A selection of vignettes are arranged to demonstrate the main findings. The first vignette (Fig. 1), demonstrates several inter-related findings and also demonstrates how the analytic language can be applied to describe and analyse a complete learning episode involving social and material actors.
In this vignette, multiple actors play a role in the formation and disintegration of learning networks. The human actors include other healthcare students, allied health professionals, hospital support staff, nurses, varying grades of doctor, parents and patients. Material actors include televisions, probes (and their alarms), clothes, a clerking sheet, a store cupboard, medical equipment, drug cupboard and a library. Many of the material actors, such as televisions and probes produce sounds, the semiotic function of which (in the context of a learning network) inhibits the formation and maintenance of learning networks by diverting human actors’ attention and apparently disrupting thinking.
Two Short-lived clinical learning networks were formed; firstly, where students practiced talking to a patient (20 minutes) and secondly, where students received impromptu teaching from a consultant (25minutes). However, these networks take 2 hours and 20 minutes to initiate.
The first network in Vignette 1 is generated through a facilitating action by a junior doctor who identified a patient for the students to examine. However, the network appeared to be unstable. It was continuously on the verge of disintegrating due to the inhibiting forces of the nurses, the material actors and the patient’s family. The learning network finally disintegrated with the arrival of a consultant who performed new facilitating interactions with students that created a second learning network which took place in a store cupboard. However, as the location of the consultant is discovered, the learning network is interrupted by the inhibiting actions from junior doctors and nurses performing the action functions required by the service network. The consultant continues to maintain the learning network through her facilitative action functions that prioritise the learning network over service needs.
However, within a short period of time the service demands require the consultant’s attention and she has to leave. When the consultant leaves the cupboard, the inhibiting actions overwhelm the tenuous learning network and it disintegrates almost immediately. The students then try for another two hours to initiate a new network without success. In this observation period, the functional clinical learning networks lasted a total of 45minutes out of the six hours scheduled for clinical learning that day. Unsuccessful network initiation action functions accounted for four hours and thirteen minutes of this time.
The students struggle with physical characteristics of wards, such as layout and also patient locations, partly because they did not have pens and paper to write down patient locations or sometimes because ward layouts were somewhat disorientating – being linked by various passages and doors that were often keycode protected. Students did not wear white coats and so often left simple items like pens and notebooks in rucksacks as they could not keep them about their person. Due to service pressures, patients were frequently not where they might be expected and were situated on ‘outlier’ wards. This was tracked through the hospital computer system. Students lacked the information (logins and passwords) to enable their use due to hospital policies barring students from access. Paradoxically therefore, despite being technically proficient in IT, students often appeared as ‘technological refugees’ in this environment.
Ambivalent interactions were often observed between human actors in this context. For example, in this vignette, the semiotic action of the first nurse is characterised by seemingly facilitative initial verbal interactions (but immediately followed by a ‘but’). However, the whole interaction was overlain with unmistakeable inhibitory non-verbal semiotic functionality. These ambivalent interactions often appeared to disorientate students and delay network formation. In the vignette, the students continued their action functions of planning, searching for and locating patients and then negotiating with gatekeepers (often nurses). The semiotic functions of a second nurse appear to encourage the students to continue trying and after 45 minutes they succeed in initiating a learning network through interacting with a patient. However, this learning network ended after 5 minutes when the Consultant led ward round arrived. The ward round provided the opportunity for another learning network to form with the Consultant launching a question-and-answer session with the students. This second learning network also lasted a few minutes as it disintegrated when the ward round moved on to another patient.
The environment is analytically dense with myriad interactions between many actors (nurses, managers, children at ward school, doctors, laundry delivery personnel, ward staff at fountain, crying baby, water fountain, saturation monitor alarm). All the material actors appear to be exerting inhibiting network effects, constantly threatening the maintenance of the learning network. The consultant teacher facilitates network maintenance through ‘filtering’ the considerable load produced by the combined action and semiotic functions of the multiple actors involved in this network. However, the students appeared to lack this filtering ability and are particularly disturbed by the sound of crying. This appears to affect recall of basic scientific knowledge which was at odds with the same students’ ability to recall detailed and complex information during subsequent observations in a tutorial in a classroom setting. In contrast, senior clinicians consistently appeared to be adept at this kind of filtering. This ‘filtering’ ability (or lack of it) contributed to a commonly observed mismatch of teacher expectations and student ability to retrieve or process information in this environment.