Improving transitions between clinical placements

Background: Students regularly transition between clinical learning environments as they rotate through their clinical placements. These transitions are stressful for learners, as they must navigate unfamiliar policies, people and physical spaces. It is important to reduce cognitive overload at the start of each placement through appropriate inductions. Our governance processes found there was significant variation between induction processes at our affiliated teaching-hospital sites: our aim was to optimise and standardise these. Approach: We opted for induction websites for each of our affiliated hospital sites, as these could be dynamically updated and quality assured. Our websites were informed by a conceptual framework of the clinical learning environment and the theory of sociomateriality. We co-produced them with students and other stake-holders through iterative evaluation and improvement cycles. Evaluation: To elicit end-user analysis, we conducted three focus groups with 19 students. We used the technology acceptance model to inform our topic guide and coding categories. Students reported that the websites were useful, easy to use, and fulfilled a significant unmet need. Implications: Induction websites can be optimised through the involvement of a range of stakeholders and the application of theory. They can be pushed to students before each new placement and used to scaffold in-person inductions. Further research is needed to explore the wider impacts of improved site inductions on participation and engagement with clinical learning opportunities and on student satisfaction and experience.

Approach: We opted for induction websites for each of our affiliated hospital sites, as these could be dynamically updated and quality assured. Our websites were informed by a conceptual framework of the clinical learning environment and the theory of sociomateriality. We co-produced them with students and other stakeholders through iterative evaluation and improvement cycles.
Evaluation: To elicit end-user analysis, we conducted three focus groups with 19 students. We used the technology acceptance model to inform our topic guide and coding categories. Students reported that the websites were useful, easy to use, and fulfilled a significant unmet need.
Implications: Induction websites can be optimised through the involvement of a range of stakeholders and the application of theory. They can be pushed to students before each new placement and used to scaffold in-person inductions. Further research is needed to explore the wider impacts of improved site inductions on participation and engagement with clinical learning opportunities and on student satisfaction and experience.

| INTRODUCTION
Transitions within medical education are dynamic processes in which individuals move from one set of circumstances to another. 1 Major transitions include the change from 'pre-clinical' classroom environment to the 'clinical' patient-focused environment, from student to doctor, and from junior doctor to consultant. 1,2 These major transitions happen infrequently; a more regular occurrence is the transition between clinical learning environments (CLEs). In the later years of their degrees, students rotate through a series of clinical placements, in order to experience a diversity and breadth of practice necessary to develop specialty-specific expertise. 3 For example, at our institution, fifth-year students rotate through 11 clinical placements, in specialties ranging from obstetrics and gynaecology to psychiatry. 4 Our aim was to standardise and optimise clinical placement inductions to reduce the cognitive load and educational 'dead space' associated with moving between CLEs. Each CLE is a unique, complex and dynamic interplay of personal, social, organisational and material factors, 5 and each requires acclimatisation. 1,6 An analogy might be a child moving school, or consultant starting work at a new hospitalthey have the same role, but within a different environment. The change in environment places an increased cognitive burden on students. They need to understand who is who, where things are and how things are done locally before they can fully engage in the new CLE. 7 That is, there is likely to be educational dead-space at the beginning of each rotation whilst students navigate unfamiliar people, roles, policies, procedures, timetables, systems and physical spaces. 8,9 The importance of these situated stressors has been fore fronted recently in the medical education literature through the theory of sociomateriality. Those 'thinking sociomaterially' 10 acknowledge rather than deny 'the constitutive entanglement of the social and the material in everyday life'. 11 Our aim was to standardise and optimise clinical placement inductions to reduce the cognitive load and educational 'dead space' associated with moving between CLEs.
A good induction (also called orientation) can help overcome some of these situated stressors. 8,12,13 We heard this consistently and repeatedly from students through our governance processes at affiliated teaching hospital sites. We also heard that inductions were of variable quality between hospital sites. We sought to improve quality by identifying and then providing information that students sought regardless of site.

