Factors influencing the resilience of clinical education in general medicine in Iran: a qualitative content analysis study | BMC Medical Education

Study design

This study employed a qualitative approach and conventional content analysis to describe a phenomenon. By addressing the “how” and “why” of the research, this type of study can yield rich and diverse insights into individual experiences [15]. The qualitative content analysis helps to better understand the phenomenon under investigation [16]. We used qualitative research methods to explore how participants’ experiences shaped their understanding and how that evolved. Content analysis can provide reliable outcomes, generate insights, and guide organizational activities based on textual data [17].

Setting

The present study was conducted at Shiraz University of Medical Sciences, one of the most important medical education centers in southern Iran. This public university, located in the city of Shiraz, was founded in 1946 and consists of various faculties such as the school of health, medicine, nutrition sciences, new medical sciences and technologies, virtual education, nursing and midwifery, paramedical, rehabilitation, pharmaceutics, dentistry, management and information. The university currently comprises 17 faculties with more than 10,000 students, 200 majors, 782 faculty members, 54 research centers, 13 educational hospitals, 49 medical hospitals, and 32 health care networks, and provides health care services to more than 4 million people. In addition to educational and research activities, the university provides services to patients and the needy by providing complex therapeutic activities such as liver, heart and kidney transplantation, along with other advanced therapies, and serves as one of the largest and most prestigious universities in Iran [18].

Participants

Purposive sampling was used in this study. In this type of sampling, participants are selected based on their first-hand experience and knowledge about a phenomenon, and the sampling ends when the data are saturated. Accordingly, the participants were faculty members of the Faculty of Medicine responsible for clinical teaching in university-affiliated clinical centers, specialists in medical education, and students in the clinical phase of general medicine. To ensure maximum variation, faculty members from the clinical education program were selected based on age and diverse work experience. Since clinical training for medical students occurs in the final three years and at different levels, we aimed to maximize diversity in our sample by including students in the clinical semester from various admission years. Exclusion criteria included the participants’ unwillingness to continue cooperation. A total of 16 students and faculty members from Shiraz University of Medical Sciences were selected and interviewed (Table 1).

Data collection

In-depth, semi-structured interviews were conducted in Farsi over eight months, from September 2023 to April 2024, with the permission of the University Vice-Chancellor for Research. Each participant was interviewed individually. Participants’ experiences were extracted according to the study objectives. All participants were asked to recall their experiences from the beginning of their clinical training period until the interview. For example, if a student was interviewed at the end of the 13th semester, the questions covered all their experiences up to that point. The time and location of the interviews (in a private room at the hospital) were arranged with the subjects who agreed to participate.

To start the interview, we first asked a general question: “Tell me about your experience regarding resilience in the clinical education of general medicine?” As the interview progressed, the questions were directed towards the purpose of the research. Based on the responses, we asked the participants the following questions for a deeper understanding of the concept being investigated: “What do you think the characteristics of a resilient clinical education are?” “What are the strategies and motivations for resilience in clinical education in our system?” Probing questions were also asked, such as “Can you explain more?”, “Could you elaborate?”, and “You mentioned that… could you explain further?” At the end of each interview, questions such as “Do you have any other comments?” and “Do you think there is a question that hasn’t been addressed?” were also asked.

All interviews were recorded with the participants’ permission. The first researcher, who had the necessary training to conduct qualitative studies, transcribed the interviews. Only the first researcher knew the participants’ identities, while the other researchers received anonymized interview transcripts. Depending on the interviewees’ conditions and their satisfaction, the duration of the interviews ranged from 30 to 60 min, with an average of 45 min.

Data analysis

Data analysis was performed simultaneously with data collection using the five-step content analysis approach proposed by Graneheim and Lundman [19]: 1. The text of each interview was transcribed word for word, and to achieve a general understanding of the content, we carefully read the text several times. 2. Sentences related to the research topic were identified as meaning units. 3. Primary codes were extracted. 4. The extracted codes were classified into conceptual categories based on similarities and differences. 5. By systematically comparing the initial conceptual categories, more abstract concepts were generated. The analysis was primarily conducted by the first author, with continuous supervision by the other authors. In coding the interview transcript, the researcher noted their own experiences and assumptions (reflexive memos) to consider how these might influence their interpretation. One observer analyzed parts of the data alongside the first author, and interpretations were continuously discussed with all authors at each stage, including coding, grouping of codes, and interpretive levels of the themes, to ensure trustworthiness.

