develop professional skills have their origin in cognitive psychology. Most models share the idea of stages based on a notion of professional skills as a set of attributes, such as knowledge, skills and attitudes. [13],[14],[15] Dreyfus and Dreyfus [16] developed a five-stage model of professional development: Novice, advanced beginner, competent, proficient and expert levels. In their view, professional skills are not context-free. In this model, the character of skills needed becomes more evident at each level. The more advanced skill levels could only be achieved by experience in practical work situations. According to Dall'Alba and Sandberg, [17] the skills in these models are defined and described as attributes detached from a context, namely, the practice to which they refer. They state that this approach reflects a container view of practice. Dall'Alba and Sandberg [17] have presented an alternate model of professional development in which a horizontal dimension (increasing experience of skill development) and a vertical dimension (embodied understanding of practice) are cornerstones. They argue that each individual's professional development does not occur by a fixed sequence of stages. Professional development of skills depends on the particular profession, the individuals and their needs and knowledge, as well as learning situations.

By participating in a healthcare community, the student is able to receive instructions and practical training during supervision. Supervisors and staff can invite students to observe and mimic actions and interactions to develop and improve their own performance. [18],[19] A skilful clinical supervisor shares with the students how to treat and how to behave professionally and thereby stimulates development and growth. [20] An increased awareness of the pedagogical strategies in use will increase the clinical supervisor's teaching skills, which benefit the students' ability to learn. [21]

Important aspects of a good learning environment are opportunities to experience continuous patient contact, to transform experience into knowledge, to be active, to receive mentoring and feedback and to have time and space for supervision. [22] Reflection and feedback help students by clarifying what good results are, by facilitating reflection on learning and by delivering information to students about their performance. [23] Deep engagement in a task takes time. If supervisors do not have sufficient time, they will not be able to engage with students and learning. [24]

There has been little research exploring students' views of learning when participating in a complex and time-scarce contemporary and ever-changing healthcare community. The aim of the present study was to identify students' views of generic aspects of this healthcare environment that facilitate or hinder learning related to professional competence.


  Methods Top


Setting

Karolinska Institutet, Stockholm, Sweden, provides education at the university level for medical students, nurses and allied professionals. In addition, three university colleges provide nursing education. The Swedish undergraduate medical education programme consists of 11 semesters and the nursing programme of 6 semesters. The first semesters are dominated by theoretical studies, alternating with short periods of workplace learning. The latter parts of both programmes are characterised by patient-focused education, with recurrent periods of workplace learning in different parts of the healthcare organisation, mostly hospital-based. Nursing students have from a few workplace-days in semester one to 15 weeks during semester six. The periods of workplace learning for medical students vary from 4 days during semester one to between 3 and 10 weeks per semester during the rest of the programme.

Participants and Study Design

Medical students during semesters five and six at Karolinska Institutet and nursing students during semesters two to six at Karolinska Institutet and the university colleges completed an extensive questionnaire regarding their perceptions of the clinical learning environment. The nursing students were invited to participate directly after finishing a period of workplace learning. A questionnaire was then sent by regular mail. Medical students were invited to participate at the beginning of semester 6 out of 11. They received verbal information and were offered the opportunity to answer the questions at a scheduled time. Permission to carry out the study was given by the regional ethical board in Stockholm, Sweden. Informed consent was obtained from all students in accordance with the Declaration of Helsinki after receiving information of the purpose, method and planned publication of the study, as well as the fact that participation was voluntary. In order to obtain richer data and a deeper understanding of students' views, we asked a purposive sample of students to participate in an interview.

All medical students answering the questionnaire were in the midst of their studies. Therefore a complementary interview was performed with medical students during the last semester, to be able to compare different experiences of workplace learning during all their studies. The chosen method was based on the work of Patton, [25] who asserted that triangulation can be achieved by combining both interviews and free text answers in a qualitative analysis.

