Communities of practice: A theoretical framework for undergraduate longitudinal placements

There has been a global shift towards longitudinal placements in undergraduate medicine, which are believed to play an important role in supporting medical student learning and professional identity formation. A better understanding of how learning occurs on such placements is needed, and community of practice (CoP), a social learning theory, has been proposed to form their pedagogical foundations. However, empirical research exploring learning through CoPs on longitudinal placements is limited.

Findings: Routine evaluation data were available for 57% (n239) of students and indepth interviews were carried out with five students and three tutors across eight placements.Themes identified through inductive thematic analysis were (i) participation within CoPs, (ii) enablers of legitimate peripheral participation and (iii) socialising agents.
Student legitimate peripheral participation was greatly facilitated by making contributions to patient care, a welcoming clinical environment, access to the informal spaces and repertoires of the practice and effective brokerage of educational activities by tutors.
Discussion: CoP is a theory that allows us to make tangible the somewhat abstract when deepening our understanding of how students learn on longitudinal placements.The extent to which students become legitimate peripheral participants varies, and this theoretical framework allows us to consider the factors that can enable such participation, with implications for how educators design curricula and placement infrastructure.

| BACKGROUND 1.| Longitudinal placements
There has been a growing global trend towards longitudinal clinical placements in medical schools, 1 believed to play an important role in supporting student learning and professional identity formation, 2 and designed to better reflect the complex and holistic nature of modern medical care, as well as address workforce recruitment challenges. 1,3particular subtype that has gained traction is longitudinal integrated clerkships (LICs), in which students participate in the comprehensive care of patients over time, meet the majority of the year's learning outcomes across disciplines simultaneously and do so through continuing learning relationships with their patients' clinicians. 4It is this continuity that is believed to be central to the pedagogical benefits of such placements.Around half of the medical schools in the United States are offering longitudinal placements, 5 as well as an increasing number in the United Kingdom. 6Additionally, the Consortium of Longitudinal Integrated Clerkships (CLIC) lists LIC programmes in Canada, Australia, South Africa, New Zealand and a small handful of other countries, with much of the literature originating in North America and Australasia. 7Cs provide contextual continuities of time and space which facilitate meaningful interpersonal relationships with tutors, peers and patients; relationships that are proposed to form the locus of professional identity development. 80][11] In addition to these 'hard' outcomes, students tend to perform better in domains, such as patient-centredness, managing uncertainty, reflective skills and self-efficacy, and are perceived as more prepared for practice. 11

| Communities of practice (CoPs) and longitudinal placements
While these outcomes are well documented, there is limited empirical evidence regarding the mechanisms through which such placements work.CoP, a theory of social learning, has been proposed as a potential theoretical framework underpinning the pedagogical effectiveness of LICs. 1,9,11,12This theory, developed by Wenger, describes learning as a participatory social process involving collective construction of knowledge within naturally occurring communities. 13Learning as participation occurs through local actions and interactions, within the context of wider cultural norms.Novices enter the community as 'legitimate peripheral participants' and, through engagement and participation in the community, move from the peripheries to 'a socially sanctioned central responsibility and legitimacy'. 14Ongoing participation in the community's work leads to progressive competency and proficiency with tasks, language and organising principles of that community.Over time, a common identity among participants is fostered, and the link between socialisation and identity formation is realised. 14[20] 1.3 | What 'counts' as a LIC?
It has been argued that narrow definitions of LICs presented in some typologies 21 that strictly adhere to the definition outlined earliermay not reflect real-world educational practice and that a more nuanced evaluation of the extent of continuity and longitudinal elements are more meaningful. 11,22In the UK health care system, General Practitioners (GP), often termed primary care physicians or family physicians elsewhere, form the gateway of care, and patients encountered in GP practices are undifferentiated and often multimorbid, allowing students to draw on a breadth of specialties and care pathways.The UK LIC picture demonstrates a diversity of configuration and a predominance of GP sites, and it has been argued that international definitions of LICs should be adapted for the UK context, recognising the strength of our healthcare model in supporting longitudinal and integrated episodes of care. 23 King's College London, we run a longitudinal programme for 400 Year 2 medical students, during which they attend an urban general practice site for 21 days over an academic year, in groups of eight, under the supervision of a consistent GP tutor.The days in practice have been designed to provide opportunities for authentic patient contact, insights into primary care, and to enable students to develop clinical skills, as well as their professional identities.While our programme does not fully align with traditional LIC typologies due to its lack of cross-specialty/site integration, if we acknowledge the particulars of the UK context and more fluid typologies, this programme can be considered within the LIC umbrella, as reflected by its inclusion within the UK LIC think tank. 24It is important to acknowledge this context when considering this study and the gaps in the literature that it addresses.Unique to our programme are the junior status of the students, and the whole-cohort nature of the programme, with LICs usually occurring in more senior years on an optional basis.