Trustworthiness

For assessment of the trustworthiness of the collected data, Guba and Lincoln’s standards for scientific rigor in qualitative research were used: credibility, confirmability, dependability, transferability [20]. To enhance credibility and dependability, the researcher continuously engaged with the data and reviewed the interview texts multiple times for a comprehensive understanding. This process was further strengthened by ensuring maximum diversity in sampling, member checking, peer checking, and external debriefing. In peer review, two qualified researchers assessed the accuracy of the data analysis. During member checking, some participants confirmed the alignment between the study findings and their experiences. For transferability, clear explanations were provided about various aspects of the study, including sampling, data collection, and the research field. To ensure dependability, we preserved all documents related to the study so that others could verify the study process.

Ethical considerations

The ethical approval for the study was obtained from the Research Ethics Committee of Shiraz University of Medical Sciences (IR.SUMS.REC.1402.250). All procedures were performed following relevant guidelines and regulations, including the Declaration of Helsinki. Before conducting the interviews, the participants were given detailed information about the study objectives, and their signed informed consent was obtained before the interviews were recorded. The anonymity of the participants and their responses was maintained, with pseudonyms or codes used to protect their identities. Participation in the study was entirely voluntary and did not impact academic progress. Participants could withdraw at any time. Interview data were encrypted and stored on a personal hard drive for long-term preservation. We assured the participants that they could view the group findings if desired.

Findings

Out of 16 participants, 10 were faculty members and 6 were medical students. The participants’ experiences and perceptions were extracted and analyzed. Based on the results of the analysis, 12 categories were extracted within three main themes after coding and comparing the codes based on similarities and differences: “Facilitators of resilient clinical education”, “Barriers of resilient clinical education”, and “Prerequisite factors of resilient clinical education” (Table 2).

Theme 1. Facilitators of resilient clinical education

The theme “Facilitators of resilient clinical education” refers to the factors that make clinical education more resilient. Based on the participants’ experiences, this concept pertains to the six basic components: resident as a teacher, collaborative learning, effective communication, support for faculty, resilient at the individual level and valuing expertise.

Resident as a teacher

This category highlights the positive impact of involving residents in internship training and underscores the necessity of utilizing them in critical situations to enhance the resilience of clinical training. According to most participants’ experiences, assistants perform their educational roles more effectively when these roles are defined as duties and obligations within the educational system.

“However, the resident views the sick student from a more relatable perspective, treating them at the same level as an intern student. The resident communicates and explains in an easily understandable way. Additionally, during critical times, the resident’s role in education becomes very prominent.”[F2].

“If residents are going to teach us, it is better if this responsibility is defined as part of their duties from the beginning. When they accept this responsibility, I believe they will be more committed to the training.”[S3].

Collaborative learning

According to the participants’ experiences, one factor that facilitates the resilience of clinical education in critical conditions is the adoption of cooperative education. Accordingly, the elements that lead us to cooperative education are listed below as a subcategory:

Launching a mentorship system

Mentoring in education involves a relationship between two individuals, where the mentor plays a supportive and advisory role for the learner. This relationship enhances the learner’s skills and knowledge through the mentor’s experience. According to the participants in this study, implementing a mentorship system is crucial for high-quality education because it promotes individual growth and development while ensuring the transfer of skills and professional standards to the next generation.

“I believe the mentoring system that started during the Corona period and became common among children was very effective. It established good relationships and was very helpful for those who didn’t know much.”[S1].

Networked learning

Networked learning involves developing and maintaining relationships with people and information. In networked learning, communication is structured so that individuals support each other’s learning. According to the participants’ perceptions, network learning opportunities that can be provided to students in times of crisis, such as during the COVID-19 pandemic, include the formation of learning groups, communication channels, and educational pages on social networks.

“During the initial COVID-19 outbreak, everything became chaotic. However, when we started WhatsApp groups and Telegram channels and stayed in contact, the situation improved. Anyone with educational resources or useful information would post it on the channel, and we would plan to study or share the work.”[S4].