Data Collection

Questionnaire data were collected during 2007-2010. With the above aim in mind, we gathered all free text responses to an open-ended question; "Feel free to leave comments or feedback in general on the clinical education you just have participated in and on the questions in this survey". All statements related to experiences and perceptions of the quality of learning in a clinical environment were gathered, resulting in text material from 98 students. During 2008-2010, interviews were conducted: One group interview with three medical students and two individual interviews with nursing students. Students were chosen to obtain a purposive sample. One moderator and one co-moderator performed the interviews. The moderator's role was to guide the discussion, but not to take part, to share views, to engage in the discussion or to influence the outcome of the interview. The co-moderator's role was to observe, to take notes and to add and ask complementary questions. [26] An interview guide was developed and used, with semi-structured questions built on a preliminary categorisation of free text data. The questions aimed to illuminate learning in the clinical environment, study results, student participation and perceived quality of supervision. The interviews were tape-recorded, the material was played several times and transcribed verbatim by the first author. The medical students received oral information on the study during participation in an optional clinical course at the hospital during semester 11. Three students participated. The nursing students were contacted by e-mail during workplace learning in semester four and six. Upon agreeing to participate, a time for the interview was scheduled.

Data Analysis

As a first step, preliminary categorisation was performed on free text answers in order to focus the interviews on the most relevant content. Then, free text and interview data were analysed together by qualitative content analysis described by Graneheim and Lundman. [27] The method focuses on variations in the content of the text by identifying differences and similarities. The text was read several times to get a sense of the whole. Units of analysis were identified according to the purpose of the study. We identified meaning units focused on students' views of learning in a hospital-based healthcare environment. Each meaning unit was given a code. Meaning units and attached codes were grouped into preliminary categories according to content. Text, meaning units and codes in each main category were read and re-read in order to detect differences and similarities forming subcategories. Then, categories were labelled definitively and grouped into themes. Manifest content, that is, what was actually stated in the data was presented in categories, while themes were seen as expressions of latent content, or interpretation of data. [28] All authors conducted the process of reading, re-reading and categorisation together. [29] Quotes are presented to reinforce the analytical findings. Certain linguistic and grammatical revisions have also been carried out because of the transition between spoken and written language and when texts were translated into English. [30]


  Results Top


In total, 406 students (336 medical and 70 nursing students) returned the questionnaire, with a response rate of over 95%. Quantitative questionnaire data are not presented here. Seventy-five of the medical students, aged 21-44 years, and 23 of the nursing students, aged 22-47 years provided free text answers. Two-thirds of the participants were female.

The students described wide-ranging pedagogically important observations that could be understood to form three themes. Examples of meaning units, categories and subcategories underpinning these themes are presented in [Table 1]. [Table 2] shows a summary of the results with all themes, categories and subcategories.
Table 1: Process of content analysis illustrated by examples of condensed meaning units, subcategories and categories that correspond to the three themes

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Table 2: A summary of themes, categories and subcategories


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Management-Planning and Organising for Learning

This theme illustrates how students understand management, planning and organising for learning, both at the healthcare department and of the educational programme. They identified management and planning of how to relate content and learning activities to syllabus and to workplace as a responsibility of deans and directors of courses in the educational programme. They also used expressions illustrating provision of space and resources for supervision and learning as a responsibility of the healthcare department and its staff. Students described the two management structures as being separate.

Relating content and learning activities to syllabus and to workplace

Statements indicated that students did not understand how time was allocated to different course contents. For example, students had expected more time for workplace learning in order to improve their practical skills.

"Clerkship is a very important learning activity…that should be given more time during the programme" (Nursing student, questionnaire data).

There were expressions illustrating students' satisfaction as being part of an inspiring university college environment with competent teachers, staff and a supportive organisation.

"I feel proud and happy to belong to this school with its amazing competence, enthusiastic teachers and high quality" (Nursing student, questionnaire data).

Students valued opportunities to be a part of the daily work at the ward, and simultaneously learning practical skills. They particularly emphasised the possibilities to practice and demonstrate clinical skills on an authentic patient while the supervisor was watching, and then receiving individual feedback on performance. Opportunities to learn during interprofessional activities were much appreciated.

"I had an opportunity, when a physiotherapy, an occupational-therapy and a medical student and I made a joint home visit, to formulate a care plan. Very instructive and very fun! More of that! (Nursing student, questionnaire data).

The learning objectives as given in the syllabus were not always evident to the students. They were either unclear or too abstract to be used as a guide to workplace learning.

"It's those learning objectives that I'm thinking about because I can't decide by myself how far I should go, and how much I should know" (Nursing student, interview data).

