Development of hidden curriculum skills in a COVID‐19 vaccination centre

During the COVID‐19 pandemic, many medical students were deployed as vaccinators. This study set out to capture the lived experience of students at a London‐based mass vaccination site, understand what they learned, how this learning compared to their experience of usual medical education and how any identified benefits might be leveraged in a post‐pandemic context.

sometimes addressed, but largely in a secondary capacity.One study of student vaccinators at Stanford University 5 does provide some foreshadowing of the issues faced by contemporary student vaccinators, particularly around vaccine hesitancy and socioeconomic determinants of health.This academic backdrop leaves several questions unanswered, particularly around the student experience of these activities and how front-line clinical practice can support their educational journey.There are also gaps in understanding why some students avoid this kind of voluntary activity, which might inform the design of more inclusive educational activities in future.

| AIMS
This project sought to understand the experience and implications of medical students working as vaccinators in this environment through the following aims: 1. to explore the subjective student experience of front-line clinical responsibility; 2. to compare student perceptions of learning in this context to intended and hidden curriculum areas; 3. to consider how any identified benefits might be realised postpandemic.

| METHODS
To draw out areas of conscious and unconscious competence, as well as the thoughts and feelings evoked by the experience, a phenomenological approach was adopted.

| Setting
Morris House Group Practice is a Primary Care centre in North London, which served as a COVID-19 mass vaccination site, as well as providing vaccination outreach services.Vaccinators worked in pairs, or as individuals with a non-clinical volunteer completing data entry, in clinical rooms.Vaccinators were supervised at arms-length by an on-site senior clinician who was available via two-way radio.Briefings were conducted each morning, to disseminate standard operating procedures, clinical updates, discuss significant events and progress reports.

| Participants
Eligible participants were clinical-years medical students with at least 36 hours of experience in the vaccinator role at Morris House Group Practice.Due to the limited total number of eligible students working at the vaccination clinic, convenience sampling was used to maximise participation.Recruitment was conducted on a rolling basis, by email, during briefings and in clinics.Eight participants were recruited in total.Whilst there was no intention or attempt made to draw conclusions about participant characteristics, such as gender identity, ethnicity or religion, the participants recruited broadly reflected the diversity of those characteristics, in relation to London medical schools.

| Data collection
Semi-structured interviews of up to 45 minutes were conducted through Microsoft Teams* and transcribed by the researcher.
Transcripts were then imported to NVivo † for coding and analysis.

| Analytic approach
Thematic analysis was used, based on the iterative approach of Braun and Clarke. 6The researcher read and re-read interview transcripts to gain a general understanding of the data, before identifying initial codes representing key concepts.Codes were then organised into broader themes based on their similarities and differences.Themes were reviewed and refined through an iterative process of comparing codes and ensuring they reflected the overall dataset.
To ensure the rigour and trustworthiness of the analysis, the researcher engaged in reflexivity, reflecting on their own biases and assumptions throughout the analysis. 6,7Although member checking is a typical strategy for ensuring the validity of the themes, it was not feasible in this study as the participants had moved on to clinical *Microsoft Teams, Microsoft (https://www.microsoft.com/en-us/microsoft-teams/groupchat-software).† NVivo release 1.6.1,QSR International (https://www.qsrinternational.com/nvivoqualitative-data-analysis-software/home).placements, which made it complex to provide secure access to the dataset or codebook.Instead, the researcher consulted with an experienced qualitative researcher to review and validate emergent themes.These themes were then interpreted in the context of contemporary literature in the field.

| FINDINGS
Four major themes emerged from analysis of the data, centred on the opportunities and challenges that emerge from exposure to front-line clinical work, as described below.

