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Purpose: There is a paucity of research into the processes surrounding the transition from residency to the position of attending physician. This report retrospectively investigates the question: Are attending physicians adequately prepared and trained to perform the tasks and duties of their new position? This study aimed at formulating a conceptual framework that captures the transition and is applicable beyond discipline- or location-specific boundaries., Method: Individual semistructured interviews were conducted and analyzed using a qualitative, grounded theory approach. Between January and May 2009, 14 physicians were interviewed who had commenced an attending post in internal medicine or obstetrics-gynecology between six months and two years earlier, within the Netherlands. Interviews focused on the attendings' perceptions of the transition, their socialization within the new organization, and the preparation they had received during residency training. The interview transcripts were openly coded, and through constant comparison, themes emerged. The research team discussed the results until full agreement was reached., Results: A conceptual framework emerged from the data, consisting of three themes interacting in a longitudinal process. The framework describes how novel disruptive elements (first theme) due to the transition from resident to attending physician are perceived and acted on (second theme), and how this directs new attendings' personal development (third theme)., Conclusions: The conceptual framework finds support in transition psychology and notions from organizational socialization literature. It provides insight into the transition from resident to attending physician that can inform measures to smooth the intense transition.

Introduction: Identity threats, such as stereotype threat and microaggressions, impair learning and erode well‐being. In contrast to identity threat, less is known about how learners experience feelings of safety regarding their identity. This exploratory study aims to develop a theory of identity safety in the clinical learning environment. Methods: This multi‐institutional, qualitative interview study was informed by constructivist grounded theory and critical pedagogy. Participants were clinical students at three public medical schools in the United States in 2022. Investigators purposively sampled participants for interviews based on their responses to an 11‐item survey with an open‐ended question soliciting students' personal identities and responses to both the racial/ethnic and gender Stereotype Vulnerability Scales. The investigators interviewed, coded, constantly compared and continued sampling until the codes could be developed into categories, then concepts and finally into a theory. The team engaged in critical reflexivity throughout the analytic process to enrich data interpretations. Results: Sixteen diverse students were interviewed. We organised their identity‐salient experiences into identity threat, threat mitigation and identity safety. Participants experienced identity threat through unwelcoming learning environments, feeling compelled to change their behaviour in inauthentic ways or sociopolitical threat. Threat mitigation occurred when a participant or supervisor intervened against an identity threat, dampening but not eliminating the threat impact. Participants characterised identity safety as the ability to exist as their authentic selves without feeling the need to monitor how others perceive their identities. Identity safety manifested when participants demonstrated agency to leverage their identities for patient care, when others upheld their personhood and saw them as unique individuals and when they felt they belonged in the learning environment. Discussion Attending to identity safety may lead to educational practices that sustain and leverage team members' diverse identities. Identity safety and threat mitigation may work together to combat identity threats in the learning environment. In this edition of @medEd_journal, @jbullockruns et al. describe identity safety, where learning environments allow learners to exist as their authentic selves. The figure is worth 1000 words. [ABSTRACT FROM AUTHOR]

During placements abroad, healthcare students are confronted with different personal and professional challenges, related to participation in practice. This study investigates when and how students respond to such challenges, and which coping and support mechanisms students use to overcome these. Twenty-five international students shared their experiences about physiotherapy placement in The Netherlands. Using a critical incident technique, we asked participants to recall events where participation was affected by an unforeseen situation, in or outside the clinic. Further, we explored students' strategies of seeking support within their social network to overcome individual challenges. Two researchers applied thematic analysis to the interview data, following an iterative approach. Team discussions supported focused direction of data collection and analysis, before conceptualizing results. Participants described a wide range of challenges. The scope and impact level of challenges varied widely, including intercultural differences, language barriers and inappropriate behaviour in the workplace, students' personal context and wellbeing. Mechanisms employed by students to overcome these challenges depended on the type of event (personal or professional), making purposeful use of their available network. Students involve clinical staff, peers, family and friends during placement abroad, to make deliberate use of their support network to overcome challenges in participation, whereas the academic network remains distant. Findings may help reflect on the roles and responsibilities of academic staff and other professionals involved with placements abroad. Healthcare programmes should ensure support before, during and after placement is within students' reach. [ABSTRACT FROM AUTHOR]

