‘It's a gamble’: A phenomenological exploration of medical students' learning experiences as newcomers to clinical communities of practice

Medical students become members of the clinical team through participation in their activities, as described by Lave and Wenger's situated learning theory. While there is research into how medical students cognitively engage in clinical learning, there is limited work on clinical experiences using a social theoretical lens such as situated learning theory.


| INTRODUCTION
Lave and Wenger 1,2 describe a community of practice (CoP) as a team of colleagues with a common purpose such as a clinical team caring for patients.Legitimate peripheral participation is the mode through which newcomers to the CoP become experts (Figure 1).To be legitimately peripheral, a newcomer's position must provide 'a way of gaining access to sources for understanding through growing involvement (p37)'. 1 This involvement should be simple at first and then progress to become complex and confer greater responsibility within the CoPs.Thus, legitimate peripheral participation is dynamic, describing an inward trajectory towards centrality in the CoP.Initial involvement of medical students often includes observing professional conversations and discussing patient problems with doctors, 3 performing procedural skills 4 such as venepuncture or note-taking during ward rounds.More complex activities often involve taking histories, doing examinations or performing full consultations. 5,6These activities can be made simpler for newcomers by providing closer supervision 7 or limiting students to a narrower scope of practice. 8The activities deemed useful for medical students have evolved through a long tradition of workplace learning in Medicine and are organically structured to enable learning through participation. 9,10To participate in the work system, newcomers must be accepted as members of the CoP, which involves being granted access to shared knowledge and to opportunities to participate authentically.
To be legitimately peripheral, a newcomer's position must provide 'a way of gaining access to sources for understanding through growing involvement (p37)'. 1 The existing literature applying Lave and Wenger's theory of situated learning to pre-registration medical and nursing students' placements has demonstrated the relevance of legitimate peripheral participation to these environments. 3,5,11,13,15,16 Additionally, the interaction is more useful when it is friendly and constructive.11,13,17,18 This participation takes the form of either observation or involvement in practice.3,4,6 Discourse between student and clinician stimulated by such co-participation grants the student access to expert knowledge.3,19 When legitimate peripheral participation occurs, this leads to the development of skills and knowledge 3,6,12 and increased identification with their health profession. 6,12,20 Crucil to the development of a medical identity is participation in authentic activities, meaning the activity contributes to the care of patients.3,8,20 Wenger, who was involved in Steven et al.'s study, 3 identified that students who took part in inauthentic activities for the sake of their learning were not part of the health care CoP because they did not share the purpose of the CoP, patient care.They described conversations focused on what students needed to know for exams as an example of inauthentic dialogue that resulted in lower quality learning. Chen et al.8 identified that inauthentic practice such as interviewing patients on the ward exclusively for the sake of learning led to feelings of alienation.In contrast, students taking part in patient care felt included and useful to the team, 4,8 which led to feeling like a doctor.20 Crucial to the development of a medical identity is participation in authentic activities, meaning the activity contributes to the care of patients.3,8,20 Much of the existing literature examining situated learning theory in a health care education context applies situated learning theory to nursing students rather than medical students in their first clinical placement years, so research on nursing students was included in the literature search. Also,there are studies examining very early experiences of health care at the outset of medical school.21 However, this represents a much earlier phase of training than the remit of this study and is less about the learning journey of becoming a doctor and more about clinical exposure to general team-based care.Furthermore, prior studies examining students' lived experience mostly focus on a single element, such as identity, 20 or a single environment, such as GP practices, 5 and do not focus on medical students in their first clinical year. Morever, few studies address the UK context and very few use an in-depth phenomenological approach.Finally, the researchers in the literature are mostly health care professionals, which could introduce social desirability bias to data collection.In this study, participants were interviewed by a medical student. To address thi gap in the literature, the researcher performed a hermeneutic phenomenological study of medical students in their first year of clinical placement in the United Kingdom using Lave and Wenger's theory of situated learning as a lens, comparing different clinical environments.This research offers a novel, rich and holistic explanation of how medical students access meaning through participation in their first year within clinical communities, and the challenges they face, from their own perspective.The research question was, 'What is the lived experience of medical students as newcomers participating in clinical communities of practice?'.