| Theme One: Negotiating an evolving professional identity
The concept of professional identity is gradually displacing more generic principles of professionalism in medical education.Participants reflected on their identity, as students, healthcare professionals and team members, aligning with the concept of Communities of Practice (CoP), and the 'constant negotiating of the self' through interaction with those around you. 8 Participants spoke frequently about how they identified themselves to patients.In the absence of specific instructions, participants almost universally introduced themselves as 'vaccinators'.Participants frequently reported feeling the 'medical student' label was unpalatable to patients, despite identifying this way on clinical placements, and frequently dismissed themselves as 'just a medical student', suggesting a degree of dissonance with this label.Reflecting on their return to clinical placement after working as a vaccinator, one participant described how identifying as a medical student now felt 'like a demotion'.
Participants frequently reported feeling the 'medical student' label was unpalatable to patients.
Participants' work as vaccinators also appeared to support development of their overall sense of identity, confidence and belonging, and these impacts appeared to continue after returning to routine clinical placement.It was also notable that participants generally displayed a high degree of confidence in their own approach to consent, whilst being more critical of others.
Participants generally displayed a high degree of confidence in their own approach to consent, whilst being more critical of others.Some adopted a more direct approach to obtaining consent.In this case, the participant appears to take entry into the room as sufficient to imply consent for vaccination.The patient's uncertainty appears to be seen as a barrier to obtaining consent, more than an opportunity to engage in shared decision-making and increase patient autonomy.This contrasted with the approach of participant eight who describes a more patient-centred approach.However, whilst critical feedback received from more senior colleagues appeared acceptable to participants, peer feedback was more frequently challenged or rebutted.Despite this, participants generally described feeling confident in challenging peers and seniors, as a result of the good working relationships within the team.
Whilst critical feedback received from more senior colleagues appeared acceptable to participants, peer feedback was more frequently challenged or rebutted.In terms of reflecting on and coping with more complex encounters, the idea of formal feedback and group debrief was actively suggested by several participants.I've seen other people not injecting correctly and wondered, like, maybe if we all had some kind of formal feedback, [it] would be quite useful for everyone to, kind of, openly discuss what they're not confident with.

(Participant 6)
Participants also broadly complimented the morning briefing, which provided them with up-to-date guidance and feedback on clinical incidents.They also universally appreciated the ability to access senior support via walkie-talkie, in making them feel safe.

| DISCUSSION
This study revealed and confirmed several issues familiar to medical educators, but also demonstrated their relevance to the relatively unfamiliar context of clinical-years medical students working in frontline roles.

| Negotiating an evolving professional identity
In terms of professional identity development, student responses appear to demonstrate meaningful progress towards Kegan's third stage of identity development, 11 in which students move beyond superficial role-playing as doctors, into the socialisation stage, responding and adapting to external expectations, behaviours and professional values.This supports the idea that front-line, multidisciplinary working positively impacts the evolution of professional identity in a way not currently achieved by more passive clinical rotations.However, participants' expressions of identity were often based on flawed assumptions about how patients might respond, raising the possibility that less-confident students in this role might underestimate how patients view them and adjust their developing identities to match this lower expectation.
Front-line, multidisciplinary working positively impacts the evolution of professional identity in a way not currently achieved by more passive clinical rotations.… participants' expressions of identity were often based on flawed assumptions about how patients might respond.

| Unmasking motivations for clinical work
Autonomy and wellbeing are known to be key modifiable contributors to intrinsic motivation, 12 as corroborated in this study, which demonstrated a clear desire by participants to feel independent and clinically responsible.Making these activities mandatory might complicate or detract from this, although optional student-selected modules might offer a good compromise between autonomy and drawing these experiences into the curriculum.The study also reinforced the importance of balancing autonomy with adequate support, whilst highlighting that this balance is likely to vary between students and certainly between student year-groups.

| Developing co-regulated ethical decisionmaking skills
The co-location of students with more experienced near-peers, allied health professionals and general practitioners, appeared to facilitate greater co-regulated learning, which described learning that takes place through interactions with others. 13However, it should be noted that when left to their own devices, students strongly favoured working with friends or other students of similar experience and ability, which potentially dilutes this effect.
Co-location of students with more experienced near-peers, allied health professionals and general practitioners, appeared to facilitate greater co-regulated learning.
Medical student understanding of consent and the legality of student-obtained consent is known to be limited 14 and, whilst some participants reflected on their performance, they more frequently critiqued their peers than themselves.Medical students are known to find delivery of objective or critical peer feedback difficult and anxiety-provoking, [15][16][17][18][19] even after appropriate training, which suggests that these skills should be introduced and normalised early, particularly as peer feedback and mentoring are mandatory Outcomes for Graduates 20 in the United Kingdom.