Context: Longitudinal qualitative research is an approach to research that entails generating qualitative data with the same participants over extended periods of time to understand their lived experiences as those experiences unfold. Knowing about dynamic lived experiences in medical education, that is, learning journeys with stops and starts, detours, transitions and reversals, enriches understanding of events and accomplishments along the way. The purpose of this paper is to create access points to longitudinal qualitative research in support of increasing its use in medical education. Methods: The authors explore and argue for different conceptualisations of time: analysing lived experiences through time versus analysing lived experiences cross‐sectional or via 2‐point follow‐up studies and considering time as subjective and fluid as well as objective and fixed. They introduce applications of longitudinal qualitative research from several academic domains: investigating development and formal education; building longitudinal research relationship; and exploring interconnections between individual journeys and social structures. They provide an illustrative overview of longitudinal qualitative research in medical education, and end with practical advice, or pearls, for medical education investigators interested in using this research approach: collecting data recursively; analysing longitudinal data in three strands; addressing mutual reflexivity; using theory to illuminate time; and making a long‐term commitment to longitudinal qualitative research. Conclusions: Longitudinal qualitative research stretches investigators to think differently about time and undertake more complex analyses to understand dynamic lived experiences. Research in medical education will likely be impoverished if the focus remains on time as fixed. Seeing things qualitatively through time, where time is fluid and the past, present and future interpenetrate, produces a rich understanding that can move the field forward. Lived experiences in medical education, with their starts, stops, detours, transitions, and reversals, determine understanding of events. Longitudinal qualitative research offers a way to gain knowledge into these dynamic journeys. [ABSTRACT FROM AUTHOR]

In competency-based medical education, direct observation (DO) of residents' skills is scarce, notwithstanding its undisputed importance for credible feedback and assessment. A growing body of research is investigating this discrepancy. Strikingly, in this research, DO as a concrete educational activity tends to remain vague. In this study, we concretised DO of technical skills in postgraduate longitudinal training relationships. Informed by constructivist grounded theory, we performed a focus group study among general practice residents. We asked residents about their experiences with different manifestations of DO of technical skills. A framework describing different DO patterns with their varied impact on learning and the training relationship was constructed and refined until theoretical sufficiency was reached. The dominant DO pattern was ad hoc, one-way DO. Importantly, in this pattern, various unpredictable, and sometimes unwanted, scenarios could occur. Residents hesitated to discuss unwanted scenarios with their supervisors, sometimes instead refraining from future requests for DO or even for help. Planned bi-directional DO sessions, though seldom practiced, contributed much to collaborative learning in a psychologically safe training relationship. Patterns matter in DO. Residents and supervisors should be made aware of this and educated in maintaining an open dialogue on how to use DO for the benefit of learning and the training relationship. [ABSTRACT FROM AUTHOR]