Providing space and resources for supervision and learning

Students did not speak directly about the heads of healthcare departments, but were aware whether the workplace was well-organised and provided quality health care and space for supervision. They realised that supervisors did not always have enough time to tutor and not always sufficient pedagogical competence. They indicated that supervision sometimes was supposed to occur without disturbance or interruption of daily patient and collegial duties.

"Everything went so fast, in a very stressful way, and the supervisor I've got simultaneously had to do a lot (patient-related duties), so it felt like he didn't have time for me…" (Medical student, interview data).

Students described several complicating aspects at the workplace that resulted in unplanned and unpredictable supervision and learning opportunities. Learning sometimes seemed to be what students made of it.

"I've always experienced that what you learn at the ward is very haphazard, depending on who you are and which supervisor you have. In some aspects, it is very worrying what this could imply; it could result in different students learning different things" (Medical student, interview data).

Material prerequisites such as computers, clothes and physical space were important aspects that influenced students' learning opportunities.

"If I start in the pharmacy area… often, as a student, you feel that you're in the way, you stay put in a corner, and there is no space for you" (Nursing student, interview data).

Students felt secure and developed professional skills when they had an opportunity to perform and receive feedback and questions from their supervisor.

"… I've got the same supervisor, who interrogated me continuously on what disease and why, and why do you dispense these drugs, what is this and why all the time; this will make you really active" (Nursing student, interview data).

Workplace Culture

This theme illustrates the students' experience of culture and interactions between employees at the workplace. We identified students' perceptions of hierarchies and of communication at the workplace.

Hierarchies

Certain phrases indicated that students were aware of several hierarchies in the healthcare organisation. Hierarchies within and between different professions seemed to affect learning quality and they perceived that a resident was a better supervisor if resident and chief consultant had trust in each other. Students stated that hierarchies between different professional categories could create barriers to learning.

"Doctors talk to assistant nurses and assistant nurses talk to nurses and nurses talk to doctors. So it doesn't become a hierarchy (with a situation of) 'we are more skilled and you're less so' and so on. Instead, you should respect each other's competence… otherwise it will become a dull atmosphere" (Nursing student, interview data).

There were expressions of negative experiences when one student group was prioritised at the expense of students of another profession at the same time and in the same ward. There were illustrations of how staff could belittle students by not inviting them to participate in teamwork.

"I remember during the surgery course when you sometimes had to stay stuck to the wall in the operating theatre…. you don't learn very much by staying there for several hours where you can barely step forward because then someone is roaring at you to look out. Then you feel that you just want to go home" (Medical student, interview data).

Communication

Students described different and complex interactions that shape workplace culture. They pinpointed the importance of communication and interplay between themselves and the staff.

"A great atmosphere is when the staff communicates with each other and that this characterises everything, which means that the registrar communicates with us… this means more education, and vice versa: A place where you don't communicate with each other… you don't really know what people think and this implies less learning" (Medical student, interview data).

Students identified the importance of being able to reply and to be paid attention to. A supportive atmosphere is when staff approaches students' questions and mistakes openly and as learning opportunities.

"A permissive atmosphere, where you're allowed to make a mistake, where you can ask questions, and there is time to discuss and explore things…" (Nursing student, interview data).

Students expressed the significance of that the head of a ward had legitimacy among staff and that the working team treated each other with respect in a student-friendly atmosphere. They expressed the importance that the head of the ward acted as a good example and welcomed students to the ward.

"I think that the head nurse of a ward should be more open and approach students in a welcoming way. She should set a good example" (Nursing student, questionnaire data).

They pointed out the importance that colleagues accepted and supported the fact that one of them was a supervisor, and that they had time to supervise.

"And then to receive some support from the colleagues and don't have to have responsibility for the most difficult patients at the same time (as you supervise). The others must understand that it takes time to supervise" (Nursing student, interview data).

Learning a Profession

This theme illustrates the students' experiences of supervisors' attitudes and approach to students and their learning. It relates to how they show enthusiasm and build relationships with students. The theme includes students' understanding of feedback on performance and how supervisors support students' professional development.

Attitudes and approach to learning

A competent supervisor acted professionally and explained how the student could think and perform. It seemed important that supervisors felt secure in their role so that the student could be a natural companion during the supervisor's working day. It was important that a supervisor gave them opportunities to perform independently in order to develop professional skills.

