Perceptions of preparedness: How hospital-based orientation can enhance the transition from academic to clinical learning

Background Clinical placements are essential for applied learning experiences in health professions education. Unfortunately, there is little consensus on how best to prepare learners for the transition between academic and clinical learning. We explored learners’ perceptions of hospital-based orientation and resulting preparedness for clinical placement. Methods Sixty-three learners participated in a total of 18 semi-structured focus groups, during their clinical placements. Data were analyzed thematically. Results We organized learners’ perceptions of hospital-based orientation that support their preparedness for placement into three themes: (1) adequate site orientation for learner acquisition of organization acumen and (2) clinical preceptor training to support unit/service and (3) individual components. Conclusion Thoughtful attention to hospital-based orientation can support learners in transitioning from academic to clinical learning. Hospital organizations should attend to all three components during orientation to better support learners’ preparedness for clinical learning.


Introduction
An essential component of health professionals' training is applying theoretical and conceptual knowledge in the clinical context. Experiential learning during clinical placements offers learners the opportunity to practice and demonstrate the combination of knowledge, attitudes, and skills in complex care environments. 1 Academic leaders of health professions education programs recognize the importance of these clinical experiences, and often proactively work to support learner preparedness for clinical placements. Adding to the importance of this topic for clinical sites, recent provincial legislative changes to the Occupational Health and Safety Act 2 in Ontario identify learners as 'workers', therefore Ontario hospitals have a statutory responsibility in preparing learners for clinical learning.
A key enabler in preparing learners to successfully transition between academic and clinical learning is orientation. Orientation for medical and nursing learners transitioning from the academic settings to clinically-based learning has been explored in the literature. [3][4][5][6] We wanted to explore orientation activities for learners that occur within the hospital setting, or 'hospital-based orientation' (HBO). Newly graduated staff nurse orientation has been extensively explored, 7,8 however, we were unable to find any literature exploring learners' perceptions of HBO.
In 1998 a team of Australian medical researchers created a Preparedness for Hospital Practice survey tool in order to evaluate the adequacy of junior doctor's undergraduate medical training in preparing them for hospital practice. 9 The survey defined eight domains of preparedness for clinical learning that focused on learners' self-reported skill and knowledge acquisition. 9 Many academic institutions also focus on skills and knowledge improvements during the transition from academic to clinical learning, using multiple strategies and approaches. [10][11][12][13][14] Interestingly, and perhaps in slight contrast to the training as orientation mentioned above, rehabilitation sciences preceptors and learners e64 (occupational therapy, physiotherapy, and speechlanguage pathology) identify the learners' personal attributes and interpersonal skills -such as willingness, professionalism, communication and interaction, and personal attributes and skills, as key indicators of preparedness for clinical learning. 15,16 In a study of recent nursing graduates, medical learners, and organizational representatives, four dimensions of work readiness ('the extent to which graduates possess the attributes that prepare them for success in the workplace') were identified: work competence, personal characteristics, social intelligence, and organizational acumen. 17 For us, the organizational acumen dimension in particular could be a useful lens to understand how HBO prepares learners to successfully transition from academic to clinical learning.
As a first step towards supporting learners transitioning from academic to clinical learning, we sought to understand the learner perception of HBO. We asked: 1) how do learners perceive HBO?, and 2) how does HBO impact clinical learners' perceptions of preparedness?

Methods
We used a qualitative description methodology to explore learner perceptions of HBO and preparedness across nine hospital sites across the Greater Toronto Area. 18 The Research Ethics Boards at all participating hospitals approved this study (Toronto Academic Health Science Network Research Ethics Board #16-380).

Participants
We used convenience sampling to recruit learners who were on placement of at least two weeks from February-October, 2017. Recruitment across all hospital sites involved distributing electronic and paper flyers. Learners self-selected to participate in the study and received no remuneration.
A total of 63 learners agreed to participate [51% (n = 32) from nursing, 11% (n = 7) from medicine and 38% (n = 24) from allied/health disciplines (physiotherapy, occupational therapy, respiratory therapy etc.)]. All learners participated in a focus group at the site where they were attending placement. As we were exploring learners' perceptions of what orientation was, we did not select a target window between the start of a learner's placement and participation in the study.

Data collection and analysis
The lead author or the research assistant led semistructured focus groups. We conducted eighteen, 45-60-minute focus groups. Sixteen consisted of two to ten participants per site, and two of the planned focus groups became individual interviews due to participant attrition. Learners self-selected focus group dates, resulting in seven of the focus groups being uniprofessional, and the mixed. We recorded and transcribed verbatim the focus groups. The lead author and a research assistant carefully read and coded all transcripts, and held meetings monthly to distill initial themes and modify the interview guide. The core research team (LB, VC, RK, LJ, and BB) analyzed the entire data set with a final coding structure. We stopped collecting data once no new information or themes were being identified. 19,20

Results
Orientation consisted of three themes organized by three components: site, unit/service, and individual. These three components influenced learners' perception of preparedness for their clinical placement. See Table 1. for representative quotations of each.

Site
The first component of orientation, site, consisted of organizational requirements learners needed to complete to move forward with their placement. Learners described gaining site-specific knowledge that supported their perception of inclusion in the clinical setting.
This component also included gaining access to electronic systems, receiving security identification badges, and information about where to go on the first day. Learners also appreciated that orientation had the ability to increase the efficiency with which they could begin learning.

