Article Text
PDF
Abstract
Introduction The clinical environment is recognised to influence learning for healthcare professionals, with the described challenges likely extenuated in low- and middle-income countries that are tackling resource limitations. There is limited research on factors influencing learning in clinical environments in low- and middle-income countries, with no scoping review on this topic published to date. This review will identify the key factors described to shape learning in clinical environments for healthcare professionals in low- and middle-income countries.
Methods and analysis A scoping review will be performed according to Joanna Briggs Institute (JBI) methodology and reported following Preferred Reporting Items for Systematic reviews and Meta-Analyses extension for Scoping Reviews guidelines. Databases to be searched include MEDLINE (Ovid), Embase (Elsevier), CINAHL (EBSCO), Web of Science, ERIC (Education Resources Information Center) and Global Health (CABI) from 1990 to present with no language restriction. Following abstract and full-text screening by two independent reviewers, data will be extracted by two independent reviewers and presented in diagrammatic or tabular form, accompanied by a narrative summary. Results will be summarised using quantitative and qualitative analyses. Data will be organised using the components of the clinical learning environment to present factors shaping learning, described challenges, outcomes of interventions and reported recommendations for improvement.
Ethics and dissemination Ethics approval is not required. Findings will be disseminated through conference presentations and publication in a scientific journal. Results will be used to inform future studies exploring stakeholder perspectives on clinical learning in paediatric oncology in low- and middle-income countries.
Trial registration details This protocol was registered on Open Science Framework on 5 September 2024; https://osf.io/ysedk.
- MEDICAL EDUCATION & TRAINING
- Education, Medical
- Capacity Building
This is an open access article distributed in accordance with the Creative Commons Attribution Non Commercial (CC BY-NC 4.0) license, which permits others to distribute, remix, adapt, build upon this work non-commercially, and license their derivative works on different terms, provided the original work is properly cited, appropriate credit is given, any changes made indicated, and the use is non-commercial. See: http://creativecommons.org/licenses/by-nc/4.0/.
Statistics from Altmetric.com
Strengths and limitations of this study
This study will be the first to identify and review research on the key factors described to shape learning in clinical environments for healthcare professionals in low- and middle-income countries.
The search strategy was developed iteratively with a research librarian to ensure a comprehensive search in line with study objectives. The review will follow a rigorous approach according to the Preferred Reporting Items for Systematic reviews and Meta-Analyses extension for Scoping Reviews guidelines.
A clinical learning environment conceptual framework coupled with workplace learning theory will be used for comprehensive, structured data collection and presentation for this complex, difficult-to-characterise topic.
A limitation of this study is the lack of stakeholder consultation; however, a trainee based in a low- and middle-income country will be intentionally included in the research team to strengthen methodology.
Introduction
The clinical learning environment (CLE) influences learning for healthcare professionals and students, whose learning is shaped by workplace interactions and activities and their engagement with these.1–3 The CLE is defined as the overlapping space between the clinical patient care setting and the educational context holding formal teaching and assessment.1 Recognised CLE challenges include organisational issues comprising understaffing, service delivery and workload,4 likely exacerbated in low- and middle-income country (LMIC) institutions facing resource limitations. LMICs, defined by World Bank classifications by income level, face greater health challenges related to resource limitations, including access to education, training and mentoring.5 6 Capacity-building interventions are demonstrated to improve health outcomes through their education and training focus.7 8 As large organisations such as the WHO continue to focus on capacity-building initiatives,9 we require systematic knowledge about how learning is shaped in unique LMIC clinical environments so that future endeavours can have maximal impact on workplace learning, and therefore the care delivered.
Vocational learning in practice is recognised across many workplaces and healthcare professions.10–12 The CLE has influence on longitudinal learning skills, including goal orientations and self-regulated learning behaviours, demonstrating its importance for healthcare professionals.13 This environment is recognised to be shaped by social interactions, organisational culture, and physical and virtual components influencing learning.10 Available tools guide organisations by providing frameworks and enabling measurement of the CLE and its domains.14 15 The majority of CLE literature focuses on high-income countries, limiting our understanding and thus our ability to harness the power of workplace learning in the unique environments of LMICs.
