"Figuring It Out on the Fly” Learning Through Complexity in Clinical Practice During COVID-19

• In Event: Integrating Life-Informed Complexity for Practical Professional and Higher Education

Abstract

1. Objective or Purpose
As educators in the health professions, we require an understanding of the requisite skills learners will need to rely on when navigating complexity and uncertainty in their clinical practice. To date, formal training to navigate uncertainty in practice is lacking despite the fact that uncertainty and complexity were amplified by the Covid-19 pandemic; it illuminated the gap in training physicians receive to function in uncertain environments. Through our study we hope to take practical steps to integrate observed findings into formal curricula.
2. Perspective(s) or theoretical framework
We use the Cynefin framework (Snowden & Boone, 2007) as a sensemaking tool combined with the informal and incidental learning theory (Authors). Both frameworks are dynamic in nature and allow for situational perspectives to be included in the analysis.
3. Methods, techniques, or modes of inquiry
We interviewed frontline physicians with varied clinical experiences who either worked in the emergency department (ED) or the intensive care unit (ICU) at an urban, academic, tertiary-care hospital in Philadelphia, Pennsylvania. We used Critical Incident Technique (CIT) to explore the lived experiences of these frontline physicians as they worked through uncertainty and complexity during the first wave of the Covid-19 pandemic.
4. Data sources, evidence, objects, or materials
We find decision making and learning patterns as a consequence of the decision burden that physicians face amidst uncertainty and complexity in their clinical practice. We further find that learning and decision making are influenced by the physician’s physical, emotional, social and situational contexts (see Figure 1. attached at the end of the document).
5. Results and/or substantiated conclusions or warrants for arguments/point of view
The Covid-19 pandemic changed the environment that health-care workers were accustomed to working in. Physical spaces were reorganized, new equipment was utilized, evidence-based literature was sparse or non-existent, and there were more questions than answers. We describe how changes in the physical, situational, emotional, and relational domains were influential to our participants ability to “figure it out on the fly” (PHY03) and make decisions.
In this uncertain, complex and often chaotic learning environment, the themes that emerged for decision-making and learning were interdependent: applying prior knowledge, using pattern recognition, and then cross-checking information with team members. Learning emerged through trial and error, intentional and thoughtful experimentation, poking at the periphery of a problem, accessing alternative sources of information, and, ultimately, the accumulation of knowledge.
6. Scientific or scholarly significance of the study or work
Through this study, we have identified decision-making and learning patterns that can help medical students to prepare for uncertain and complex environments. Our findings can directly lead to new curriculum development, for example in the form of case-based learning where students are prompted to engage in: 1) sense-making using the Cynefin framework; 2) naming the type of uncertainty at hand; and 3) identifying appropriate problem-solving strategies. Our work is significant as it contributes towards normalizing uncertainty intrinsic to clinical practice and provides students with the tools they need to address uncertainty in the clinical learning environment.

Authors

• Henriette Lundgren, University of Georgia

• Dimitrios Papanagnou, Thomas Jefferson University