Unit/service
The second component of orientation, unit/service, included knowledge or training that learners perceived enabled them to learn effectively and safely in that specific unit/service area and with that team. Learners identified the need for area-specific information such as tours of areas, schedules for training, and where items are located. Learners also identified that the orientation had to be specific to each clinical area, as tasks and processes were different in each setting. Knowledge gained in this component facilitated learners' perceptions of their ability to safely function in that specific area/unit. Learners' perception of the completeness of their unit/service orientation also impacted their perceived ability to collaborate with the team. Finally, learners identified knowledge and insights about the members of the team, and their roles as a way to prepare to respond to situations as they arose.

Individual
The third component of orientation was individual. Learners described where they were in their academic journey, including an understanding of their learning goals, roles, responsibilities, and accountabilities. Discussions with their preceptors significantly shaped this understanding. Learners also perceived that having clearly defined responsibilities supported them to identify their own roles within the team. Learners identified how to be successful in their placement, through clear preceptor expectations.

Discussion
A health professions learner is successful when they are able to consistently demonstrate a certain level of competence, appropriate for their level of training, and required for their profession. Clinical placements contribute substantially to this process. Our study provides some insight into learners' preparedness to transition from academic to clinical learning by identifying three major components of HBO (site, unit/service & individual). Work readiness dimensions of work competence (knowledge and skills) [11][12][13][14]15,[21][22][23] and personal characteristics 15,16 have been explored in studies, however, we could not find studies detailing the organizational acumen dimension (knowledge of the area, procedures, and policies) and its relationship to learner preparedness. Our findings suggest that opportunities to develop specific organizational acumen during HBO could play an important factor in helping learners feel prepared transitioning between academic and clinical learning. Our results demonstrate that learners are able to consistently articulate what HBO is and how it impacts their preparedness, despite participants representing multiple professions, and experiencing different HBO's at different times.
Learners were seeking out tangible knowledge and items that facilitated access to learning opportunities within the clinical setting in the site component of orientation. Learners found it extremely difficult, if not impossible to fully participate in the clinical setting without access to the clinical site's policies and procedures, electronic systems etc. (organizational acumen). These findings are consistent with the categories within Walker et al.'s work readiness study, which indicated the need for specific knowledge related to the clinical sites' policies and procedures. 17 Learners clearly identified the requirements of being prepared to learn, including orientation items that promoted learner safety in the unit/service component of orientation. This included understanding of the learner specific role in difficult situations, and/or identification of key support persons to ask for assistance when learners felt unsafe. Amy Edmonson's work related to psychological safety in teams reinforces these findings. [24][25][26] Edmonson defines psychological safety as 'the degree to which people perceive their work environment as conducive to taking these interpersonal risks' 24 and argues that in psychologically safe environments, learning is fostered by the individuals' belief that they are safe to seek assistance and support. 26 Finally, learners benefited from having clearly identified roles and expectations for success. This meant specific opportunities to perform the skills and tasks of their profession in the individual component of orientation. A clinical preceptors' ability during HBO to support learners' preparedness is reflected in the literature through best teaching practices. Sutkin's 2008 scoping review of what makes a good clinical teacher identified teacher characteristics such as 'organized and communicates objectives' and 'individualized attention to students' and 'stimulates e67 or inspires trainees thinking' which aligns with the learners' perceptions in this study. 27 The results of this study provide the opportunity to conceptualize learners' preparedness for successfully transitioning between academic and clinical learning, as the 'ability to safely learn and perform in the clinical environment through the acquisition of organization-specific knowledge and access, socialization into their unit/service area and identification of expectations and goals.' As hospitals have an obligation to support clinical learners, we wish to highlight two key elements over which hospitals have a degree of control during HBO planning and resource allocation. The first is providing adequate HBO that supports learners' acquisition of organization acumen. The second is ensuring clinical preceptors have the training required to support components of orientation in which they play a large role, i.e. the unit/service and individual components.
In conclusion, as hospitals and academic institutions continue to work closely together to prepare learners, to identify roles and responsibilities, and to provide clear systems of communication will be key in ensuring consistent messaging and adequate systems of support for learners.

Limitations
The different compositions of our focus groups (intraprofessional vs. interprofessional) could have created different dynamics in each group, thus potentially impacting the content of the discussions. Participants also had different orientation timelines and experiences depending on their program of study and specific hospital placement. While the differences facilitated an exploratory approach to the topic, it also limits our ability to narrow findings to a specific learner group or generalize beyond our own system.

Conclusion
This study provides preliminary information related to the relationship between HBO and learners' perceptions of preparedness for transitioning between academic and clinical learning. Currently, academic institutions' focus on preparing learners includes an emphasis on knowledge and skill acquisition and we argue HBO can also play an integral role in learners' preparedness at the unit/service and individual levels. First, HBO ensures that learners obtain the site's organizational acumen, and second, HBO prepares clinical preceptors for their role through basic faculty development programming.
Although we explored learners' preparedness for clinical placement with HOB, we did not explore the relationship between academic institutions compared to HBOs. Health profession group-specific explorations of orientation could be an important next step in determining different learner groups' perceptions as well as the relationship between academic and HBO.