Many factors influencing the CLE are likely exacerbated in LMICs, including working conditions and sociocultural factors, reported to be challenging to improve.4 16 Factors negatively influencing junior doctor learning, including underfunded, understaffed and overcrowded clinical environments, are more likely with financial constraints recognised to negatively impact time for educational pursuits.4 Studies of LMIC healthcare professionals describe poor working conditions with limited orientation, supervision and feedback, and resourcing, including staff accommodation and remuneration.17 18 The potential increased readiness for involving junior staff with clinical activities in LMICs is compromised by less available senior support, likely impacting learning.19 In the digital era, learning occurring via partnerships is increasingly performed virtually and may not be context-specific.20 This is likely magnified in LMICs, with fewer local content experts and reliance on external teaching partnerships. Improved understanding of these environments is likely to improve the quality of broader educational initiatives.
Conceptual framework
Workplace learning theory is the theoretical framework for this scoping review, describing learning through practice, local workplace practices and social factors,21 and informing our analysis by sensitising us to the key factors known to shape clinical learning. Social constructivism as our epistemological stance acknowledges how individual learner tasks, activities and settings impact on workplace learning.22 Multiple conceptual CLE frameworks have been described, with complex characterisation due to multiple influencing factors. In clinical environments encompassing varied cultures and resources, exploring social interactions and personal and team factors shaping learning is vital to optimise learning by reflecting unique local practices.22 Pedagogically rich workplace participatory practices or activities are recognised to shape learning outcomes, with each individual’s engagement also impacting learning.22
Gruppen et al developed a CLE framework synthesising multiple conceptual frameworks and incorporating four main components comprising personal, social, physical and virtual spaces, and organisational.10 16 This framing has been used to evaluate CLE measurement instruments, demonstrating variation particularly in measured domains.15 While Billett’s workplace learning theory, highlighting the importance of workplace-based interactions and activities, provides a key underpinning of this study,21 the above conceptual framework incorporates a well-defined structure encompassing additional CLE components, including psychosocial, organisational and material aspects.10 16 Thus, we have used this framework coupled with workplace learning theory to enable comprehensive, structured data collection.
Overall objective
Despite the recognised role of the CLE, there is sparse literature regarding factors affecting clinical learning in LMICs. This scoping review will identify available evidence on factors shaping learning in clinical environments for healthcare professionals in LMICs. Subanalysis will identify for which professions the literature reports and described recommendations for improvement. This study will have an international scope and include healthcare professions across various disciplines and specialities. Characterising factors reported to shape clinical learning will enable health professional educators working in or with LMICs to strengthen educational activities and support advocacy. Collating available recommendations for CLE enhancement would enable further vital research in this complex domain and bolster implementation of successful reported approaches.
An initial preliminary literature search performed on 2 August 2024 on MEDLINE (PubMed) resulted in 67 manuscripts. With the addition of Specific Medical Subjects Headings (MeSH) terms as listed in the search strategy in online supplemental appendix I, 158 citations were obtained. A broader search of PROSPERO, MEDLINE, the Cochrane Database of Systematic Reviews and Joanna Briggs Institute (JBI) Evidence Synthesis demonstrated no current or in-progress scoping or systematic reviews. Our preliminary review found systematic and scoping reviews on related topics, including examination of experiential learning programmes in LMICs,23 interprofessional education in global healthcare,24 and impact of learning abroad programmes.25 However, there is scant research on learning in CLEs in LMICs distinctively, including factors impacting on these environments.
Supplemental material
Our preliminary search results highlighted the scarce available literature for a systematic review. Thus, we chose a scoping review to determine the extent of the literature on learning in clinical environments and associated factors. The overarching objective is to evaluate the literature on factors shaping learning in clinical environments for healthcare professionals and students in LMICs and document any reported recommendations for improvement. With increased global capacity-building initiatives in LMICs, evaluation of learning in these clinical environments is required to better target educational programmes. Obtaining data regarding factors influencing clinical learning in LMICs will allow the design of more effective educational interventions for capacity building in these areas of increasing need.
Review question
This scoping review aims to respond to the following main question and subquestions: ‘What evidence is available on factors shaping learning in clinical environments for healthcare professionals in LMICs?’
Subquestions
For which professions does the literature report on factors affecting clinical learning in LMICs?
What recommendations have been described for improvement of the CLE in LMICs?
Methods and analysis
Inclusion criteria
The inclusion criteria will follow the PCC (Population, Concept, Context) mnemonic following JBI methodology.