| Our inquiry
This study set out to explore the extent to which students on a longitudinal placement participated and learnt within CoPs (if at all).
Because LICs have been proposed to confer their benefits through their contribution to professional identity formation (PIF), 8 a major part of our study, carried out as part of a Masters in Clinical Education, focused on PIF, though deeper exploration of these findings lies outside the scope of this paper.There is little in-depth research exploring the relationships between longitudinal placements, CoPs and PIF, a gap we seek to address.

| Study design
Our epistemological position is constructivist, with a belief that knowledge is socially constructed, aligning with the principles of social learning theories.It is important to acknowledge that our position influenced all aspects of the inquiry.
A case study methodology was chosen for its capacity to generate a 'thick description' 25 of the phenomenon under study.A rich picture can be built with this approach through exploration of a bounded unit (the case) and triangulation of various data sources and modalities, aligning with the deeper exploration of participants' experiences of a placement. 26

| Setting and participants (the case)
This study was conducted at an urban London medical school during the 2020/2021 academic year.Due to the impact of the COVID-19 pandemic the study design was changed from longitudinal to retrospective, allowing the programme to be researched in its prepandemic format.Therefore, a purposive sampling approach was used, inviting students and tutors who had undertaken the programme in 2019/2020 to participate.Data from routine student evaluation of the 2019/2020 academic year were included, representing 57% (n239) of the cohort.
There were five student participants and three tutor participants.
There are no prescriptive guidelines regarding sample size for this form of research, 27 where the emphasis is on seeking knowledge that is rich and deep.Large volumes of rich data were generated from this approach, which aligned with the nature of our inquiry and epistemological outlook.

| Data collection
As per case study methodology, various data sources and modalities were used (Figure 1).
Student participants were asked to write and submit a reflection about the impact of the placement on their learning prior to their indepth semi-structured interview.Free-text responses were extracted from the routine 2019/2020 evaluation data, in which students were asked about the impact of the placement.
Within the interview, participants were asked to diagrammatically represent important relationships to stimulate discussion and explore underlying meaning; an approach that has been previously used in medical education research. 28The activity gave participants agency to explore what they felt was important and meaningful, generated diverse diagrammatic depictions of their world view and stimulated deeper exploration of their experiences and perspectives.Figure 2 shows an example of the rich material produced.
In-depth interviews were also conducted with tutor participants.
All interview guides were piloted and developed iteratively alongside ongoing data collection and analysis.

F I G U R E 1 Data sources and collection methods.
Due to pandemic restrictions video interviews lasting between 60 and 90 min were carried out on Zoom, from which audio recordings were generated and transcribed.

| Data analysis
Thematic analysis of the data was undertaken; this approach requires an immersive search for meaning and patterns in the data from which codes and themes are systematically generated 29 and is well suited to case study methodology by virtue of its capacity to generate detailed, rich and complex meanings.The analysis was primarily inductive, though sensitised by CoP theory; this aided the analysis of quite complex relationships between themes and concepts and offered fresh and conceptually resonant vocabulary.Peer review of analysis was undertaken by S.M., leading to further refinement of concepts and themes.

| Ethics and quality
This study was granted ethical approval by the King's College London Research Ethics Committee in December 2020 (ref 20817).L.K. was the programme lead and primary researcher, with S.M. supervising the dissertation.L.K.'s insider researcher status allowed for more nuanced understandings of the programme and data but was acknowledged for its influence on the study design and implementation.The study was designed to limit potentially coercive influences associated with her role.L.K. kept a reflexive journal, and both authors regularly held reflexive discussions to manage some of the challenges of being an insider researcher.Rigour was further achieved through generating a thick description of the case, aligning the research approach with the area of inquiry and our epistemological perspective and triangulation of data.

| FINDINGS
Three themes were developed from our findings (Table 1) which will now be discussed.See Table 2 for the codes used for data extracts.

| Participation within CoPs
Active participation within the wider CoP of medicine and the multiple CoPs encountered throughout their clinical training is a critical way in which students internalise the professional skills, values and identity required to become physicians. 16It is through the social fabric of these communities that our second-year students were able to make the transformational shift from pre-clinical to clinical learner, and here, we explore the extent to which students identified and participated as members of these CoPs.

