Understanding the meaning of autonomy : creating a learning space for professional becoming in clinical education

The overall aim of this thesis was to understand the meaning of the phenomenon autonomy in learning, related to medicine and health-care students’ perceptions of learning and development in clinical education. We know little about how autonomy influences individual thinking, action and awareness of learning in clinical education. Studies in this thesis showed a connection between autonomy and experiences of authenticity. There is also a knowledge gap concerning authenticity as phenomenon featured in a medical education context. An understanding of the ways in which students’ learning and professional development are facilitated by autonomy and authenticity is considered vital for future development of clinical education.

This thesis is ontologically and epistemologically grounded within the social constructivist-interpretative paradigm. The overall aim was achieved through four research questions, represented by the aims in four scientific studies that together constitute the findings in this thesis. The conducted research was positioned within the phenomenological hermeneutic research tradition, describing and understanding phenomena and their meaning revealed through hermeneutics. The studies were undertaken using narrative inquiry. Context for studies I-IV are students’ clinical placements, at hospital wards and clinics in a primary care setting, or in some cases in a home care setting or a laboratory environment.

Studies I, II and IV, rest on paradigmatic narrative reasoning, whilst study III apply narrative analysis and the construction of stories, however after a theoretical analysis of the collected data. Analysis of data in this thesis rests heavily on the work by Ricoeur, and the view of interpretation as the “hinge” between language and lived experience. Findings show that autonomy was shaped of and given meaning by Autonomy as a qualitatively different view of a discipline, Autonomy as a social phenomenon, and Autonomy as authentic experience. Autonomy in learning constituted a social phenomenon and something that evolved in relation to others. Findings in this thesis also displayed connections between autonomy in learning and experiences of authenticity in clinical education. Furthermore, findings indicated that transformative learning processes contributed to the development of professional identity, triggered by authentic practical experiences, and the perceived meaning of these experiences.

Authentic clinical experience, here interpreted as internal authenticity, was a prerequisite for experiencing membership in a community of practice, thus making internal authenticity a component in the development of professional identity. Students perceived a need for attachment, i.e. attachment to patients, to supervisors, to the workplace, to the situation and to reasoning and knowledge. Authenticity was enhanced when relationships with supervisors, patients and other professional categories were formed. Thus, attachment is here seen as a condition for experiencing authenticity, and authenticity is here a prerequisite for autonomy.

List of scientific papers

I. Fredholm Nilsson, A. & Silén, C. (2010). ”You have to know why” - The Influence of Different Curricula on Nursing Students’ Perception of Nursing. Scandinavian Journal of Educational Science. 54(6), 631-642.
https://doi.org/10.1080/00313831.2010.522974

II. Fredholm, A., Henningsohn, L., Savin-Baden, M., Silén, C. (2015). Autonomy as both challenge and development in clinical education. Learning, Culture and Social Interaction. 5, 20-27.
https://doi.org/10.1016/j.lcsi.2014.08.003

III. Fredholm, A., Henningsohn, L., Savin-Baden, M., Silén, C. The practice of thresholds: autonomy in clinical education explored through variation theory and the threshold concepts framework. [Submitted]

IV. Fredholm, A., Manninen, K., Hjelmqvist, H., Silén, C. Feeling like a doctor - Medical Students’ Experiences of Authenticity and Professional Development. [Submitted]