Population
This review will consider studies including healthcare professionals and students, including undergraduate and postgraduate learners. Healthcare professionals may include nurses, physicians or medical assistants, community health workers, allied health and healthcare professional staff of any discipline. Due to the vital role of clinical learning in healthcare, studies relating to students across all healthcare disciplines will be included. This review will encompass any clinical environment, including hospitals, outpatient clinics and community health services. Village health workers and volunteers will be excluded due to being based in a different learning environment.
Concepts
This review will consider studies reporting on factors affecting clinical learning.
This includes studies exploring factors affecting learning in the clinical environment, describing challenges for learning in these unique clinical environments and any recommendations or interventions used to improve CLEs. Studies which mention the clinical environment but are not focused on factors affecting learning will be excluded.
Context
This review will consider studies focused on clinical settings in LMICs, as defined by the World Bank,6 with no geographical limitations. Settings include hospitals, primary care clinics and community health settings. Studies referring to high-income countries only will be excluded.
The inclusion and exclusion criteria may be refined in an iterative process as the researchers become more familiar with available literature.
Types of sources
This review will include published, peer-reviewed, quantitative, qualitative and mixed methods literature. Given the barriers to research in LMICs, we expect low availability of studies relevant to our question. Thus, review articles, expert opinion papers, conference abstracts and grey literature will be included. Case reports, case series, clinical guidelines and practice guidelines are not relevant to the question and will be excluded. Studies published within the previous 30 years will be included to align with recognition of the influence of workplace learning theory.26
Study design
This scoping review will be conducted in accordance with JBI methodology for scoping reviews and reported in line with the Preferred Reporting Items for Systematic reviews and Meta-Analyses extension for Scoping Reviews (PRISMA-ScR).27 28 This protocol was registered on Open Science Framework on 5 September 2024.
Search strategy
The search strategy will aim to locate published and unpublished studies. The search will be performed in English, with no language limit applied. An initial limited search of MEDLINE (PubMed) was undertaken to identify relevant articles. Discussions between a librarian at the University of Queensland and the lead researcher (TSR), along with sample included articles to identify key text words and index terms, were used to inform the full search strategy. The search was refined with other team members in an iterative process (CN, AZG, DCM). The search strategy was developed to explore the following core concepts: factors affecting learning in clinical environments, professions for which this learning is reported on and LMICs. The search strategy, including all identified keywords and index terms, was adapted for each included information source. Titles, abstracts and indexed subject headings of sample articles were examined, and a full search strategy was developed in MEDLINE (online supplemental appendix I). Reference lists of included articles will be evaluated for additional articles, and a grey literature search will also be conducted.
Although factors shaping learning will be explored, due to the low anticipated volume of results, the keyword “factor” will not be used in the search to maintain breadth of literature. The search will be focused on clinical placements or clinical learning and combined with Specific Medical Subjects Headings (MeSH) and keywords related to healthcare or healthcare student professions, clinical placements and LMICs. Specifically reported professions or specialities will be manually evaluated and recorded during screening and analysis. Reported LMICs will be verified against historical World Bank data and will include all countries at any time classified by the World Bank as LMIC since 1990.
The databases to be searched for peer-reviewed literature and conference proceedings include MEDLINE (Ovid), Embase (Elsevier), CINAHL (EBSCO), Web of Science, ERIC (Education Resources Information Center) and Global Health (CABI). A search for unpublished studies will include, but not be limited to a broad web-based search and relevant organisation websites relating to clinical education and global health. These include the WHO, World Bank, International Clinical Educators, World Federation of Medical Education, International Association for Health Professionals Education and International Nursing Association. We anticipate that the above approach will be sufficient to capture both peer-reviewed and grey literature.
Study selection process
The screening process will be two-phased: screening titles/abstracts and, if they meet inclusion criteria, a subsequent full-text review. All identified citations will be collated and uploaded into Endnote VX8 (Clarivate Analytics, PA, USA) and subsequently into Covidence (Veritas Health Innovation, Melbourne, Australia), where duplicates will be removed. Titles and abstracts will be screened in Covidence by two independent reviewers for assessment against the inclusion criteria (TSR, DCM). Abstracts in a language other than English that meet the study’s criteria for full review will be translated using an online platform.