Objectives: Managing uncertainty is central to expert practice, yet how novice trainees navigate these moments is likely different than what has been described by experienced clinicians. Exploring trainees' experiences with uncertainty could therefore help explicate the unique cues that they attend to, how they appraise their comfort in these moments and how they enact responses within the affordances of their training environment. Methods: Informed by constructivist grounded theory, we explored how novice emergency medicine trainees experienced and managed clinical uncertainty in practice. We used a critical incident technique to prompt participants to reflect on experiences with uncertainty immediately following a clinical shift, exploring the cues they attended to and the approaches they used to navigate these moments. Two investigators coded line‐by‐line using constant comparison, organising the data into focused codes. The research team discussed the relationships between these codes and developed a set of themes that supported our efforts to theorise about the phenomenon. Results: We enrolled 13 trainees in their first two years of postgraduate training across two institutions. They expressed uncertainty about the root causes of the patient problems they were facing and the potential management steps to take, but also expressed a pervasive sense of uncertainty about their own abilities and their appraisals of the situation. This, in turn, led to challenges with selecting, interpreting and using the cues in their environment effectively. Participants invoked several approaches to combat this sense of uncertainty about themselves, rehearsing steps before a clinical encounter, checking their interpretations with others and implicitly calibrating their appraisals to those of more experienced team members. Conclusions: Trainees' struggles with the legitimacy of their interpretations impact their experiences with uncertainty. Recognising these ongoing struggles may enable supervisors and other team members to provide more effective scaffolding, validation and calibration of clinical judgments and patient management. The authors demonstrate that trainees cope with distrust of their appraisals of uncertainty by rehearsing steps, checking interpretations with others, and calibrating their impressions with more experienced team members. [ABSTRACT FROM AUTHOR]

Context: Transitions in medical education are dynamic, emotional and complex yet, unavoidable. Relationships matter, especially in times of transition. Using qualitative, social network research methods, we explored social relationships and social support as medical students transitioned from pre‐clinical to clinical training. Methods: Eight medical students completed a social network map during a semi‐structured interview within two weeks of beginning their clinical clerkships (T0) and then again four months later (T1). They indicated meaningful interactions that influenced their transition from pre‐clinical to clinical training and discussed how these relationshipsimpacted their transition. We conducted mixed‐methods analysis on this data. Results: At T0, eight participants described the influence of 128 people in their social support networks; this marginally increased to 134 at T1. People from within and beyond the clinical space made up participants' social networks. As new relationships were created (eg with peers and doctors), old relationships were kept (eg with doctors and family) or dissolved over time (eg with near‐peers and nurses). Participants deliberately created, kept or dissolved relationships over time dependent on whether they provided emotional support (eg they could trust them) or instrumental support (eg they provided academic guidance). Conclusions: This is the first social networks analysis paper to explore social networks in transitioning students in medicine. We found that undergraduate medical students' social support networks were diverse, dynamic and deliberate as they transitioned to clerkships. Participants created and kept relationships with those they trusted and who provided emotional or instrumental support and dissolved relationships that did not provide these functions. It is well‐established that relationships are crucial to effective education. Here Atherley et al. explore how relationships change as students transition into clinical training. [ABSTRACT FROM AUTHOR]

Smartphone use is rampant in everyday life and is increasing in: patient management, teaching and learning of medicine and health research. There is untapped potential to use smartphones as research tools in MER for a range of research approaches. Qualitative research is increasingly common in medical education research (MER). Smartphone use as a research tool has not been well explored in MER and this Guide will be useful to researchers considering integrating smartphones specifically in qualitative MER. First, we discuss the potential for smartphones in qualitative MER. Then, we discuss the opportunities and drawbacks for using smartphones in qualitative MER. We then provide three principles to consider when conducting smartphone MER: communication, ethics and reflection. Next we share ten lessons that emerged from the literature and our experiences. We end by looking to the future of smartphones in qualitative MER and hope this Guide provides evidence-based information to optimise smartphone use in qualitative MER. This Guide is important as there is an urgent need to redefine ethical boundaries to account for blurred lines between personal and professional use of smartphones. [ABSTRACT FROM AUTHOR]

