You won’t learn until you want to: medical students’ experiences of the educational nature of the clinical environment | BMC Medical Education

The participants in this study included 4 bachelor’s and 2 master’s nursing students, 4 medical students, 4 surgical technologist students, 3 midwifery students, 3 dental students, and 1 laboratory science student. Among the participants, 10 were male and 12 were female. More detailed information is provided in Table 1.

From the analysis of the interviews, 435 meaning units were extracted and grouped into four main categories and eight sub-categories. These items are listed in Table 2.

1-a) The first category extracted from the participants’ experiences was “Ultimately, you are alone”, which includes the subcategories “Passion for Learning” and “Student Under Pressure.” The experience of being in the clinical environment was beautiful for the students; they found it interesting and attractive to see and feel medical subjects up close. Students mentioned that theory serves as an introduction to practical learning; however, they consider theory courses to be dry and are eager to learn in the clinical environment. To such an extent that they study in advance to perform as well as possible in the clinical environment. Participant 20 stated in this regard, “The patient asked me what this medicine is, but I didn’t know. I searched on Google and learned then told him. I try to read in advance so that I can answer the patient’s questions so he trusts me”. Another student mentioned, “I created a telegram channel and told the students in the lower year who are fed up with the dry theory lessons to come to the hospital; for example, I am in the lung department and I can help you. We will see a case together. It had a great impact on their learning” (P: 11).

Students believe that their effort, demand, and search are necessary for better learning. The participants stated “you have to go after it to learn” and “learning happens where I want”. A midwifery student stated: “If I see a doctor teaching an intern, or other groups such as nursing instructors are teaching, I go and listen, or if they are doing practical work, I go and observe. In my opinion, internships and clinical practicums also depend on the student’s curiosity and willingness to work and learn, because we have students who are afraid and do nothing and do not move forward. The student’s courage is very important” (P: 17).

Students tend to be given independence by the instructors after the initial training until they can manage the patient by themselves. Participant 14 stated, “I think the instructor should teach the procedure that we are going to do, then take a test from one of the students, then tell me to do it yourself and tell me the result. If they give us independence according to a certain framework, it will make us progress”.

1-b) Students in different disciplines have mentioned experiencing pressure in various ways. One of these is the numerous duties demanded of the student. One student mentioned, “The work is hard, too much, and there is no time. I am mostly here until the evening, I go home, and I have to come again in the morning. I don’t have much time to study” (P: 3). A surgical technologist student stated, “Most of the personnel sit and eat breakfast while they tell us to go to the operating room and impose the responsibility there on us” (P: 2).

The need to do perform routine ward tasks in addition to studying assigned courses imposes significant stress on students. Participant 19 stated, “In many wards, we can’t sleep even for an hour when we are on duty 24 hours. It really puts a lot of mental pressure on a person. A lot of stress reduces the educational load”. Sometimes, students experience stress due to the way their instructors treat them. For example, Participant 2 mentioned, “We have an instructor who puts so much pressure on us that even the simplest tasks become challenging. If someone makes a mistake, they shout things like, “You made your sterile gloves unsterile! Now hurry up and open the next one! Hurry up!” It really feels like they’re just trying to catch us out, and it makes the whole learning environment really stressful”. Sometimes student stress is caused by a lack of previous experience. Participant 18 stated, “The instructor asked me to do the episiotomy, even though I had no experience at all, not even on a model. I was very stressed”.

The students reported experiencing inappropriate behavior in the clinical environment by instructors and even staff, which was unpleasant and a negative experience for them. Participant 10 says, “There was an empty room, I went to sit in that room, then one of the staff said to go outside and I want to sit. This kind of behavior shows the top-down view and the hierarchical system in the medical field”. Another student stated, “The senior doctor comes and shouts at the resident, then the resident comes and vents his anger on me. When a mistake happens, they say that the student did it, as if they cannot find a wall shorter than the student’s wall” (P: 10).

2-a) Students consider the instructor as their primary source of learning, and perhaps the importance of the teacher’s role has led to the instructor’s performance being under the student’s scrutiny. Instructors provide students with support and self-confidence. Participant 5 mentioned, “At first, I was afraid to enter the operating room and help. The instructor came and helped us, saying that we should go into the environment and do something so that our fear would disappear”. Participant 18 stated about the instructor’s companionship, which gave them self-confidence, “Our teacher said that we should not show fear in front of the patient. We used to do whatever we wanted to do with confidence, as if we had years of experience. The instructor stayed at a distance from us. She would observe, and whenever we felt we couldn’t handle it or thought we were doing something wrong, she would completely understand and help us”.

2-b) From the interviews with the participants, it is evident that they desire proper planning and discipline in the instructor’s activities, which should include a degree of strictness but also be supportive rather than destructive. In this regard, Participant 15 highlighted the importance of the instructor’s persistence, stating, “Some instructors are persistent; it is important to them that the student learns properly. They want the students to be different and literate individuals. However, our faculty is full of instructors who come to complete the mandatory commitment period and do not care about the students at all”.