"It's very important to have a good supervisor; a good supervisor to me is one who could convey how to think, I'm very focused on that… how I do when I make decisions, what different signs I should consider, what different findings to account for and then to match this with your previous knowledge and create your thesis, the way to proceed" (Medical student, interview data).

It was important that supervisors wanted to supervise and felt that this was an important mission. Students met both good and bad role models. They emphasised the importance that supervisors had confidence in students and supported them to work on their own.

"It's important that a supervisor can teach and then subsequently know when it's time to allow a student to work a little more independent, because you need to be free in some aspects and to feel that the supervisor has trust in you. I think that you learn a lot more when you can feel freer" (Nursing student, interview data).

Show enthusiasm and build relationships

Most of the supervisors were good pedagogical resources if they had sufficient time to supervise. An enthusiastic and engaged supervisor contributed a lot to a good learning environment.

"Now I have a great supervisor who's very engaged and she really wants to teach me everything; she's well prepared and knowledgeable and she's proud to be my supervisor" (Nursing student, interview data).

Students described the value of a good relationship between supervisor and student during patient-based learning.

"I had large problems with my first supervisor. We didn't work together at all, but with the second it worked real fine" (Nursing student, questionnaire data).

Feedback on performance

Students indicated the importance of personal feedback from the supervisor and of receiving opportunities to act and receive feedback on their own performance. When there were too many supervisors, the students had to demonstrate the same knowledge and skills again and again.

"Doing things without feedback is like playing darts blindfolded" (Medical student, interview data).

Students wanted recurrent opportunities to have learning dialogues with supervisors on what they had seen and performed.

"The best is to discuss afterwards with a physician, after the auscultation, to get to know what the physician thought; this usually works well" (Medical student, interview data).

Support professional development

Students emphasised the significance of participation in activities at the workplace. They learned how to perform and communicate professionally by being responsible for care of patients by themselves with support of a supervisor. They wanted to meet different kinds of patients in order to compare patient situations and to reflect on their own performance. They wanted to make a difference, to have a role in the workplace culture by following a patient over time and to participate in planning of care and discussion of diagnosis and treatments.

"To do important things by myself, even if this is just an illusion, as it may be at the emergency ward, it feels nonetheless like it is important that you simply could make proposals and suggest decisions and that sometimes these decisions will be used" (Medical student, interview data).

They saw their practical and theoretical education as separate parts and that the content of patient-focused learning at the ward was isolated from the rest, and considered the theoretical content as more structured and organised.

"The exams are set, the curriculum fixed, the lectures scheduled, but the training at the workplace and patient meetings are a little bit haphazard" (Medical student, interview data).

Students experienced both barriers and facilitators at the workplace that affected alignment between learning objectives and possibilities to develop professionally. Learning at different levels requires different support and supervision. At a novice stage, they merely wanted to watch and learn just enough to pass the exam. Later on, they wanted to learn by themselves and for their future professional identity by working with patients.

In the beginning, it was probably more to achieve necessary scores at an exam; now it's more to learn on your own (future profession)" (Medical student, interview data).


  Discussion Top


This study demonstrated that patient-based education in a healthcare organisation is of great significance and often an appreciated part of students' learning. Their experiences of learning in this environment could be categorised into three themes: Management-planning and organising for learning, workplace culture and learning a profession.

Management-planning and Organising for Learning

The healthcare department, where education takes place, is just a small part of an ever-changing and complex organisation. The medical university and the healthcare organisation is managed and regulated by leaders at different levels with somewhat different goals, missions and even different laws and regulations. Our results indicate that this could create an environment that is not always ideal for education and supervision, from both students' and supervisors' perspectives. These findings are in line with Soemantri et al.,[31] who emphasised the importance of studying and evaluating practical education and of mapping the relationship between educational environments as perceived or experienced by students and their satisfaction.

To create a supportive and creative learning environment for students, the organisation has to provide certain conditions, such as the ability to provide instructive education by assigning time and space for learning. These conditions will affect whether patient-based learning will become meaningful and beneficial for the student. If the organisation plans learning activities thoroughly, the student will experience excellent conditions for learning. These findings can be compared with Hult et al., [32] who stated that there is not always sufficient time for learning in healthcare organisations.