Background Learning is in delicate balance with safety, as faculty supervisors try to foster trainee development while safeguarding patients. This balance is particularly challenging if trainees are allowed to experience the educational benefits of failure, acknowledged as a critical resource for developing competence and resilience. While other educational domains allow failure in service of learning, however, we do not know whether or not this strategy applies to clinical training. Methods We conducted individual interviews of clinical supervisors, asking them whether they allowed failure for educational purposes in clinical training and eliciting their experiences of this phenomenon. Participants' accounts were descriptively analysed for recurring themes. Results Twelve women and seven men reported 48 specific examples of allowing trainee failure based on their judgement that educational value outweighed patient risk. Various kinds of failures were allowed: both during operations and technical procedures, in medication dosing, communication events, diagnostic procedures and patient management. Most participants perceived minimal consequences for patients, and many described their rescue strategies to prevent an allowed failure. Allowing failure under supervision was perceived to be important for supporting trainee development. Conclusion Clinical supervisors allow trainees to fail for educational benefit. In doing so, they attempt to balance patient safety and trainee learning. The educational strategy of allowing failure may appear alarming in the zero-error tolerant culture of healthcare with its commitment to patient safety. However, supervisors perceived this strategy to be invaluable. Viewing failure as inevitable, they wanted trainees to experience it in protected situations and to develop effective technical and emotional responses. More empirical research is required to excavate this tacit supervisory practice and support its appropriate use in workplace learning to ensure both learning and safety. [ABSTRACT FROM AUTHOR]

Background: Throughout their careers, doctors and other healthcare professionals experience numerous transitions. When supporting transitions, opportunities for development and learning should be maximized, while stressors having negative impacts on well-being should be minimized. Building on our international data, this study aimed to develop a conceptual model of the trainee-trained transition (i.e. the significant transitions experienced by doctors as they complete postgraduate training moving from trainee/resident status to medical specialist roles). Methods: Employing Multiple and Multidimensional Transitions (MMT) theory and current conceptualizations of clinical context, this study undertook secondary analysis of 55 interviews with doctors from three countries (Netherlands, Cananda and the UK) undergoing trainee-trained transitions. Results: Through this analysis, the Transition-To-Trained-Doctor (T3D) conceptual model has been developed. This model takes into consideration the multiple contexts and multiple domains in which transitions take place. Discussion: This model is significant in that it has several uses and is applicable across countries: to remind doctors, managers and medical educators of the complexity of transitions; to frame and facilitate supportive conversations; and as a basis to teach about transitions. [ABSTRACT FROM AUTHOR]

Introduction: International harmonization of postgraduate medical education is gaining importance in the globalization of medical education. Harmonization is regarded as the establishment of common standards in education, while maintaining regional or local freedom to adapt training to contexts. During the development of a harmonized curriculum, tensions between standardization and contextualization may surface. To allow future harmonization projects to recognize these tensions and deal with them in a timely manner, this study aims to gain insight into tensions that may arise when developing a harmonized curriculum for postgraduate medical education in Obstetrics and Gynaecology in Europe. Methods: Focus groups were held with international curriculum developers to discuss challenges that resulted from tensions between standardization and contextualization when developing a harmonized European curriculum for postgraduate medical education in Obstetrics and Gynaecology. Data were analyzed through conventional content analysis, using the principles of template analysis. Results and Discussion: Tensions between standardization and contextualization in the development of a harmonized curriculum were apparent in two domains: 1) Varying ideas about what the harmonized curriculum means for the current curriculum and 2) Inconsistencies between educational principles and the reality of training. Additionally, we identified ways of dealing with these tensions, which were characterized as 'negotiating flexibility'. Tensions between standardization and contextualization surfaced in the development phase of harmonizing a curriculum, partly because it was anticipated that there would be problems when implementing the curriculum. [ABSTRACT FROM AUTHOR]