| Medicine as a CoP
Students identified as members of the wider CoP of medicine, with a sense of belonging and collegiality, as well as a sense of shared enterprise arising from caring for patients.
Students identified as members of the wider CoP of medicine, with a sense of belonging and collegiality.we didn't feel even as knowledgeable or anything as a doctor, but we felt more and more kind of taking further steps to reach that level of a doctor … (SI4) There was an intergenerational sense of shared trajectory within the CoP arising from the educational student-tutor relationship, prompting tutors to reflect; 'all of us have been there as medical students' (TI2).This gave rise to a shared sense of community, solidarity and common purpose with their students.

| The GP surgery as a CoP
Students' sense of membership within the CoP of the GP surgery was variable; some felt they had joined a 'family' while others felt more

| Being welcomed into the GP CoP and its repertoire
In order to develop the competency critical to membership within a CoP, participants must be welcomed by the community and granted access to its repertoire.*GP tutors played an important role in brokering the way students were integrated within the practice, influencing *Described as 'routines, words, tools, ways of doing things, stories, gestures, symbols, genres, actions or concepts that the community has adopted in the course of its existence'. 13orrection added on 14 March 2024, after first online publication: The reference citation for the preceding sentence was corrected.]An important gateway into the repertoire of the practice was the electronic record system, providing not only access to clinical information, but containing many aspects of the repertoire unique to the practice (e.g., how patient care tasks are allocated).Granting this access to novice participants signalled entrustment, and students commented on how powerful this was in supporting them to understand the functions of the GP practice and their sense of belonging.
… typing up patient notes after, calling the patient in, it sounds really silly but that kind of gives you a bit more like ownership.(SI5) Physical spaces within the practice represented either opportunities for students to participate in the informal social repertoires of the practice or conversely contributed to a sense of marginalisation if the team experienced students as overwhelming an important communal space.
… it was quite a small little kitchen and staff were always coming in and out and you'd always have to like move yourself around …. it felt kind of like we were an inconvenience.(SI3)

| Enablers of legitimate peripheral participation
Participation is an integral aspect of membership within a CoP, and for newcomers, this is expressed through becoming a legitimate peripheral participant. 13Exploring what enables this allowed us to consider the factors contributing to a CoP in which students could thrive.Closely linked to LPP was students' capacity to develop competency in both the repertoires of the practice (discussed earlier) and clinical competency.

| Authentic clinical experience and contributions to patient care
Students and tutors identified authentic clinical experiences, in particular consulting with patients, as critical to the development of the competencies required as a developing clinician and for establishing educational building blocks.
The situated nature of the learning experience also provided fresh insights into the ways in which GP practices function to deliver patient care, and there were opportunities for students to develop their cultural competency and community orientation through exposure to social problems and health inequities.
There were opportunities for students to develop their cultural competency and community orientation through exposure to social problems and health inequities.
Students had a strong desire for opportunities to make increasingly

| Operating within the zone of proximal development (ZPD)
Students described the need for supported opportunities for increased autonomy in the delivery of patient care; here, we can draw on the concept of the ZPD † which proposes that with the appropriate degree of guidance and support, often referred to as scaffolding, an individual can be guided/challenged towards the upper limit of their ZPD, maximising their potential for learning. 30† Defined as 'the distance between the actual developmental level as determined by independent problem solving and the level of potential development as determined through problem solving under adult guidance, or in collaboration with more capable peers'. 30tudents described their placement as a safe space for learning.
They appreciated graded challenge to act increasingly independently during patient interactions; while this could be met with trepidation, it was appreciated for its capacity to further their skills and confidence, and felt well balanced by support.There was an acknowledgment of a shared responsibility between learner and tutor: the main two things that facilitated that was our willingness to actually go and try it out … but also the sec- While many students enjoyed opportunities for independent learning, tutors reported that 'they were like taken aback "… What's expected of me?"' (TI2) and that 'they need to be scaffolded …' (TI3) and guided in their development of clinical and self-efficacy skills.