| METHODOLOGY
Interpretive phenomenological analysis (IPA), described by Smith et al. 22 and based on the philosophy of Husserl 23 and Heidegger, 24 was used to illuminate the full depth of students' experiences and interpretations.The focus of IPA on revealing experiences of reality as they are interpreted by participants (termed their 'lifeworld' by Husserl 23 ) made this methodology ideal to answer the research question, which is focused on the experience of medical students of 'being-in-the-world'. 24 The focus of IPA on revealing experiences of reality as they are interpreted by participants […] made this methodology ideal to answer the research question.The hermeneutic circle was used, 25 which involved an iterative, idiographic process of reading a considering the text as a whole, then entering line-by-line analysis and then revisiting the meaning of the whole text informed by analysis of the parts, reaching 'gestalt'. 22Preliminary themes were generated from reading the whole text.Next, meaning units summarising each significant line of text were written.These were then further distilled and grouped into emergent themes inductively arrived at through reflection on the meaning units and reflection on the whole transcript.A combination of bracketing and revising the researcher's preconceptions, which was in part facilitated through keeping a reflexive journal, was used to enable greater validity, and themes were generated inductively using a conceptual orientation towards Lave and Wenger's 1,2 theory of situated learning.
This study received ethical permission from the College of Life Sciences Ethics Committee at the University of Leicester (No. 28958-awrt1-ls:medicine).

| RESULTS
All participants completed online interviews.They described their experience as newcomers to clinical teams as a 'gamble'.Analysis of the transcribed data led to three main themes that typified the commonalities in their lived experience: (i) conditions for participation, (ii) modes of participation and (ii) products of participation.The themes are explored with extracts presented in tables.

| Conditions for participation
The conditions for participation were the key elements influencing student participation (Table 1).Student proactivity was the most essential factor.Students felt responsible for their proactivity and were self-critical when describing being demotivated.Their proactivity was dependent on the presence of other conditions for participation in their learning environment.These related to the clinician and the activity.
Clinician engagement with students relied on two factors: time and interest.The most frequent barrier students faced was encountering doctors who, because of lack of time or inclination, would ignore them and fail to provide learning opportunities.This was demoralising for students and drained proactivity, leaving them feeling 'useless'.On the other hand, high-quality learning environments contained staff with the time and passion to legitimise and scaffold student participation in health care activities.Poor placement organisation had a negative effect on clinician and student engagement; when CoPs were not prepared for the attendance of a student, they were less likely to be welcoming and provide access to their work system.
The most frequent barrier students faced was encountering doctors who […] would ignore them.
Useful workplace activities had to be challenging and authentic.
Authentic activity contributed to the purpose of the CoP, patient care.These activities helped students to develop their professional identity and a sense of belonging within the CoP.Students still gained knowledge from inauthentic activity but were left feeling like outsiders.This drained proactivity and could be a barrier to further participation.
Activities for students should be routine in the context of the activities of the team but challenging for the student.Participants learned best when clinicians pushed them to practice at the upper bound of their competency.As competency increased over time, activities that were initially peripheral could become marginal.For example, observing ward rounds was initially beneficial, but as students progressed, they no longer benefitted from being an observer and desired active participation.Students leaned the most when clinicians scaffolded their participation by providing guidance and ensuring patient safety.In this way, students were challenged and advanced their clinical skills and professional identity.Students were anxious about performing challenging activities and required encouragement but were grateful for the experience.
These interactions required trust between expert and student.
Students often lamented that clinicians did not supervise their practice because of time pressures, and they missed out on valuable learning.
Participants learned best when clinicians pushed them to practice at the upper bound of their competency.
T A B L E 1 Variability and conditions for participation.