Introduction: Telephone talk between clinicians represents a substantial workplace activity in postgraduate clinical education, yet junior doctors receive little training in goal-directed, professional telephone communication. Aim: To assess educational needs for telephone talk and develop a simulation-based educational intervention. Methods: Thematic analysis of 17 semi-structured interviews with doctors-in-training from various training levels and specialties. Results: We identified essential elements to incorporate into simulation-based telephone talk, including common challenging situations for junior doctors as well as explicit and informal aspects that promote learning. These elements have implications for both junior doctors and clinical supervisors, including: (a) explicit teaching and feedback practices and (b) informal conversational interruptions and questions. The latter serve as “disguised” feedback, which aligns with recent conceptualizations of feedback as “performance relevant information”. Conclusions: In addition to preparing clinical supervisors to support learning through telephone talk, we propose several potential educational strategies: (a) embedding telephone communication skills throughout simulation activities and (b) developing stand-alone curricular elements to sensitize junior doctors to “disguised” feedback during telephone talk as a mechanism to augment future workplace learning, i.e. 'learning how to learn' through simulation. [ABSTRACT FROM AUTHOR]

Objectives Undergraduate medical students are prone to struggle with learning in clinical environments. One of the reasons may be that they are expected to self-regulate their learning, which often turns out to be difficult. Students' self-regulated learning is an interactive process between person and context, making a supportive context imperative. From a socio-cultural perspective, learning takes place in social practice, and therefore teachers and other hospital staff present are vital for students' self-regulated learning in a given context. Therefore, in this study we were interested in how others in a clinical environment influence clinical students' self-regulated learning. Methods We conducted a qualitative study borrowing methods from grounded theory methodology, using semi-structured interviews facilitated by the visual Pictor technique. Fourteen medical students were purposively sampled based on age, gender, experience and current clerkship to ensure maximum variety in the data. The interviews were transcribed verbatim and were, together with the Pictor charts, analysed iteratively, using constant comparison and open, axial and interpretive coding. Results Others could influence students' self-regulated learning through role clarification, goal setting, learning opportunities, self-reflection and coping with emotions. We found large differences in students' self-regulated learning and their perceptions of the roles of peers, supervisors and other hospital staff. Novice students require others, mainly residents and peers, to actively help them to navigate and understand their new learning environment. Experienced students who feel settled in a clinical environment are less susceptible to the influence of others and are better able to use others to their advantage. Conclusions Undergraduate medical students' self-regulated learning requires context-specific support. This is especially important for more novice students learning in a clinical environment. Their learning is influenced most heavily by peers and residents. Supporting novice students' self-regulated learning may be improved by better equipping residents and peers for this role. [ABSTRACT FROM AUTHOR]

Purpose: Workplace-based assessments (WBAs) were originally intended to inform learning and development by structuring effective observation-based feedback. The success of this innovation has not yet been established due in part to the widely varied tools, implementation strategies and research approaches. Using a conceptual framework of experience, trajectories and reifications in workplace learning, we aimed to explore trainer and trainee experiences and perceptions of the learning value of WBAs.Study Design: Trainers and trainees who had used at least one WBA in the previous year were invited to participate in semistructured interviews for this phenomenological study. We used a template analysis method to explore and compare the experiences of the two groups, using the emergent themes to develop an understanding of the impact of these experiences on perceptions of learning value.Results: Nine trainers and eight trainees participated in the study. Common themes emerged among the two groups around issues of responsibility and engagement along with (mis)understandings of the purpose of the individual tools. Trainer-specific themes emerged related to the concurrent implementation of a new e-portfolio and perceptions of increased workload. Trainees associated WBA with a training structure support value but could not translate experiences into learning values.Conclusions: WBAs provide trainees with a justified reason to approach trainers for feedback. WBAs, however, are not being reified as the formative assessments originally intended. A culture change may be required to change the focus of WBA research and reconceptualise this set of tools and methods as a workplace learning practice. [ABSTRACT FROM AUTHOR]

