Serious safety events as a window into clinical learning environment dynamics: A qualitative situational analysis

Clinical learning environments (CLE) are complex and have not been thoroughly explored from the perspective of advancing conceptual understanding of their unique dynamics. An opportunity to advance this understanding rests in examining specific situations, such as what happens when a student/trainee has been involved in a serious patient safety event.

Shaped by concepts of negotiated orders and discourses, we conducted a qualitative, interpretive study in a large urban university and affiliated health science centre in Canada using document analysis and semi-structured interviews. Documents and interview transcripts were analysed using concepts and tools from Adele Clarke's situational analysis.

Between March 2022 and April 2023, we conducted 17 interviews with staff physicians (n = 6), medical residents (n = 2), safety leaders and/or university administrators (n = 9). Analysis revealed counter-vailing forces that must be constantly interpreted, negotiated and re-negotiated by participants attempting to deliver on the aspirations of the CLE. Furthermore, analysis revealed potentially competing discourses about the nature of learning in the CLE, animating long-standing tensions about the role of the CLE in developing clinical expertise and professional identity.

Our study reveals counter-vailing forces, interacting policies and potential disagreements about the learning imperatives and priorities of the CLE. These counter-vailing pressures shape learning about patient safety. More than learning content or process, invested groups must also learn to negotiate risks and responsibilities distributed across multiple social arenas. These distributions are changing. Understanding these dynamics is essential for educators and researchers seeking to positively influence the CLE. Future CLE research should account for the various pressures acting on health service organizations and the possible implications for educational mandates in these spaces.