| APPROACH
We opted for induction websites for each of our affiliated hospital sites, with the intention that these would support and augment existing induction processes. Websites were chosen as they could be dynamically updated and quality assured; private and secure as they would be situated within our virtual learning environment; and accessible, being available to students before, during and after placements. We felt that insisting on standardisation to the point of rigidity was neither feasible nor desirable, given the inherent variation between hospital sites, nor would websites in isolation provide the necessary social or human connection to a new site, hence our desire to retain live inductions.
We opted for induction websites for each of our affiliated hospital sites, with the intention that these would support and augment existing induction processes. We adopted a participatory, theory-driven approach involving iterative evaluation and improvement cycles. The website content and design was grounded in the theory of sociomateriality 7 and Gruppen and colleagues' conceptualisation of the CLE 5 ( Figure 1). Our initial co-design process involved a range of stakeholders, including eight members of our digital team, two students, six faculty and four members of the undergraduate medical education team at a partner hospital known for exemplary inductions. A prototype website was circulated and iteratively improved until all were satisfied, at which point it was launched live to students. We adopted a participatory, theory-driven approach involving iterative evaluation and improvement cycles.
We then started to build websites for our other teaching hospitals (15 in total). In parallel, we conducted three post-implementation focus groups with six, nine and four students respectively to elicit end-user feedback. We used the technology acceptance model (TAM) to inform our topic guide and coding categories, which states that users will adopt a new technology if they find it useful and easy to use. 14 The TAM is well validated and, despite some criticisms, 15 continues to be the leading model for technology acceptance. 16 We preferred it over subsequent developments for its simplicity. Feedback was audio-recorded, transcribed verbatim and thematically analysed. We adopted a deductive approach, coding all relevant content and grouping codes into the categories defined by the TAM. 17 We used the feedback to iteratively improve and modify the design and content of the websites, and to inform our evaluation, which is ongoing and will include data analytics and quality assurance of website content. We received ethical approval through the Education Ethics Review Process of Imperial College London (EERP2122-074).

| Pre-implementation stakeholder perspectives
Content that was suggested by stakeholders during the co-design process included often neglected but important material information such as locker codes, locations of microwaves, electronic access arrangements and prayer facilities, amongst others. Our Generation Z students were clear that the website should be visually attractive, easy to use, and with photographs and videos (for example, walkthroughs and virtual tours). To provide this, we engaged a professional photographer and videographer and obtained permissions from press teams at our affiliated hospitals. Local education teams were keen to include site policies, such as dress code and absence reporting.
Faculty suggested bespoke webpages relating to welfare, raising concerns and needlestick injuries, which were areas of focus for the medical school. End-user feedback focused on the usability of the website, for example, students wanted the information about lockers to be made more prominent and suggested locating this information in an 'essentials' section. The results of these co-production efforts have now been included into our induction websites (Figures 2 and 3).
Our Generation Z students were clear that the website should be visually attractive, easy to use, and with photographs and videos (for example, walkthroughs and virtual tours).

| Post-implementation end-user perspectives
End-user feedback relating to perceived utility is presented in Table 1 and perceived ease-of-use in Table 2

| Perceived usefulness
Students reported that the websites were useful as they provided valuable, relevant information that helped them feel supported before and during their placement (Table 1).

| Perceived ease of use
Students reported that the websites were easy to use as they were well organised; intuitive to navigate; enhanced by photographs and videos; and readily accessible ( Table 2).

| Reflection
Significant resources were required to create and sustain the websites. The majority were required during the set-up period. These were provided with step-by-step video tutorials. However, in practice, we found that some also drew on the technological expertise of local clinical teaching fellows. We found that feeding the students' positive comments back helped motivate administrators to change their working practices and remain engaged with the websites.
Other potential strategies for mitigating resource requirements include prioritising hospitals with large numbers of students and spreading the costs with other multiprofessional providers of healthcare education who may also benefit from the resources. In our case, it was considered a worthy investment by the university considering the potential impacts on student experience and satisfaction.
So far, the theoretical risk that the websites might supplant rather than augment existing induction processes has not happened. Instead, currently, they are underutilised unless specifically emphasised during live inductions. This emphasises the social and environmental aspects of technological uptake. 15 More work is required to ensure students make best use of and benefit from them.
T A B L E 1 Quotes from students regarding the perceived usefulness of the websites. • Induction websites may improve this transition. They can be pushed to students before each new placement and used to scaffold in-person inductions. Data from our focus groups suggests that students found the websites useful, easy to use and fulfilled a significant unmet need.
• Websites can be optimised through the involvement of a range of stakeholders and the application of theory, in our case sociomateriality and a conceptual framework of the clinical learning environment.
• The most significant barrier to implementation is the resource required. We suggest strategies to minimise this, including only building websites for hospitals that host a significant proportion of students and/or coordinating with other local multiprofessional providers of healthcare education.
• The next phase of our evaluation will focus on student usage and quality assurance of content. To do so, we will analyse back-end website data and deploy online surveys.
• Further research is needed to explore the wider impacts of Conceptualization; supervision; writing-review and editing.