Under social-learning theory, what four processes influence a models impact on individual behavior?

Having presented the codes, themes and illustrative quotes from the interview transcripts, these will now be discussed in further detail.

Attention

Being present and involved

Despite needing to be physically present and able to see the action some students reported feeling in the way like ‘lemons’ or ‘ghosts’, suggesting they needed their participation to be legitimised. They described that legitimacy as coming from being given a specific role, such as taking a history from a patient. Anita, for example, described being asked by a consultant to sit and chat with a patient whilst she ate her breakfast. For the student this proved to be a rich and memorable learning experience. This purposeful role gave her an involved perspective from which to observe and maintained her attention. Lave and Wenger [14] refer to the way that newcomers to a community of practice learn by participating as legitimate peripheral participation. But opportunities for legitimate peripheral participation need to be created for medical students and the value of this should not be underestimated as the quotes from students’ demonstrated.

Teachers were also aware of this need to actively involve students, particularly those less confident ones, but due to time pressures this was not always possible. Most teachers agreed that some role models were easy to identify - what Abigail referred to as ‘superstars’. But there was an acknowledgement that other role models might be more useful, particularly in the early stages. Therefore, as has been found in other research [8] signposting less obvious behaviours, such as at what point and how junior doctors involve senior colleagues was important.

Continuity of and exposure to role models

Barriers to paying attention included lack of continuous exposure to any one role model or patient, meaning that students could not truly analyse role model’s behaviours or evaluate the impact of that behaviour on others. Attending to patterns in role models’ practice takes time and for some the short phases that tend to characterise medical students’ clinical rotations made this difficult.

Where role models had facilitated more continuous observations of their practice the educational value of this could be recognised by students. For some students, their experience aligned well with Gioia and Manz assertion that “if an observer is to learn effectively from a model it is important for the model to be credible, reasonably successful, clearly display the behaviour to be learned, and otherwise facilitate the attention process.” ([15]: 528).

Teachers also commented on the fragmented nature of clinical rotations. Difficulty in identifying patterns in behaviour and forming relationships created by lack of continuous exposure to role models seemed to be disruptive and demotivating for both students and teachers. Being aware of these challenges to attendance and opportunities to observe was important. Faculty also needed to be present in order for students to observe their practice, although as Iris pointed out, clinical teachers were still role modelling even if absent.

Aligned values

The students reported paying close attention when they observed a behaviour that aligned with their views of what was important about being a doctor. For Emily, the positive reactions she observed from her role model’s patients were more important than them having a long list of publications.

The artificial separation of scientific and medical knowledge from skills and attitudes within medical curricula can be confusing and students saw clinical rotations as a place to learn how to bring these elements of a doctor’s practice together, although they found it difficult.

Retention

There is an enormous amount for a learner to take on board when in a clinical setting and they cannot possibly be expected to retain everything they observe. In order to avoid becoming overwhelmed learners seek cues to work out what is important to retain and develop strategies for doing so.

Learning the language

Students spoke about comprehending and retaining the unfamiliar clinical language that they heard their role models use. This sometimes involved looking it up later or consulting peers.

Particularly useful role models deliberately helped students to learn the language and develop the way they communicated in the clinical setting.

Understanding thought processes

Students talked about how they valued their role models giving insight into their thought processes as this enabled them to understand the reasoning behind the behaviours they were observing, including coping with uncertainty, and helped them to make sense of and retain the particular learning point.

Liam, who like other students talked about the importance of being able to relate to their role models, attributed this relatability, in part, to him and his role models thinking alike. This seems connected to the point made earlier about the attractiveness of aligned values between role models and observers.

Meaningful reflection

Reflection is widely acknowledged as aiding development, but how do learners make use of reflection when learning from their role models? Even though Jason claimed not to be ‘a fan of formal reflection’ he had clearly developed a critically reflective approach to help him extract personal value from what he had observed and imitate aspects of it before deciding what to retain.

Stefan also talked about the importance of authentic reflection and the role of teachers in creating space and support for students to evaluate what has been observed in clinical settings.

Writing it down

Liam described a particularly systematic approach to aid retention and processing of what had been observed, clearly guided by his role model.

Such strategies were encouraged and signposted by teachers, with Melanie referring to use of an advanced organiser [16] to help students consciously retain what they observed. She described an example in which she asked students who were observing her on a busy labour ward to write down a few things they noticed her doing or questions she asked the patient and then, importantly, got them to reflect on why they noticed these specific things or why they thought them important. Facilitating this metacognitive process, whereby students are required to think about what and how they are learning through observation, may also enable teachers to reinforce or ‘correct’ important take away messages.

Reproduction

Opportunity to practice

The opportunity for hands-on practice has been reported as lacking from some clinical-based learning experiences [17] In our study students talked about being given the opportunity to put into practice the behaviours and strategies that they had observed in their role models. Some needed help to recognise opportunities or to be given permission to take advantage of opportunities and to participate in a legitimate and meaningful way.