Objectives The importance of self-regulated learning ( SRL) has been broadly recognised by medical education institutions and regulatory bodies. Supporting the development of SRL skills has proven difficult because self-regulation is a complex interactive process and we know relatively little about the factors influencing this process in real practice settings. The aim of our study was therefore to identify factors that support or hamper medical students' SRL in a clinical context. Methods We conducted a constructivist grounded theory study using semi-structured interviews with 17 medical students from two universities enrolled in clerkships. Participants were purposively sampled to ensure variety in age, gender, experience and current clerkship. The Day Reconstruction Method was used to help participants remember their activities of the previous day. The interviews were transcribed verbatim and analysed iteratively using constant comparison and open, axial and interpretive coding. Results Self-regulated learning by students in the clinical environment was influenced by the specific goals perceived by students, the autonomy they experienced, the learning opportunities they were given or created themselves, and the anticipated outcomes of an activity. All of these factors were affected by personal, contextual and social attributes. Conclusions Self-regulated learning of medical students in the clinical environment is different for every individual. The factors influencing this process are affected by personal, social and contextual attributes. Some of these are similar to those known from previous research in classroom settings, but others are unique to the clinical environment and include the facilities available, the role of patients, and social relationships pertaining to peers and other hospital staff. To better support students' SRL, we believe it is important to increase students' metacognitive awareness and to offer students more tailored learning opportunities. [ABSTRACT FROM AUTHOR]

Introduction: Recent changes in postgraduate medical training curricula usually encompass a shift towards more formative assessment, or assessment for learning. However, though theoretically well suited to postgraduate training, evidence is emerging that engaging in formative assessment in daily clinical practice is complex. Aim: We aimed to explore trainees' and supervisors' perceptions of what factors determine active engagement in formative assessment. Methods: Focus group study with postgraduate trainees and supervisors in obstetrics and gynaecology. Results: Three higher order themes emerged: individual perspectives on feedback, supportiveness of the learning environment and the credibility of feedback and/or feedback giver. Conclusion: Engaging in formative assessment with a genuine impact on learning is complex and quite a challenge to both trainees and supervisors. Individual perspectives on feedback, a supportive learning environment and credibility of feedback are all important in this process. Every one of these should be taken into account when the utility of formative assessment in postgraduate medical training is evaluated. [ABSTRACT FROM AUTHOR]

Context Why and how do students seek feedback on their performance in the clinical workplace and which factors influence this? These questions have remained largely unanswered in research into workplace learning during clinical clerkships. Research on feedback has focused mainly on feedback providers. Whether and how feedback recipients actively seek feedback are under-examined issues. Research in organisational psychology has proposed a mechanism whereby feedback seeking is influenced by motives and goal orientation mediated by the perceived costs and benefits of feedback. Building on a recently published model of resident doctors' feedback-seeking behaviour, we conducted a qualitative study to explore students' feedback-seeking behaviours in the clinical workplace. Methods Between April and June 2011, we conducted semi-structured face-to-face interviews with veterinary medicine students in Years 5 and 6 about their feedback-seeking behaviour during clinical clerkships. In the interviews, 14 students were asked about their goals and motives for seeking feedback, the characteristics of their feedback-seeking behaviour and factors influencing that behaviour. Using template analysis, we coded the interview transcripts and iteratively reduced and displayed the data until agreement on the final template was reached. Results The students described personal and interpersonal factors to explain their reasons for seeking feedback. The factors related to intentions and the characteristics of the feedback provider, and the relationship between the feedback seeker and provider. Motives relating to image and ego, particularly when students thought that feedback might have a positive effect on image and ego, influenced feedback-seeking behaviour and could induce specific behaviours related to students' orientation towards particular sources of feedback, their orientation towards particular topics for and timing of feedback, and the frequency and method of feedback-seeking behaviour. Conclusions This study shows that during clinical clerkships, students actively seek feedback according to personal and interpersonal factors. Perceived costs and benefits influenced this active feedback-seeking behaviour. These results may contribute towards the optimising and developing of meaningful educational opportunities during clerkships. [ABSTRACT FROM AUTHOR]