| DISCUSSION
Aligning with the literature, students strongly identified with the CoP of medicine, and this supported the development of their identity trajectories as doctors. 15,16This embedded itself within student experiences at the GP surgery, manifesting as a strong affiliation with the 'doctor team'; however, there were varying degrees of integration within the wider GP CoP.
Various enablers of LPP supported students' integration within the GP CoP, and these were optimised when relationships were brokered by the GP tutor, students were welcomed into informal communal spaces and the repertoire of the practice and students were engaging in meaningful and reciprocal activities with non-doctor members of the team.Of note, physical spaces could be inclusive to learners but equally risked marginalising them if they were perceived to be exerting an unwelcome pressure on physical resources, such as taking over the kitchen space.This tension was most keenly The socialising effects of role modelling, mentorship and the peer group were profound and potentiated by the continuity elements.This study provides unique insights into the impact of delivering such programmes to junior students on a whole-cohort basis, an area that is underrepresented in the literature.In this context, consideration needs to be given to the additional support and scaffolding requirements that will enable students to establish themselves as legitimate peripheral participants within the clinical CoP.Rather than these considerations deterring educationalists, we argue that there is a strong educational argument for offering such programmes early on in the medical curriculum for all students, embedding the development of self-efficacy and PIF universally at the start of their clinical trajectories.By doing so, we increase educational equity such that those students most in need of developmental support receive this early on, rather than the already-engaged minority who are likely to be over-represented on voluntary programmes. 11ere is a strong educational argument for offering such programmes early on in the medical curriculum for all students, embedding the development of self-efficacy and PIF.
Study limitations include small participant numbers and being based at a single institution.However, the richness of the data aligned with the nature of our inquiry, and the thick description, characteristic of case studies, should support readers to draw naturalistic generalisations between our case and their own context 26 (Table 3).
T A B L E 3 Key practice points for supporting longitudinal clinical placements using communities of practice approach.
• Place continuity relationships at the centre of curriculum design; these relationships include those with tutors, clinical setting, peers and patients.• Enable student legitimate peripheral participation (LPP) through: Providing authentic clinical experiences and opportunity for graded increases in entrustment, autonomy and responsibility Providing a welcoming clinical environment with opportunities for authentic engagement with all team members Providing access to the clinical community's key repertoires, in particular electronic record systems and social spaces • Nurture a clinical CoP environment through: Encouraging delivery of teaching by a diversity of professionals within the clinical team Integrated opportunities for students to reciprocally engage with non-doctor members of the team (including administrative staff), for example, through improvement projects Considering the pressures students place on physical space and/or other resources and how to mitigate this • Explicitly introduce communities of practice (CoP) theory into student and tutor teaching • Ensure clinical tutors are supported to develop: Role modelling awareness An understanding of their role in brokering student role legitimacy within the clinical team An understanding of the theory of zones of proximal development to further encourage student LPP Strategies to encourage positive peer group dynamics • Support student self-regulated learning to potentiate their capacity to develop role legitimacy and engage within the CoP-particular consideration to this if developing curricula for more junior students.

