title: Contextual tensions of the clinical environment and their influence on teaching and learning.
abstract: BACKGROUND
  Academic medical centres face major challenges, and finding creative, effective strategies to support patient care and teaching are critical for survival. At the centre of these challenges is clinical teaching.
  
  
  OBJECTIVE
  To characterise how context influences clinical teaching.
  
  
  METHODS
  Multiple embedded case-study design analysed 3 internal medicine in-patient teams. Direct observations, interviews and documents were data sources. Triangulated data, audit trails and member checks enhanced trustworthiness.
  
  
  RESULTS
  Three tensions influenced clinical teaching: 1, patient census; 2, time sensitivity of the context; and 3, the multiple and conflicting commitments of participants. Patient census exhibited the greatest influence and was the catalyst for teaching, learning, and the allocation of total time. Time functioned as an important element influencing the pace of action, reflective and interpretative cognitive processes of the team, time available for action, and the general fatigue of the team. Conflicts among the multiple roles of ward team members disrupted individual and team teaching and learning.
  
  
  CONCLUSIONS
  Clinical teaching is an open system influenced by multiple forces. Learning, teaching and patient care were very closely coupled, and learning knowledge and using knowledge were parts of the same process within the clinical context.
authors.affiliation: Department of Internal Medicine, University of Missouri-Columbia, MA 213 Medical Sciences Building, Columbia, MO 65211, USA.
authors.forename: Kimberly G
authors.initials: KG
authors.lastname: Hoffman
authors.forename: Joe F
authors.initials: JF
authors.lastname: Donaldson
mesh_terms: D002983:Clinical Competence / Q000592:standards*; D004502:Education, Medical, Continuing / Q000379:methods*; D006784:Hospitals, Teaching / Q000379:methods / Q000592:standards / Q000706:statistics & numerical data; D006801:Humans; D007388:Internal Medicine / Q000193:education*; D007396:Internship and Residency / Q000379:methods