Peer learning

Peer learning is a process in which students learn with and from each other. According to the participants’ experiences, different strategies can be applied for this purpose: student–led workshops, study groups, peer-to-peer learning partnerships, and group work.

“Sometimes, a series of lectures, workshops and group works are determined for them, which they have to do in the groups they have already formed. That means the students themselves are also used for training.”[F4].

Effective communication

Effective communication is the process of exchanging ideas, thoughts, opinions, knowledge, and data in a way that ensures the message is received and understood clearly and purposefully. The participants’ experiences reflect the view that effective communication encompasses teacher-student interactions, peer interactions, and university interactions.

“We could not enter the qualitative world or mental space of our students. It is essential to create a shared quality world between professor and student, as well as among students themselves. This requires resilience.”[F1].

“Establish and strengthen our communication with professors from various locations. Currently, we are jointly conducting our conferences with several universities.”[F5]

Support for the faculty

As to supporting professors, participants have noted the importance of attention to training programs and the promotion of professors.

Teacher training program

The need for clinical professors to complete empowerment courses, facilitate training, increase digital literacy, and address educational needs were among the points mentioned by the participants.

“As I mentioned, teachers play the main role. Therefore, supporting professors, addressing their problems, and focusing on their educational needs are crucial for building resilience.”[F7].

Teacher promotion program

As to the professors’ promotion program, the participants’ statements reflect the need for psychological support for professors, the promotion of efficient professors, and an emphasis on the non-research-oriented nature of the promotion program.

“We should also recognize the dedication of professors. Promotion should not be based solely on publishing articles. Professors sacrificed their lives during the COVID-19 pandemic and did need psychological support.”[F6].

Resilient at the individual level

According to the participants’ statements, one of the motivating factors in achieving resilient clinical education is the individuals’ personal resilience. This resilience is reflected in self-reflection, clinical self-efficacy, perseverance, and job commitment.

“Based on 70 years of continuous education in medical sciences, both general and specialized, a series of promotion keys and indicators of clinical efficiency and resilience can be observed in the professors and the system. These indicators play an important role in the continuation of education.”[F3].

Valuing expertise

Valuing and referring to experts is very important when a crisis occurs. According to the participants’ statements, planning by experts and having academic independence motivate people to be resilient in clinical education.

Planning by experts and academic autonomy

“I don’t know much about these things. There is a need to form specialized working groups to examine all aspects and develop a plan.”[F8]

“Academics should be given the freedom to act. They should entrust responsibilities to their assistants and trust the intelligence and capabilities of those within the university.”[F6].

Theme 2. Barriers of resilient clinical education

Based on the participants’ experiences, the concept reflecting the barriers to resilience in clinical education involves two basic components. The first is the feelings conveyed to physicians by society, and the second is the laws that have been passed.

Sense of community

Sense of community is a feeling of belonging that members have, a sense that they matter to each other and to the group, and a shared belief that their needs are met through their commitment to being together. Based on the participants’ experiences, this feeling is meaningful through understanding one’s job position in society and the trust people have in doctors.

Job position

A job position refers to a person’s specific role in an organization or society, including the job description, responsibilities, location, and requirements related to what the person in that position should know and be able to do.

“What kind of trouble has society brought to doctors that makes them believe they are no longer supposed to learn or do anything? They feel they are just supposed to finish this course, become a resident, or emigrate.”[F5].

Trust in physicians

Trust is a crucial element in any interpersonal relationship, and it is important in the patient-doctor relationship.

“Society has also changed. If you ask the old professors what they did in the past, they say they had to deliver babies, see 20-day-old infants, treat 70-year-old men, and manage myocardial infarctions. They were removing moles, performing circumcisions, and doing limited surgeries because society demanded it. However now, there is a famous saying: ‘See him tonight and I will take him to a doctor tomorrow!'”[F5].

Poorly crafted policies

Poorly formulated policies can lead to confusion, inconsistency, and frustration for those who must both follow and implement them. Based on the participants’ statements, these policies include the heavy workload of clinical professors, non-scientific management, and a treatment-oriented and research-oriented educational system.

