Article review: Learning in a chaotic environment

Most great education articles can be found on PubMed. On occasion, however, one falls through the cracks and only appears in the ERIC database (Education Resource Information Center). Such is the case of a fascinating qualitative education article on how EM residents learn in a chaotic environment such as the Emergency Department. It also taught me a lot about how a good qualitative study should be conducted.

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
Previous studies are either teacher-centric or focus on what the learners feel about teaching. This study posed the unique question: How do learners feel that they learn in the chaotic ED setting?

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.

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
2. Focused learning moments
  • 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
3. Repetitive cycles
  • 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
4. Intense experiences
  • 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
Many of the learning "episodes" are interconnected. One event may trigger multiple learning episodes. This learning may start in the ED but learning continues often times outside of the ED "cloud" when reading at home or discussing with colleagues. This might appear something like the above schematic showing the learning process of EM residents.

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.

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.

Goldman E, Plack M, Roche C, Smith J, Turley C. Learning in a chaotic environment. Journal of Workplace Learning. 2009; 21(7):555-74.
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