| Modes of participation
When the conditions were met, participants described learning via observation and involvement in practice (Table 2).Participants stipulated that observation was only valuable if accompanied by an explanation of what the clinician was doing and why and how the activity impacted on patient's care.This type of discourse helped students to think like a doctor.Although observation was an important first step students' most valued learning when they were involved in practice.Students identified a lack of progression from observation to practice as a significant issue.
Students identified a lack of progression from observation to practice as a significant issue.When the conditions for participation were met, participants underwent legitimate peripheral participation that developed their skills, professional identity and relationships with the CoP.These products reinforced participation by increasing the likelihood the conditions were met.Themes were interlinked as three stages in a selfreinforcing Cycle of Participation (Figure 2).This cycle reveals why every student described placement learning as variable: their enriching experiences of participating in authentic practice were interspersed with experiences of proactively seeking opportunities to participate but failing.This occurred when the conditions for participation were not met, resulting in a negatively reinforcing effect on the cycle that drained proactivity.On the other hand, students in environments where the conditions were consistently met experienced a positively reinforcing effect on their participation across the placement, leading to greater fulfilment of the products of participation.To summarise, participants described their experience of placement as a 'gamble' because fulfilment of the conditions for participation was variable, leading to inconsistent reinforcement of the Cycle of Participation.

| Products of participation
T A B L E 2 Modes and products of participation.Themes were interlinked as three stages in a self-reinforcing Cycle of Participation.… Participants described their experience of placement as a 'gamble' because fulfilment of the conditions for participation was variable.The central importance of proactivity to learning exemplifies how learning is not only a cerebral process but a social one. 1,9Without the support of a professional community that contains certain social elements such as sufficient time for interactions between students and staff and opportunities for authentic practice, learning cannot occur and students will become passive. 2,3If learning is a social process, it could be argued that the role of a clinical educator should not only be to impart knowledge to a student and expect them to be motivated to listen, but to cultivate the conditions in the clinical team for student involvement. 9In this study, students in CoPs that provided the conditions for participation experienced high-quality learning identity formation and relationship formation which together increased engagement.These experiences set a high standard that other experiences fell short of, leading to increased passivity.This led to the shared experience of variability in this study.
The condition most frequently identified as a barrier to participation is clinician disengagement, often linked to time pressures in the literature. 13,16In this study, students felt that the best clinical teachers found time to educate even in time-pressured environments.Additionally, staff explaining that they did not have time to teach rather than simply ignoring the student had a protective effect on their proactivity.One placement environment overcame this problem by employing clinical facilitators with dedicated time for students.They provided workplace-based teaching and a named point of contact within the CoP to provide access to activities.
Observation was reported as less valuable for learning than practice.This finding was mirrored by Eggleton et al., 5 who found that 'the most beneficial activity was taking a history and examining the patient then presenting their findings'.Students asked for participation to become more complex, progressing from observer to doer.
This enables movement from the CoP's periphery towards the role and responsibilities of a doctor. 20This leads to self-evaluation, 1 The Cycle of Participation.Achieving the products of participation increases the likelihood the conditions will be subsequently met and has a positively reinforcing effect on student development.
enabling the student to notice their progress, boosting their selfefficacy.As their competence and confidence increase, students identify more with the role of doctor 20 and become increasingly central participants (Figure 3).
Students' participation should be authentic to the CoP's purpose.participation was scaffolded by GPs, who selected appropriate patients and verified students' findings.Participants had more difficulty accessing scaffolding in hospitals, perhaps because they were working with a whole team, not one-to-one with a GP, so clinicians did not feel as obliged to supervise them.
It is only through authentic practice that students become part of the team.
Experienced, trusted clinicians providing scaffolding enabled students to perform more complex work.This was also found in Chen et al.'s 8 study, where clinicians supervised students' formulation of management plans.This way, students were able to make authentic decisions regarding patient care, but quality of care was ensured through scaffolding.One striking example from the present student was when one participant was supervised in making the first incision in a surgical case.The impact of that opportunity on the student was highly significant: It was the moment they decided to become a surgeon.
The impact of that opportunity on the student was highly significant: It was the moment they decided to become a surgeon.
This study has limitations.It focussed on one set of medical students from Leicester University, so the outcomes are not directly transferable.However, the findings have resonance with the literature.The study took place during the early post-pandemic period which may have biased findings.
While a clinical teacher can take actions to improve social conditions, many issues arise from factors outside of faculty control, such as high workload and understaffing.These issues have likely worsened since data collection, with 21.4% more periods of care for a patient under a single consultant at a single hospital in 2021-2022, compared with 2020-2021. 26Meanwhile, there were only 6.7% more full-time equivalent clinical staff in February 2023 27 compared with April 2021. 28Additionally, medical school places will be doubled by 2031, 29 so opportunities will be shared more thinly.This means that it is increasingly unlikely that all the conditions for participation will be When passivity is identified as an issue, clinicians should tackle the cultural or system factors that contribute to it.
Students should be legitimised and scaffolded so they can undertake authentic and challenging activities and be directed towards routine tasks that they can perform unsupervised.A student working entirely independently will not feel involved in the CoP or its work system.Medical students in the literature and this study mostly describe a social environment in hospitals where no one is directly responsible for them in the workplace and the impetus is on the student to seek opportunities. 12This leads to a diffusion of responsibility 30 that can mean no one supervises them, especially in timepressured environments. 12,13This study suggests that formally assigning staff to be facilitators of student activity, preferably selected from the CoP in the placement environment, could be beneficial.Doctors who recently graduated from medical school were found to be the most useful enablers of activity and could be ideal facilitators, although other professionals such as nurses or consultants could also serve in this capacity.This would be most effective if it ensured time is allocated to these clinicians in which to teach.Alternatively, the faculty could hire external clinical facilitators to direct students, a model used in other professions.They would not be as integrated into the specific work environment, which may impact authenticity and their level of access to the work system.However, external facilitators would not have to contend with the pressures of the work environment, freeing up their time to focus on the students.The most highly regarded placement environment in the study employed this tactic.
While clinical teachers can innovate to mitigate the impact of barriers to participation, students are still likely to encounter clinical areas where the conditions for participation are not met.Therefore, it is recommended that students are allowed the freedom to avoid these areas and find opportunities that are most useful for them.Also, channels of communication should be set up between students rotating out of a given placement and those rotating in so that advice can be given on where the best opportunities for legitimate peripheral participation can be found.Teachers could suggest topics of discussion but would ideally withdraw afterwards to avoid biasing the discussion.
To take action to improve students' experiences on placement in the current clinical environment, the factors impacting it must be well