| Balancing exposure to clinical risk with adequate support
Participants were generally happy to seek routine senior support via walkie-talkie.When considering more formal feedback, consolidation of learning and debrief, despite describing a preference for systematic debrief in interviews, in reality, participants often demonstrated their preference against this.Specifically, students would often opt to leave the clinic on time, rather than stay behind for a debrief, explaining that they felt they could cope without, even after potentially distressing patient encounters.This perhaps highlights the limits of students' insight into their needs, but also the adverse consequences of long working days.
Whilst some reported debriefing informally with colleagues or friends, formal debrief is known to contribute to building resiliency, mitigating burnout and stemming the decline in empathy that can result from 'traumatic de-idealisation and dehumanisation', particularly in early clinical years. 21,225][26] Although prevention is better than cure, it is important to consider how students might be better prepared for such events and how employers and supervisors might be better prepared to identify and support affected students. 27

| Limitations
The author's prior work as a vaccinator at the study site, as well as his roles as an educator and academic introduce several potential biases, although these were considered in the analysis.The COVID-19 context limits the transferability of conclusions to non-pandemic contexts, although the broad themes would likely be preserved, and reduced clinical pressure might facilitate greater opportunity for learning.
The study considered only one UK mass-vaccination site, which was likely run differently to other sites, and with a small group of convenience-sampled participants.Students in the vaccinator role were also likely to be disproportionately motivated compared to their peers, limiting conclusions about students who were less confident, less motivated, or who had other reasons to not take part in the vaccination effort, such as language barriers, or extra-curricular commitments.

| CONCLUSION
Students described clear benefits both to traditional clinical and hidden curriculum skills from taking part in front-line work.These benefits could be leveraged either by trying to reproduce similar opportunities in primary care settings, or by incorporating more responsibility and autonomy into routine clinical placements, using an existing framework such as Entrustable Professional Activities.Further work might consider how to adequately support students in stepping into these more independent roles, how to support greater inclusion in these activities across the student population and how to consolidate learning in more vocational settings, where learning experiences and outcomes may vary significantly.

Johannes
Driessen is an academic GP trainee at King's College London, who previously worked at the study site as a COVID-19 vaccinator.The study formed part of a Master's in Clinical Education at the University of Plymouth.Russell Hearn is a Reader in Medical Education at King's College London and a GP who was the clinical lead for vaccinations at Morris House Group Practice.
Maybe because I said I'm a vaccinator, [patients] might have thought that […] I'm qualified to a certain level, whereas if I said I'm a medical student, they might have thought that I was a bit less qualified.(Participant 4)

