Background
Emergency Departments are a prime example of a chaotic work environment with unpredictable workloads and frequent interruptions. It is also a rich environment for learning because of the large volume of patients of varying acuity. Traditional factors which support teaching and learning in the ED follow an "apprenticeship perspective" model and include:
- Having supportive supervisors and a supportive learning environment
- Getting feedback
- Having enthusiastic teachers
- Having supervisors who actively engage the learner
Methods
Semi-structured interviews of 12 volunteer EM residents (6 PGY-1, 4 PGY-2, and 2 PGY-3), lasting about 60-90 minutes, were audiotaped and transcribed. Interviews were conducted by 2 non-physician research team members. Initial data analysis was conducted by 3 non-physician team members. The de-identified data was reviewed by 2 emergency physicians team members for credibility and reliability.
Results
The interviews revealed 4 types of learning "episodes", or activities/events where learning occurred.
1. Participation in the environment
- In the day-to-day experience of working in the ED, learners get to manage multiple patients, confer with others, and participate in formal education.
- Facilitators (or triggers) for learning: Understanding expectations of resident role, volume of patient cases, observation of role models, eliciting feedback, developing self-awareness
- Short, focused learning moments of something specific
- Usually involves learning from another source (attending physician, colleague, consultant, reference material)
- Facilitators (or triggers) for learning: Directed teaching activities (brief clinical tips, procedure pearls), self-directed activities
- Learning from repeated occurrences of the same patient symptom or situation
- Facilitators (or triggers) for learning: Practicing the management of a disease or situation multiple times, self-reflection, followup of self-directed activities
- Experiences involving an interpersonal exchange between the learner and another healthcare professional (attending physician, nurse, consultant) involving patient management
- Facilitators (or triggers) for learning: Difficult cases, learner-centered concentrated teaching, first time in managing a particular case, mistakes
Interestingly, most participants commented that while attending physician teaching and the learning environment are important, the key to successful learning involves self-motivation, self-direction, and reflection.
Conclusion
Learning in chaotic learning environments can be categorized into 4 categories: participation in the ED, focused moments, repetitive cycles, intense experiences. These can occur under the same clinical circumstance and do not follow any hierarchical pattern.
Specifically in chaotic environments, it is essential that learners take responsibility for their own learning, identifying gaps in knowledge, seeking feedback, and working towards closing these gaps. Learning occurs both within and beyond the ED setting.
The table below summarizes how the residents and attendings can maximize learning in the chaotic ED environment, based on EM residents' perspectives.
One useful trick that I try to use when supervising residents, which is applicable to several types of learning is-- verbalizing my thought process in patient management decisions. This helps learners understand how I got from point A to B to C ... to H. I even go as far to describe my decision tree. "If this test is negative, I'm thinking..." and "if this test is positive, I will consider doing..."
This study is unique in that it shifts focus from "what can an attending physician do to improve the teaching of EM residents?" to "how do EM residents learn in a chaotic environment?" Understanding the individual and social context of learning in the ED can help optimize learning and teaching.
If you have trouble finding this article, feel free to email me for a copy.
Resource
Goldman E, Plack M, Roche C, Smith J, Turley C. Learning in a chaotic environment. Journal of Workplace Learning. 2009; 21(7):555-74.