Melvin, Anna
(2022)
Exploring medical student well-being during transition: a realist inquiry.
PhD thesis, University of Nottingham.
Abstract
Background
Issues relating to well-being are widely discussed in medical education and the wider profession, however, well-being is poorly conceptualised and theorised, limiting our understanding of the issues. Transitions have been highlighted as a particular area of concern for well-being. The transition literature has tended to focus on learners’ struggles, emphasising learner skill and knowledge deficits as the source of their difficulties and poorer well-being. This has resulted in limited understanding of the wider environmental factors and underlying causes of learners’ well-being through transition experiences. In this work, transition was conceptualised more broadly as an ongoing developmental process influenced by both environmental and individual factors, with the experiences in one transition affecting the next. This research aimed to improve the knowledge of how well-being is affected during transition by taking a theory-building approach, firstly clarifying the concept of well-being, and then exploring how both student and environmental factors affect well-being through underlying psychological processes during transition, and the links between well-being and learning.
Research approach
This research was conducted within the scientific realism paradigm and adapted realist methodology for problem exploration. The methodology considers how outcomes are caused by underlying mechanisms activated in conducive contexts, representing knowledge of these causal explanations in theories. Three components were designed to address the overarching research question: in what circumstances, for whom, how, and why does the process of transitioning through clinical training affect medical students’ well-being?
Component 1: Theoretical integrative review
The theoretical integrative review identified definitions and theories of well-being from the psychology literature. These were analysed for conceptual and theoretical insights, which were synthesised into a concept definition and theory of well-being. Well-being was defined as the subjective experience of life, with two dimensions – feeling and functioning – each with several attributes. The theory explained how well-being changes through three psychological processes, or mechanisms: basic psychological need satisfaction; psychological flexibility; and resource cycles. The concept definition and theory were the foundation for theory-building in the subsequent components of the research.
Component 2: Realist review
An initial rough theory of how well-being is affected by the transition through clinical training was developed, tested and refined by building on the well-being theory using the clinical training transition literature. Insights about how the transition affects well-being through interactions between contexts and mechanisms were extracted from the included documents and synthesised into context-mechanism-outcome configurations (CMOCs) under four theory areas: higher-system level factors; learning climate; student-teacher interactions; and managing well-being.
Component 3: Realist investigation
Realist interviews were conducted with medical students (n=22) and educators (n=30) and the data analysed to develop, test and refine the CMOCs from the realist review. The findings highlighted the importance of teachers welcoming and involving students, as this facilitates participation, belonging, and role clarity, activating well-being and learning mechanisms, and increasing the student’s well-being and readiness for the transition to clinical practice. However, wider contexts can affect the degree of welcome and involvement in the clinical learning environment. In less welcoming learning climates, student participation, belonging and role clarity depends on three student contexts: readiness; self-directed learning; and psychological resources. The findings also highlighted how students’ resource pools and experiences affect their well-being and developmental trajectories over time.
Conclusion
The programme of research clarified the conceptual and theoretical foundations of well-being and used these to explore how environmental and student contexts interact with various psychological processes to affect well-being and learning during the clinical training transition. A refined theory was developed on the basis of the findings and used to develop recommendations to improve well-being and learning. Overall, the findings emphasise the importance of medical education adopting a proactive compared to reactive approach, considering the role of environmental as well as individual factors, and acknowledging the complexity of issues like well-being and learning.
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