(Participant 3 ) 4 . 2 | 4 . 3 |
[…] building confidence in a clinical workplace […] was really, really positive, and I think I've been able to bring that into being on the wards now, 'cause […] I just feel so much, like, more like I'm supposed to be there.Theme Two: Unmasking motivations for clinical work Many aspects of motivation were raised by participants, both immediate motivations for requesting vaccinator shifts, but also motivation for clinical work more broadly, including career intentions.Intrinsic motivators described by participants include a sense of purpose, wanting to support vulnerable patients and local communities, and wanting to improve clinical confidence.I loved the community spirit that it brought, 'cause I'm from here and I wanted to give back to my own area.(Participant 8) Extrinsic motivators were also described, including financial incentives and the opportunity for earlier vaccination.Whilst mentioned frequently, financial incentive was generally described as a secondary motivation.It wasn't much of a key factor [but] now it's definitely a must, just given how long the hours are and how tiring I found it to be.(Participant 6) Perhaps surprisingly, only one student commented spontaneously on possible correlation with academic success as a motivating factor for participation in the clinics.Participants felt that most of the perceived educational benefit was derived over the first few sessions, before tapering off.It was also suggested that long shifts and ongoing commitment might be good preparation for Foundation Year training, whilst acknowledging that this level of commitment might detract from other educational activities.Evoking Vygotsky's concept of the Zone of Proximal Development 9 and the Yerkes-Dodson Law, 10 participants addressed the effect of unfamiliar levels of autonomy, reflecting both on perceived pressures and potential advantages.[…] as a medical student, I had never given anyone an injection, ever.So, it's just like an 'exciting fear', not like an 'unprepared fear'.(Participant 8) Whilst less confident students might struggle with this higher degree of autonomy, some responses supported the idea that more reluctant students may still benefit, if appropriately supported.I'm not the kind of person that usually steps up and takes the lead if I don't have to, so, kind of being put in a position where I have to do it, kind of just helped prove to myself that I can actually do it.(Participant 4) Participants also described their appreciation of interventions which supported their autonomy, such as the availability of support via walkie-talkie.Thinking further ahead, one participant described how their experience of providing continuity of care directly impacted their career intentions, in favour of primary care.[…] I'm definitely going to be a GP based on my experience at the vaccination centre.[…] I loved [it] the most when the person I vaccinated for their first vaccine would end up in my room for their second vaccine and they would remember me.(Participant 8) Theme Three: developing co-regulated ethical decision-making skills Making sound ethical judgements, balancing clinical priorities and providing peer feedback are complex hidden curriculum topics which can be hard to teach, but are fundamental to clinical practice.These concepts appeared throughout participant interviews, particularly in the context of consent.Differences in the approach to consent were demonstrated in the way participants balanced the quality and quantity of patient interactions.[…] there were times where I would see the threshold of what some people accepted as informed consent and I would get a bit wary.But the reason I wouldn't say much is because […] they are here for a COVID vaccine clinic.(Participant 5) This demonstrates a degree of reflection on what level of consent is required under the circumstances.However, as the same participant later explained, this consideration slowly gave way to clinical pressures.[…] unfortunately, I think over time, as we got quicker […] we would accept consent much quicker and much easier.(Participant 5) […] I was like, 'Hi, would you like to come through?'And they go, 'No, not really.'And I'm like, do you consent, or no? Like, what does that mean?But […] even if they were begrudgingly giving you consent, they were still giving you consent […].(Participant 7)

[
…] if […] there was any kind of uncertainty after explaining, I would always say, 'Would you like to go back to the waiting room for a few minutes and just have a think about it?And then you can come back and let me know what you've decided.'And that worked really, really well.Every single one came back.(Participant 8) Participants also reflected on the challenges of providing feedback to peers on their professional behaviours, in the context of shared clinical responsibility for patients.[I] just reminded [the vaccinator] a bit of what consent actually means, without sounding too mean.(Participant 6) […] when I worked with friends I would ask them, 'Oh, why do you say it like this?' Or, 'Why do you do things this way?' (Participant 5)

4. 4 |(Participant 5 )
Theme Four: Balancing exposure to clinical risk with adequate support Whilst participants were already exposed to the clinical environment during clinical placements, the vaccinator role placed them more directly on the 'front line', which increased the chance of exposure to the myriad risks routinely faced by clinicians.Participants described encountering needlestick injuries and clerical or clinical errors, with the potential for patient harm.Several participants recalled patient encounters, during which physical violence was threatened or anticipated and, in some cases, recalled being fearful for their safety.We were terrified of what was happening because it seemed to just get worse and worse.[The patient] seemed to get angrier and angrier, and we had to get [the clinical lead] to come in and deescalate the situation.Some managed to instinctively respond by empathising with patients who might be concerned or afraid, or contextualised patient behaviours after learning from other hesitant patients, for example, about historical racism in medicine.People aren't just difficult.People don't present medically in an anxious way, because they want to, there's always a reason behind that.And it's usually multifaceted and culture and society, class, money [and] education is all really heavily part of that.(Participant 8) Whilst some participants struggled with their experience of angry or hesitant patients, other participants described their exposure to these more complex encounters as a significant positive.I think learning to deal with challenging patients is probably the best thing I've learned.(Participant 6) Although students cannot be protected from encounters like this, it was highlighted that students earlier in their training may need more support in this context.In hindsight, if I was a bit younger, I maybe would have struggled with it, like if I was a second year doing vaccinating, I think that maybe the patients who were a bit mean to me would have upset me more ….(Participant 3) Another solution might be to identify existing programmes with high patient throughput in primary care, outpatient or community settings, such as sexual health clinics, which might be adapted to accommodate medical students.Seasonal vaccination programmes might come closest to providing the economies of scale offered by the COVID-19 vaccination programme, although the familiarity of the population with influenza vaccination might blunt some of the challenge that made COVID-19 vaccination potentially more educationally enriching for student vaccinators.