Professional socialisation in the clinical training environment of anaesthetic technicians’: A qualitative study

doi:10.21203/rs.3.rs-2613749/v1

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Professional socialisation in the clinical training environment of anaesthetic technicians’: A qualitative study

https://doi.org/10.21203/rs.3.rs-2613749/v1

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Background: Professional socialisation is important for developing professional identity among newly graduated health professionals. Benefits extend tojob satisfaction, work engagement, internal motivation, adjustment to professional roles, social acceptance, and a sense of belonging. The clinical environment plays an important role in determining positive or negative professional socialisation experiences. In New Zealand, the education programme for anaesthetic technicians (ATs) is transitioning from an apprenticeship model to a three-year Bachelor of Health Science. As both models include a significant element of clinical exposure, it is important that we understand what influences the professional socialisation experience. There is a lack of studies focused on professional socialisation with AT education. Therefore, this study explored the experiences of recent graduate ATs in the clinical environment to inform the ongoing development of the training programme.

Methods: This study used a qualitative, descriptive methodology. Five ATs were recruited in using purposive sampling in New Zealand during October 2020. All had graduated within the past 3 years. Semi-structured individual interviews explored participants’ interpretations of their professional socialisation experiences in the clinical environment. Data were analysed using standard qualitative analysis.

Results: Three main themes and eight subthemes emerged from the interviews: learning to behave (professionally and by following role models); learning to survive (in a hierarchical environment, with a derogatory view of being invisible, with a lost voice striving for acceptance and by conforming); and learning to thrive (with support from the professional ‘family’ and by learning about each other).

Conclusions: The findings suggest that ATs’ professional socialisation occurs in a challenging clinical context with competing professional identities and encompasses positive and negative learning experiences. In this environment, ATs’ student status may be perceived as weak and predispose them to conforming to survive. Academic and clinical education facilitators should be aware of the need to advocate for positive professional socialisation experiences. It is also important to enable an inter-professional identity to emerge to promote collaboration among future health professionals.

Anaesthetic technician

student

health professional

professional socialisation

professional identity

professional behaviour

Health professionals’ education includes development of professional values and professional identity, which emerge through effective socialisation processes [1]. Professional socialisation refers to an individual acquiring the values, attitudes, skills and knowledge necessary to competently perform their role [2] and is a continuous, longitudinal process [3]. The acquisition of professional values, attitudes and behaviours during this process enables individuals to develop and capably perform tasks relevant to their professional group [4] through subscribing to that group’s norms and ideologies. Benefits of this process include job satisfaction [5], work engagement and internal motivation [6] and facilitating the adjustment to professional roles [7], highlighting the influential nature of professional socialisation.

Lieberman (2013) described the human cognitive desire to gain social acceptance to fit in a group [8]. Individuals may alter their conduct and explicit behaviour to be accepted [9]. This sense of belonging is considered a positive aspect of professional socialisation [7, 10], but is also central to understanding potentially negative aspects of professional socialisation. This is particularly relevant for the AT profession, as students learn in a work environment where multiple different health professions operate in close proximity and perceived role boundaries are blurred. Literature from other health professional groups highlighted the influence of the work setting in determining positive or negative professional socialisation experiences but studies focused on the anaesthetic technician (AT) profession are lacking.

However, ATs in New Zealand (NZ) have historically trained under different conditions than other health professions using an apprenticeship model. After less than 12 months of clinical experience supervised by a registered AT, students typically spend the next 2 years of their training acting as the sole AT provider for an operating list. Although the programme is transitioning to a full-time tertiary-based degree, there will still be a significant clinical component during training.

Aim

This study explored the professional socialisation experiences of recent graduate ATs in clinical practice settings in NZ.

Design

This study used a qualitative, descriptive design that explored participants’ interpretations of their experiences [11] with professional socialisation.

Study setting

Participants were recent graduates of the AT apprenticeship training programme in NZ. The AT profession is a registered health profession governed by NZ’s Health Practitioners Competence Assurance Act 2003, with similar competencies to other international perioperative professions such as the operating department practitioner (UK). NZ has one accredited education provider for registration as an AT. At the time of this study, student ATs gained clinical experience through employment in a training position with an accredited training hospital in an apprenticeship model.

Participants

Purposive, non-coercive sampling was used to recruit registered ATs who had graduated no more than 3 years before this study started. A longer timeframe might affect their recall of their transition into the profession. Five participants were included in this study. Participant numbers were restricted by resources available for the study (Master’s research report).