Medical Education 2012: 46: 390-398 Context Consultants in charge of postgraduate medical education (PGME) in hospital departments ('lead consultants') are responsible for the implementation of educational change. Although difficulties in innovating in medical education are described in the literature, little is known about how lead consultants approach educational change. Objectives This study was conducted to explore lead consultants' approaches to educational change in specialty training and factors influencing these approaches. Methods From an interpretative constructivist perspective, we conducted a qualitative exploratory study using semi-structured interviews with a purposive sample of 16 lead consultants in the Netherlands between August 2010 and February 2011. The study design was based on the research questions and notions from corporate business and social psychology about the roles of change managers. Interview transcripts were analysed thematically using template analysis. Results The lead consultants described change processes with different stages, including cause, development of content, and the execution and evaluation of change, and used individual change strategies consisting of elements such as ideas, intentions and behaviour. Communication is necessary to the forming of a strategy and the implementation of change, but the nature of communication is influenced by the strategy in use. Lead consultants differed in their degree of awareness of the strategies they used. Factors influencing approaches to change were: knowledge, ideas and beliefs about change; level of reflection; task interpretation; personal style, and department culture. Conclusions Most lead consultants showed limited awareness of their own approaches to change. This can lead them to adopt a rigid approach, whereas the ability to adapt strategies to circumstances is considered important to effective change management. Interventions and research should be aimed at enhancing the awareness of lead consultants of approaches to change in PGME. [ABSTRACT FROM AUTHOR]

Abstract: Objective: The object of this study was to establish what residents in 1994 and 2003 characterised as an ideal clinical teacher and whether differences existed between residents’ views in 1994 and 2003. Study design: Setting: postgraduate medical education in the Netherlands. Subjects: 207 obstetric-gynaecologic residents. Intervention: open-ended questionnaire. Analysis: qualitative data analysis with two coding dictionaries based on current literature. Differences between 1994 and 2003 were estimated using the Chi-square test. Results: Residents preferred the ‘person’ role both in 1994 (42%) and in 2003 (48%). The ‘physician’ role was significantly more important in 1994 than in 2003; the ‘supervisor’ role was significantly more important in 2003 than in 1994 (p <0.05). Seventy percent of the comments related to ‘direct interaction’ (i.e., between residents and clinical teachers), 30% to ‘indirect interaction’ (i.e., clinical teachers’ behaviour affecting residents indirectly). Conclusion: The data showed that almost half of residents’ comments described ‘person’ role characteristics. There was a significant shift in the role ranked second, from the physician role in 1994 to the supervisor role in 2003. The findings highlighted that teachers, in order to be perceived as ideal, should adapt their behaviour to residents’ learning needs. [Copyright &y& Elsevier]

Context The clinical learning climate affects undergraduate medical students’ behaviour, satisfaction and success. Most studies predominantly describe aspects of the clinical learning climate using quantitative methodologies, such as questionnaires. This study aimed to illuminate medical students’ perceptions of the clinical learning climate, and which factors and their interactions explain differences in clinical learning climates. Methods We carried out a multi-method case study. Twelve departments of obstetrics and gynaecology distributed the Postgraduate Hospital Educational Environment Measure (PHEEM), a reliable questionnaire measuring the clinical learning environment, among medical students. After analysis (usinganova and post hoc tests), 14 medical students from the highest- and lowest-scoring departments participated in semi-structured interviews. We analysed the transcribed recordings using a content analysis approach. Researchers agreed on coding and an expert group reached consensus on the themes of the analysis. Results We found a significant difference between departments in PHEEM scores. The interviews indicated that department and medical student characteristics determine the clinical learning climate. For departments, ‘legitimacy’, ‘clerkship arrangements’ and ‘focus on personal development’ were the main themes. For medical students, ‘initial initiatives’, ‘continuing development’ and ‘clerkship fatigue’ were the principal themes. The amount and nature of participation played a central role in all themes. Conclusions Differences between clinical learning climates appear to be related to differing approaches to participation among departments. Participation depends on characteristics of both departments and students, and the interactions among them. The outcomes give valuable clues to how a favourable clinical learning climate is shaped. [ABSTRACT FROM AUTHOR]