F
I G U R E 2 Identity diagram SD3.I would identify as kind of this bigger community of medical professionals, medical students, doctors … that feeling of belonging … is just getting stronger and stronger … as time moves on, that becomes a much bigger part of my identity.(SI4) Students described transformational shifts in outlook regarding their trajectory towards becoming full members of this CoP: doctors.
marginal.I don't really feel like I knew many of the staff members other than my two GP tutors … I felt quite distanced from the rest of the staff.(SI2) Tutors were more confident in their view that students were part of this CoP and described them as 'buzzy and lively' (TI3), and contributing up-to-date medical knowledge, as well as enriching the educational identity of the practice.Students described an evolution in how they were perceived by the practice and how integrated they felt, becoming more central members over time: From the first week or two we obviously felt like a visitor … as time went on that kind of dissipated completely and we felt really, much a part of a team.(SI4) Some students identified as being 'more like part of the doctor team … because we spent almost all of the time with them'(SI1), further influenced by the overlay of shared membership within the CoP of medicine.Yet non-doctor members of the CoP were often considered to be more approachable and more prepared to entrust students with clinical tasks; 'it's almost as if she [the nurse] saw me as a doctor and she was like "okay, I've showed you how to do it, now you're going to do this one next"' (SI5).A sense of membership outside of the 'doctor team' within the broader GP surgery CoP was more complex to navigate for both students and staff, whose positionality relative to one another could feel unclear.you'd come in … and you'd explain why you're here and they'd [receptionists] always seem a bit confused … (SI3) However, this was mitigated by opportunities to actively engage with clinical and administrative team members (rather than passive observation), contributing to a deepened appreciation of the way the CoP functioned to deliver care, and students' sense of integration within it.… I feel like they [administrators] really acknowledged us and recognised that we were actually there to … help them out as well as learn … I sometimes helped them with administrative tasks … (SI5) s outlook about the students' role legitimacy.Welcoming and acknowledging students at the practice contributed to students' sense of accountability and belonging.
autonomous, yet supported, contributions to patient care.Continuity facilitated such opportunities and deepened engagement in patient care, contributing valuable experiential knowledge and promoting patient-centred attitudes.Having increased patient care responsibilities, no matter how small, promoted a sense of clinical ownership.Tutors encouraged the development of students' self-conceptions as providers of care, and highlighted how they contributed positively through their relatability, energy and having more time to spend with patients.I usually say that to them, that they have a lot to offer … we need to encourage them … they can contribute to the patient journey with some support.(TI3) Many students felt great reward at being able to work in partnership with their tutors and share the workload, providing them with a sense of role, purpose and belonging within the CoP.helping GPs and I guess making their lives a bit easier, if we do half the job then they … could have a breather.(SI4) ondary thing was them just pushing us way into deep water where we could barely swim … if you are willing and you have someone pushing you like that, I don't think there's any better way to learn … as long as you've got a safety net … (SI4) Challenge was closely linked to increasing degrees of entrustment in students' capabilities, which supported students' self-conceptions as future doctors and their sense of centrality within the CoP.'okay go and call this patient, talk to them, then come to me and tell me what's wrong with them and then I'll come in'.That's very much part of a team … that really made us feel … higher up in terms of what we should know and how we should go about … (SI4) Students demonstrated agency in seeking out learning opportunities, which was enabled by support from tutors, peer role modelling and their sense of membership in the CoP of medicine.Some students overcame interdisciplinary boundaries when seeking out learning opportunities, suggesting broad conceptions of the clinical CoP.I spoke to the podiatrist upstairs which weren't really like linked to the practice but I thought let me just shadow them and see what they do.(SI5) Role modelling, mentorship and the peer group were powerful socialising agents contributing to student identity formation and forming critical components of the clinical and educational CoPs within their placement.The impact of these agents was felt to be profound and multidimensional due to the continuity of relationships afforded by the longitudinal nature of the placement.The GP tutor embodied a positive role model for students, representing a critically influential element of the programme.Students were emphatic in their praise and admired attributes that included empathy, strong therapeutic relationships with patients, critical thinking, and ethically aligned values systems, particularly community orientation.Clear connections were made between modelled behaviour and the kinds of doctors that students aspired to become, and this supported students' sense of trajectory from novices to full members of the clinical CoP.I could see his thought process, how he tackled tricky situations, how he broke bad news … [it] made me realise … what kind of doctor I want to be … (SI2)The mentor-mentee relationship was highly valued by both students and tutors, and students experienced their tutors as authentically invested in nurturing their development.Mentorship was central to how tutors viewed their role, garnering great satisfaction from observing students' progress, as well as 'teaching them the ropes' (TI1) of their CoP.There was a sense of service among tutors: 'it's like buying a plant and seeing them grow and to me that means a lot because actually I'm giving something back' (TI1).A consistent peer group throughout the placement created an educational CoP with a sense of unity and shared enterprise, experiencing 'the same unchartered territory' (SI4).The group constituted a safe learning space in which supportive social 'bonds just got stronger' (SI4), and group reflection and teamworking skills could develop.Tutors and students acknowledged the importance of a positive group dynamic to the success of the placement and tutors used explicit strategies to achieve this, aiming to signal the importance of peer support to physician well-being.They reflected on the importance of this socialisation and support infrastructure within their own careers; 'I remember trying to find a friendly face … somebody to chat with, somebody to work with' (TI2).
experienced between students and non-clinical staff and may relate to a more uncertain sense of positionality relative to one another; this may be compounded by non-clinical staff often having limited decision-making power over the integration of learners within the clinical environment.Student membership within multi-professional clinical CoPs, such as the GP surgery, is subject to complex dynamics relating to existing cultures and hierarchies.The socialising effects of role modelling, mentorship and the peer group were profound and potentiated by the relational continuities within the placement, adding further weight to the imperative for longitudinal programmes.It is important that medical schools provide support for tutors in the development of role modelling, mentorship and facilitation skills; in our institution, this is achieved through a structured teacher development programme and comprehensive quality assurance processes involving cycles of feedback and support.Explicitly conveying to tutors and students the importance of a positive peer group dynamic also enhances the development of an educational CoP and signals important messages about the impact of peer relationships to future professional working and physician well-being.
Critical to LPP is the opportunity for the novice to develop competency in the repertoires of the practice, and given the heterogeneity of clinical GP placements, tutors should be encouraged to consider what this might look like in their setting.Improvement projects embedded within the clinical setting can encourage students to explore such repertoires and engage with the wider team in a reciprocal manner, further strengthening their integration within the CoP.Clinical competency is encouraged to flourish in the context of a safe and nurturing environment in which challenge and support are finely balanced within the zone of proximal development; this clinical competency is critical to students' identity trajectories from novices to more central members of the CoP of medicine.8,13