“All the medical work in public hospitals that people visit today is the responsibility of the educational system. In practice, the private sector does not carry the burden of treatment. In addition to the educational work, the amount of healthcare work is high, and this treatment load is entirely borne by the professors and the educational system.”[F10].

Theme 3. Prerequisite factors of resilient clinical education

The prerequisites for resilient clinical education refer to the necessary items and initial planning needed to achieve resilient clinical education. Based on the participants’ experiences, this concept can be described in four components: strong knowledge bases, adequate operational sources, sensitivity to possible threats, and the culture of learning from experiences.

Strong knowledge bases

One of the important factors for the resilience of clinical education during a crisis is a strong knowledge base. Based on the participants’ experiences, several factors should be considered for this purpose. These factors are listed as subcategories below:

Complementary courses

Experience has shown that supplementary courses can reinforce and enhance learning. Based on the interviewees’ experiences, these courses can include both face-to-face and online formats, tailored to the needs of the audience.

“Every month, for at least three hours, sometimes in person and sometimes online, I discuss common diseases with them from the perspective of someone who graduated here and understands their needs.”[F2].

Up-to-date educational content

Training content should be updated based on expected skills for better utilization of learning opportunities.

For example, without any pressure, you should have instructed all departments to establish their online lecturing infrastructure and continuously update their content. This content should be periodically reviewed and utilized. The IT department should develop and maintain the online lecturing infrastructure, prepare and deliver it to the departments, and gather feedback from them.”[F4].

Self-directed learning

Self-directed learning is a process in which learners are responsible for designing and evaluating their learning experiences. According to the participants’ perceptions, self-directed learning facilitates learning and self-management in students.

“In my opinion, self-directed learning is the solution, and we should move towards cooperative education. We need to move away from spoon-feeding students. Strengthening self-directed learning at the university level will allow students to make decisions about their own learning.”[F1].

Blended learning

Blended learning, a thoughtful integration of e-learning and face-to-face learning, is popular in medical education. Participants’ experiences highlight the effectiveness of this method in empowering both students and professors.

“We need to prepare videos of some procedures, record them, and provide them to the students. Some procedures should be done in small groups, while others should be presented through lectures. We can also combine various educational models.”[F9].

Up-to-date instructional strategy

Up-to-date educational strategies are crucial for promoting and facilitating learning. According to the participants’ experiences, various strategies can be employed: using modern techniques and simulators, providing feedback, rethinking approaches, and conducting interactive workshops.

“You should avoid using repetitive methods! There are many new techniques available globally that can be adopted, such as simulators and innovative online workshops.”[S5]

Adequate operational sources

Another important prerequisite for having resilient clinical training is adequate operational resources. In this context, participants referred to financial resources and infrastructure development.

“We must recognize that without adequate financial resources, our efforts will be ineffective. Many countries that allocate a budget in advance to address crises experience less damage and achieve their goals more easily.”[F7].

“In my opinion, we should use the opportunity presented by the COVID-19 pandemic to strengthen our infrastructure and maintain those improvements.”[F9]

Sensitivity to possible threats

According to the interviewees, predicting potential crises and having a separate strategic plan for each one are crucial factors in preparing for effective confrontation and resilience against crises.

“We must always have a plan. The education system needs a Plan B so that if something happens, we don’t have to start from scratch. We should be able to switch to a pre-prepared program.”[F10].

The culture of learning from experiences

Developing a culture of learning from past experiences and retaining the lessons learned from crises is essential for resilient clinical education. According to the participants, this can be achieved through organizational learning and knowledge management.

Organizational learning

Organizational learning refers to the process of gathering and transforming the knowledge of the employees in a company into its overall knowledge base [21].

“The virtual experience during the COVID-19 era was a significant achievement. It revealed the weaknesses and strengths of virtual education. We should not dismiss it now by saying that virtual education does not exist. Instead, we should leverage its strengths and address the deficiencies in our educational content. This valuable experience should not be overlooked.”[F10].

Knowledge management

The participants pointed to the creation, collection and storage of knowledge in the direction of knowledge management.

“We must ensure that if a crisis occurs, we have, for example, 100 lectures prepared in advance by our professors. We need to have backups of these lectures and have them recorded and stored securely.”[F5].