Students from different disciplines tended to prefer a practical focus in the clinical environment, rather than instructors solely discussing theory. One participant stated, “Our instructors only teach theory. They say, ‘Let’s go to that corner,’ and then they just start explaining theory. Clinical instructors should engage in practical work” (P: 20). Similarly, another participant said, “Instructors should enhance students’ clinical performance. Currently, our instructors teach 80% theory, which is boring” (P: 21).

One of the concerns of the students has been the evaluation method at the end of the course, as they sometimes consider the impact of non-educational factors on the evaluation results to be unfair. A surgical technologist student stated, “Evaluation is not based on learning at all; it is based on appearance. You can go and sit in a corner of the operating room and do nothing, but in the end, because you were accepted by the system in terms of appearance, you will get a good grade.” Another participant stated, “The head nurse is from a particular ethnicity and treats students of that particular ethnicity better. A student of that ethnicity could go to rest for an hour, do nothing in the ward, but still receive better grades than mine” (P: 20).

3-a) Students face problems and deficiencies when they are in the clinical environment, which has led to the emergence of the code “Half and incomplete clinical environment” from their interviews. One of the challenges for students has been the lack of resources; they have not received proper training equipment. Participant 10 stated, “I’m learning the same way; I don’t learn according to the standard. For example, when I see that one sterile pack is used for two people, I learn accordingly, in a half and incomplete manner”. Similarly, dentistry students mentioned, “The problem with our faculty is the lack of facilities. We don’t have many things that we can learn to use. For example, in the endo ward, it is very obvious that everyone should use a rotary and apex locator because, in the future, you will work with these devices in the office, but we don’t have these tools at all”.

In the previous sections, we discussed the issue of students working under pressure despite the existence of such conditions. However, we observe that students do not have proper amenities. A nursing student stated, “In the emergency department of the teaching hospital, we don’t have a chair for students to sit! How long should we stand? There is no proper place to sleep. For example, if you sit down for a moment, the head nurse says in a bad tone, ‘Get up’”. They also talked about the conditions and problems of the dining hall, dressing room, and pavilions.

3- b) The participants do not consider the learning opportunities to be equal for everyone. The lack of specific educational rules and policies in some cases leads to a feeling of inequality among students. For example, in a maternity ward, there is no clear rule about who should deliver a baby-the gynecologist or the midwifery student. While the educational system requires both students to have delivered a certain number of babies by the end of the course, this creates a kind of competition. They discuss the unequal interaction between different disciplines and students. Participant 18 stated, “In the labor ward, there is a challenge between midwifery students and residents about who will manage natural childbirth. Most of the time, the residents manage natural childbirth, but this is the right of the midwifery students”. Participant 7 mentioned, “Once we went to coordinate to find a place to hold a class. The official asked what field of study we were in, and we said nursing. He responded in a bad tone that we don’t have a class for you. Whereas if our major was medicine, they would have classes for us”.

On the other hand, accepting a large number of students that exceeds the educational capacity of the system leads to fewer educational opportunities for each individual. The determination of the number of students for each educational center is done centrally by the Ministry of Health of Iran. Participant 3 stated, “There are too many of us and we can’t fit in the patient’s room. In outpatient clinics, because our number is large and the number of patients is fewer, we have to divide the patients among ourselves, so the number of patients we receive is less”. One of the dentistry students mentioned, “When you enter the class, 20 other students enter with you. How can an instructor teach something to 20 people? Sometimes we can’t even see! how much space is there around the unit to see how the tooth extraction technique works?” (P: 15).

4-a) The participants considered communicating and interacting with others in the clinical environment as necessary for learning, so communication can be considered a key to learning in practice. Students learn and improve by interacting with different people in the clinical environment. Participant 8 mentioned he learned to work with ward equipment from nurses, or Participant 9 stated, “I learned suturing from operating room staff”. Another student says, “Everyone is under pressure and the workload is high in the clinical environment, so I try to find people who are fine and connect with them. For example, I contact the nurse to learn how to administer angiocaths. I like to do something to learn” (P: 11).

Students have also experienced the help and companionship of seniors in facilitating learning. A dentistry student stated, “This may seem like a small thing, but it was very important to put the suction in the patient’s mouth, how to let the patient not feel pain and not be bothered. I learned this from my senior” (P: 1).

4-b) Through their experiences, the students reported that communication with patients and even their companions was a learning experience for them. This learning was not limited to scientific and technical knowledge but also enhanced their social skills. A nursing student stated, “One of the patient’s family members in the nephrology ward was very knowledgeable and answered every question we asked. We learned colostomy care and many other things about that disease” (P: 14). Participant 17 mentioned, “Some patients have good information about their disease; what the test is, what the symptoms are, but there was also a patient who did not know anything”.

Students emphasize that patients are diverse and that it is crucial to communicate with them appropriately. Participant 8 mentioned, “We learned professional ethics in the clinical environment; how to deal with an elderly patient, a child, an uncooperative patient, or someone with financial problems”. A midwifery student stated, “Sometimes patients misbehave; many of them have family problems or have experienced miscarriages. This helped us learn how to treat everyone. In fact, we learn the right interaction in the clinical environment” (P: 18).