Full texts of potentially relevant studies will be retrieved for detailed assessment against the inclusion criteria by two independent reviewers (TSR, AZG). Reasons for exclusion of full-text papers not meeting the inclusion criteria will be recorded and reported. Disagreements arising between reviewers during the study selection process will be resolved with a third reviewer (CN). The search results will be reported in full and presented in a PRISMA flow diagram.29
Data extraction
Data will be extracted from included papers by two independent reviewers using a data extraction tool developed by the reviewers. Extracted data will include details about the source (author, year of publication, reference), main document objective, population (profession of participants and level of training if relevant), context (country of origin, income level and clinical setting), study methods, and key findings relevant to review objectives (factors reported to influence learning in the clinical environment, recommendations for improvement). Workplace learning theory will be used to extract data related to practice curriculum, pedagogic and epistemological practices to enable theory-informed understanding of the CLE in LMICs.21 A draft data charting tool is provided and was adapted from the JBI template data extraction instrument (see online supplemental appendix II). This tool will be revised as necessary during the process of extracting data from each included study, with modifications detailed in the full review. Any disagreements will be resolved through discussion or with a third reviewer. Authors will be contacted to request missing or additional data, where required.
Supplemental material
Data analysis and presentation
Data will be collated, and quantitative and qualitative analyses will be used to summarise results. Thematic qualitative analysis will not be performed, not being the aim of a scoping review.27 Instead, inductive content analysis will be performed with a narrative description of findings and a quantitative description of identified components. The reporting of review findings will be guided by PRISMA-ScR.28 Extracted data will be presented in diagrammatic or tabular form in alignment with scoping review objectives. Specifically, data will be presented per geographical region and per professionals described in the literature to respond to the review subquestions. Basic numerical analysis of the number and percentages of studies per region and type of profession will be used for data presentation. Data will be mapped with a table and organised using CLE components to present factors shaping learning in these settings, describing challenges and outcomes of any interventions. A separate table will be used to collate and describe any reported recommendations in the literature for improvement of clinical learning to further respond to the subquestions. A narrative summary of findings organised around CLE conceptual framework will accompany tabulated and/or charted results, describing how results relate to the review objective and questions. Any protocol amendments will be documented and presented in the scoping review publication.
Stakeholder consultation
This study will not include the optional JBI methodology step of stakeholder consultation; however, an LMIC-based trainee will be intentionally included in the research team to strengthen methodology and ensure relevance.
Patient and public involvement
Patients and the public were not involved in this research, due to not being appropriate for this review topic.
Ethics and dissemination
Approval from a human research ethics committee is not required as no human participants or unpublished data will be used. Findings of the scoping review will be disseminated through professional networks, conference presentations and publication in a peer-reviewed journal. This review will be followed by a quantitative survey and then a qualitative study exploring stakeholder perspectives on available resources and factors influencing clinical learning in paediatric oncology in LMICs.
Ethics statements
Patient consent for publication
Acknowledgments
We acknowledge and thank Mr David Honeyman, Librarian at The University of Queensland for his assistance in the development of our search strategy. This scoping protocol and subsequent scoping review will contribute towards a Doctor of Philosophy for the corresponding author.
Footnotes
X @chnoble, @amyzgray
Contributors TSR conceptualised and designed the project, developed the search strategy and data collection tool, and was responsible for writing the protocol. CN, DCM and AZG made contributions to the conceptualisation and design of the protocol. CN, DCM and AZG provided guidance for the search strategy. CN, DCM and AZG provided edits to the manuscript and all authors have approved the final version of the manuscript. TSR is the guarantor.
Funding The authors have not declared a specific grant for this research from any funding agency in the public, commercial or not-for-profit sectors.
Competing interests None declared.
Patient and public involvement Patients and/or the public were not involved in the design, or conduct, or reporting, or dissemination plans of this research.
Provenance and peer review Not commissioned; externally peer reviewed.
Supplemental material This content has been supplied by the author(s). It has not been vetted by BMJ Publishing Group Limited (BMJ) and may not have been peer-reviewed. Any opinions or recommendations discussed are solely those of the author(s) and are not endorsed by BMJ. BMJ disclaims all liability and responsibility arising from any reliance placed on the content. Where the content includes any translated material, BMJ does not warrant the accuracy and reliability of the translations (including but not limited to local regulations, clinical guidelines, terminology, drug names and drug dosages), and is not responsible for any error and/or omissions arising from translation and adaptation or otherwise.