PATIENT CONSENT STATEMENT
No patients were involved in this study.Students consented to be interviewed for this research and for their anonymised data to be used in this study.

PERMISSION TO REPRODUCE MATERIAL FROM OTHER
Semi-structured interviews were designed drawing on the literature and piloted.The sample of seven students was purposefully selected using opportunity and snowball sampling from the first clinical year, Year 3, at Leicester Medical School.Placement leads publicised the study to their students and forums and emailing lists were used.Students had 12-week placements were in general practice, general medicine and general surgery.They were interviewed once, from 3 weeks into their final placement (March 2021) after almost a year of learning experiences.Interviews lasted from 45 to 90 min.To ensure participants felt comfortable, they were given the choice of online or face-to-face interviews.Participants kept a diary of their experiences on the day of the interview to minimise recall bias.The diary aided explorations of their experiences on the day.
Participation within the CoP led to identification with the role of doctor.They also described developing as a medical student, gaining new skills and knowledge.Being recognised as competent by the CoP increased participants' confidence and increased the likelihood they would find opportunities to participate in practice.Engaging in activities alongside clinicians also led to the formation of meaningful relationships.This positively reinforced student development and increased trust between student and clinician which engendered further co-participation.Relationships were more likely to develop with longer time periods in one clinical place as short placements hampered their ability to participate as they did not have time to earn trust.
4 | DISCUSSIONThe findings of this study emphasise where and how learning can be maximised when medical students join clinical teams.Being actively involved in learning within the practice community requires legitimate peripheral participation1 and is stalled when the conditions for participation are not met.When a CoP provides the right conditions, students in this study became more engaged.In environments without the right conditions, students became passive learners or would leave to study at home, making re-commencement of the cycle less likely.Therefore, the conditions for participation exert a positive or negative reinforcing effect which impacts engagement.This finding is supported by Thrysoe et al.,17 who found that being overlooked and not engaged by staff led to negative emotions and greater passivity.The present study adds to this by showing the mechanisms behind how passivity can then prevent a student from making further attempts to learn from the team.The factors that create the Cycle of Participation in the domains of conditions, modes and products, are reflected in both the medical student and nursing student literature.This suggests that the 'Cycle of Participation' could also be relevant to nursing students and other allied health professionals.
Steven et al.'s 3 distinction between authentic participation contributing to patient care and inauthentic participation occurring only for student learning explains Chen et al.'s 8 finding that students felt like a burden on placement because they did not contribute to care.It is only through authentic practice that students become part of the team.This reinforces Fredholm et al.'s 20 account of how authentic experiences led to identity formation.To some extent, engaging in inauthentic practice is necessary to gain the competence to participate without risking patient safety.However, although interviewees in this study were newcomers to clinical environments, they were able to participate safely with appropriate scaffolding, and these experiences were the most enriching.Authentic practice occurred on GP placements without compromising patient safety because students'