Giving students opportunity to legitimately participate in the team may involve considering the roles and expectations of the existing clinical team.

Most students recognised the need to be proactive about identifying and creating their own opportunities for practice and some had strategies for arranging these.

Students’ also highlighted the value of being supported by a role model to identify in advance, in a systematic way, tasks and skills that they could learn through modelling and observation with opportunity for practice.

Feedback

When referring to opportunities to put into practice the techniques that they had observed, students highlighted the value of feedback that both reinforced desired behaviours and suggested aspects for development, especially where it was highly contextualised and immediate.

Shivani talked about making use of the student perspective and adopting a more dialogic approach to feedback [18] on what has been observed in way that could offer suggestions for development for both teachers and students.

Motivation

Feedback

Finally Bandura argued that if students are to learn from and reproduce the behaviours that they observe in their role models they need to be motivated to do so. For many students this was a question of direct reinforcement, whether this was a self-regulated process involving perceptions of ‘wanting to please’ or further reinforced by direct, positive feedback, including more independence.

Observing other’s responses - vicarious reinforcement and punishment

Two further interesting and useful concepts from Bandura’s social learning theory are vicarious reinforcement and vicarious punishment. Bandura proposed that when observing others we not only learn from their behaviour but also from the reactions of other people to the role model’s behaviour. This is potentially a very efficient way to learn as it allows us to learn from others’ mistakes. Our student interviewees identified a number of examples of being vicariously reinforced or punished and described how the reactions of patients, colleagues or fellow students influenced their decisions to reproduce behaviours they observed. For example, Liam, who was vicariously reinforced having closely observed this paediatrician, chose to adopt his communication technique as a result of the calming effect it appeared to have on children.

Conversely an example of vicarious punishment refers to what Jason considered to be brusque treatment of a patient. He was vicariously punished by the interaction between a role model and patient and as a result talked about wanting to deliberately avoid reproducing this behaviour in his own practice because of the patient’s reaction.

Jason also highlighted barriers that interruptions in exposure to patients and clinicians poses for students wanting to convert observation into practice. It appears to be important to create opportunities for students to observe outcomes of interactions (or for them to be discussed), as well as seeing the behaviour that led to them. Students reported receiving mixed messages about appropriate behaviour through vicarious reinforcement. As Iris commented the less desirable behaviours observed in clinical settings can have a powerful influence, a view supported by Gibson [5], who highlights the value of learning from negative traits as well as positive aspects of role models. Furthermore Bucher and Stelling [19] found, to their surprise, that rather than identifying complete roles models amongst their senior colleagues, as had been assumed, medical students actively identified specific attributes to emulate and to reject, in a process of creating a vision of their ‘ideal selves’. Clinical teachers recognised that students made decisions about who were useful role models on the basis of vicarious reinforcement. in the form of successful clinical outcomes, and/or positive reactions from patients and colleagues. Stefan spoke about how students might use clinical outcomes to judge the value of a particular behaviour when deciding whether to adopt or adapt them.

Reciprocating

Student also saw satisfaction and reward in being part of the reciprocal role model cycle themselves and referred regularly to the culture of peer support in medical school.

In terms of closing the reciprocal loop Liam, for example, also talked about how he sent a letter, email or card to his role models to thank them.

However, in general it is unclear how aware role models are of the influence they have on those observing them and indeed how they could be more effective. Clinical teachers commented that they seldom received direct feedback on the impact of their role modelling but Shivani recalled that students had commented on how she had interacted with a patient thus highlighting for her the value medical students derived from being able to closely observe a role model in action. Feedback on how role models have influenced those around them is potentially an important of untapped source of evaluation data.

Limitations

Whilst this paper has emphasised the benefits of modelling and observational learning, students also highlighted the limitations. This included that the ability to imitate the actions of others and carry out clinical tasks might not be accompanied by underpinning clinical knowledge or rationale in the mind of the learner.

Another limitation is created by the lack of constructive alignment [20] between the formal undergraduate medical curricula, often with an emphasis on gaining knowledge and exam-based assessment, and the authentic, skills-based learning in the clinical setting. This resulted in some learners prioritising revision for their exams over taking the opportunity to learn from observation in the clinical setting.

Finally the unfamiliar and haphazard nature of observational learning opportunities in the clinical settings proved challenging for students to identify and follow to their logical conclusion thus limiting the learning process that Bandura describes. Even when student interviewees described successful learning having taken place it became apparent that they were often not in control of, or even conscious of, the process occurring, let alone able to guide themselves through the four stages identified by Bandura.

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From: A skill to be worked at: using social learning theory to explore the process of learning from role models in clinical settings