Students have different views on learning objectives depending on their level of competence. Sometimes, they feel that learning objectives of a course are undefined and not aligned with what could be learnt in a specific ward. These facts could confuse students in terms of what to learn and why. Dornan et al.[33] confirmed that central parts of learning are supported by involvement in patient care at a level appropriate given the student's stage of education.

Workplace Culture

The way that communication and interaction takes place in this "community of practice" does affect how staff treats students: If they appreciate students, if students are seen as a necessary evil or as future colleagues. If students are ignored they cannot count on opportunities to participate in daily activities. Dornan et al.[33] confirmed that the ability to be involved in a workplace community is strongly connected to the behaviour of its staff. When students in this study did not become a natural part of the workplace culture, they experienced feelings of not getting enough space, time and room to develop their knowledge and performance. This finding can be linked to Wenger, [11],[12] who pointed out the difference between students being just "guests" there to learn or being expected to contribute to the development of the community of practice.

We see that hierarchies are sometimes ingrained in a workplace culture at healthcare departments. Some of these hierarchies occur within a profession and others between different staff and professional categories or between staff and students, or even between different student groups. These hierarchies degrade the working climate and create barriers to learning. An illustrative description of this in the present study is a student who visited an operating theatre but did not get invited to participate in the surgical activity. We see this as an example of a legitimate but peripheral participant in the community, and of how such a person is treated in the workplace culture. [10]

If students experience hierarchies as ingrained in the workplace culture, it is difficult for them to develop the skills of a professional. This is in line with Sandberg [34] who described that a supportive working climate with respect, cooperation, feedback and information is important to be able to participate in a working team. As expected, students in this study perceive that they learn more by participating in a motivating and permissive healthcare team. Participation in the team facilitates the student's achievement of professional competence and a sense of wholeness, giving the student a positive state of mind.

Learning a Profession

Students perceived that patient-based learning in a healthcare organisation is an important part of their development as a professional and they achieve more professional skills by participation in patient work. This observation is similar to the work of Dreyfus and Dreyfus, [16] who pointed out that more advanced skill levels could only be attained by experience in practical work situations.

The supervisor is a very important person to the student in many ways, especially through their building of a relationship with the student, and in supporting their relationships to patients and by being a professional role model. This is in line with the work of Stenfors-Heyes et al., [20] who stated that, from a supervisor's perspective, a good clinical supervisor stimulates students' growth through positive feedback on their work. They share what it is to be a professional, from possessing basic scientific knowledge to guidance in the social and emotional aspects of the profession. Supervisors show how things should be done, explain to the students what is going on, what they should do and what to learn.

Students who had the opportunity to receive feedback were more satisfied with their placement. Students want to be able to rely on their supervisor, but also to be given the opportunity to take responsibility for patients and to do things with patients on their own. This was also mentioned by Nicol and Macfarlane-Dick, [23] who noted that reflection and feedback help the student to develop professional skills in many ways. Students' in this study indicate, as in line with Dall'Alba and Sandberg [17] a need of and a joy gaining "increasing experience and skill development" as well as an "embodied understanding of practice". Both are substantially facilitated by their acceptance in the community of practice at the ward.

Patient-based learning takes place in a complex environment with several contradictory influences affecting students and their learning. Creating time and space for students and their learning seem to improve students' perception of the value of patient-based education. Future research in this area is needed for a more detailed understanding of factors in complex clinical environments that hinder or facilitate learning.

Given the design of the study, we did not perform any direct observations of student learning in the healthcare environment. The results are based on students' perceptions of their learning. However, we used a triangulated method by gathering both free text answers and interview data from nursing as well as medical students. To increase trustworthiness and transferability further, we have included data from both students at novice and more experienced level. Further, investigator triangulation was applied and all researchers engaged in the analysis contributed different professional perspectives and experiences. [25]

To conclude from a student perspective, a good learning environment is characterised as a space where management; planning and organising for learning are coherent and supportive. Students feel confident if the community of practice at the workplace accepts them. Their learning of a profession is facilitated if competent and enthusiastic supervisors give them opportunities to interact while having their own responsibilities in this community. In the future, further studies should be carried out to illuminate how complex interacting conditions in health care affect the environment in which students learn to become future healthcare professionals.


  Acknowledgments Top


Financial support was provided through the regional agreement on medical training and clinical research (ALF) between Stockholm County Council and Karolinska Institutet.

 
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