E 3
The trajectory of increasing centrality in the CoP via successive iterations of the Cycle of Participation.met in clinical teams.Action is required from clinical teachers to mitigate the impact of these challenges.An important finding is that student proactivity was not wholly dependent on the student.Every participant reported experiencing proactivity in positively regarded environments and passivity in poorly regarded ones.Therefore, student agency can be improved by clinical teachers through modification of the conditions in the workplace.When passivity is identified as an issue, clinicians should tackle the cultural or system factors that contribute to it, such as lack of clinician engagement or lack of appropriate activities and address them.
understood.The Cycle of Participation model provides a frameworkfor how these factors interrelate to affect student involvement in clinical practice.It could be useful as a framework for quality improvement, with the conditions providing targets for improvement and the products providing outcomes.Furthermore, future qualitative research could explore each of the conditions for participation in greater detail or examine the same topic from the clinician perspective rather than the student perspective.Additionally, other health professions could be studied to examine the applicability of the 'Cycle of Participation' to other health professions.5| CONCLUSIONThis study asked the question, 'what is the lived experience of medical students as newcomers participating in clinical communities of practice?'.The answer revealed through analysis of the data is that their experience was highly variable because the frequency with which the conditions for participation were fulfilled was highly variable.Given the issues identified by students often arose from the social environment, understanding the social structure governing students' experiences on placement is key to identifying solutions.This is especially important in the context of increasing pressure on clinical communities, which inevitably impacts the relationships between staff and students.Students' experiences in this study had commonalities, described through the model, the 'Cycle of Participation'.The conditions for participation in this model are recommended as targets for improvement that would reduce variability.AUTHOR CONTRIBUTIONS Alistair W. R. Taylor: Conceptualization; investigation; writingoriginal draft; methodology; visualization; data curation; formal analysis; writing-review and editing; project administration.Elizabeth S. Anderson: Conceptualization; methodology; project administration; visualization; writing-review and editing; supervision.Simon Gay: Conceptualization; writing-review and editing.ETHICAL APPROVAL This study received ethical permission from the College of Life Sciences Ethics Committee at the University of Leicester (No. 28958-awrt1-ls:medicine).This included ethical management of data collection, management and storage.Access to the student cohort was granted by the medical school gatekeeper.
'And bless his heart, the next surgery after that, like straight after, he even let me do the first incision.And he let me suture afterwards like, that was, and he let me do drilling as well.So that was like one of the most incredible experiences ever.[…] I think I realised like, in that moment, I was like, "Okay, I think I want to be a surgeon.I think this is for me"'.(P07) Variability and conditions for participation Emergent themes Quotes Variability 'I would always try actively go to placement, knowing that [it is] very variable.Almost like a gamble.There might be something good.I might learn a lot today, there might be nothing on the wards and I've just wasted my time.I just don't know how I feel about education being referred to as a gamble'.'They didn't interact, which was kind of what felt like, yeah, I was a nuisance.[ … ] I don't mind like going up to doctors and like asking questions.You should do that, you should put yourself forward.But […] when it gets to the point where you're always putting yourself forward, and […] they're not willing to give anything back.They-I remember, like asking questions, and it'd just be like, "Let me try and answer this as fast as possible so I don't have to like engage with the medical student"'.(P07) Appropriate activity 'At one point, […] one of the doctors he um, he said, […] "this patient, he's already set up on an ECG.But if you need to get signed off, we can just take the stickers off him, and then you can just put it on again […] and I'll sign you off." […] Again, like I really did feel like I was using up his time, because he had a lot of stuff to do'.(P07)