Data collection

A semi-structured interview guide, used to elicit participants’ professional socialisation experiences, included 19 open-ended questions; 14 questions drawn from a similar study [12] and adapted to the AT context, and five questions developed from a review of published literature that explored interprofessional education and socialisation. Open-ended questions encourage open and expressive responses, with probing questions used to elicit more detail [11]. Interviews, conducted via Zoom, lasted approximately 60 minutes. Participants consented to interview recording. Pseudonyms were used to preserve participants’ privacy and potentially identifiable information was removed. Memos recorded throughout the interviews captured the researcher’s immediate perceptions of participants’ responses and non-verbal cues. Participants could review their transcript (member checking) for any necessary clarification [13] and helped validate the data [14]. These comparative and inductive techniques enabled rich data to be discovered [14].

Data analysis

Data were iteratively analysed using qualitative content analysis [15]. An inductive approach where data analysis and collection co-occurred in an ongoing process was used to guide further data collection [14]. The recordings were transcribed verbatim, allowing familiarity with and insights about the data to develop. First, data were reduced through coding. Memos used to record modifications of coding decisions during the analysis, supported reflective processes [16]. Next, data were reconstructed by applying content analysis to the interview transcripts. Codes were grouped into categories reflecting higher levels of abstraction and latent meaning [17] and then into themes as recurring patterns emerged. Qualitative content analysis emphasises credibility and trustworthiness rather than validity and reliability as in quantitative research [18]. The use of reflective processes (e.g. memos) and member checking helped to ensure the credibility and trustworthiness of this study.

Ethical considerations

Following Massey University Human Ethics Committee (MUHEC) processes, this project was evaluated by peer review and judged to be low risk. Therefore, a low-risk notification was made to and recorded by MUHEC [26]. Participation was voluntary and all participants provided informed consent.

All participants (one female and four males) worked in the public sector. Three main themes emerged from the interviews: learning to behave; learning to survive; and learning to thrive. These themes reflected the complex perioperative practice setting that student Ats must navigate.

Learning to behave

This theme included two subthemes: learning to behave professionally and learning to behave by following role models.

Learning to behave professionally

Participants were asked how they would describe an AT who behaved professionally. Although there was no consensus across the group, certain values associated with professional behaviour were described, including punctuality, enthusiasm, tolerance, advocacy, and respect (for patients and colleagues).

Like punctual, enthusiastic, well-mannered, tolerant, keenness to learn and willing to teach others…it’s just someone who is all those. (Participant A)

There was consensus on how student ATs learned professionalism, with professional growth described as evolving over time, but ultimately beginning from day one.

…you’re just shadowing someone and watching what they do and how they interact…you get paired up with them and that’s obviously how you start off. (Participant B)

But although part of their curriculum, they did not recall formally learning about professionalism in their academic studies, and participants’ responses appeared disconnected from how this learning may be applied to practice.

...there is nothing in there (academic programme) that teaches you how to be an anaesthetic technician on the ground. (Participant B)

I’m not sure that we ever sort of go over professionalism…it’s more just something you’re expected to pick up on the job… (Participant E)

Learning to behave by following role models

Participants’ perceived role models as critical for students’ socialisation in terms of the values and behaviours underpinning professionalism.

…[supervisors] sort of teach you what you do and don’t do in theatre and how you should and shouldn’t act. (Participant E)

As ATs typically do not practice directly alongside another AT after the first 12 months of training, students had limited time to learn professional values and behaviours. Therefore, participants looked for feedback from others to validate their actions when they were unsure.

…a situation would come up and I’d go ‘oh, I don’t think I handled it the right way’…talk to the other technicians about it and they’d go ‘Oh, yeah, I had the same thing. And this is what I did, and now I do this’. (Participant B)

Thus student ATs’ behaviour was influenced by others’ actions and behaviours in the workplace.

You pick and choose bits and pieces that you like about what certain people do, and maybe steer clear of stuff that you don’t think is so good. (Participant E)

However, participants noted that it was sometimes difficult for students to determine if a certain behaviour was right or wrong, especially given the limited time spent learning directly from another AT.

…they don’t really know what to filter to, what are the things to listen to…they don’t have any baseline… (Participant C)

…you’re probably more inclined to learn from doctors than from your peers at that time…you don’t work that closely with other techs at that point. (Participant B)

Formation of participants’ initial professional identity was also influenced by negative professional socialisation experiences. As the operating room is a work environment where multiple health professions (and professional identities) converge, observed practices may present conflicts for students regarding correct behaviour. As students working as the sole AT, this influenced participants’ perceptions because they lacked role models to rationalise observed behaviours.

…its quite hard…even if you’re a positive person…you’re on a shift with eight more people [who] are all over-worked and they’re negative… (Participant C)

Learning to survive

This theme encompassed four subthemes covering learning to survive: in a hierarchical environment; with a derogatory view of being invisible; with a lost voice striving for acceptance; and by conforming.

Learning to survive in a hierarchical environment

Participants shared various aspects that challenged their ability to act professionally, including feeling unprepared for parts of the role. The hierarchical nature of the clinical environment was evident across participants’ narratives. They reported observing behaviours that were unexpected during the initial stage of professional socialisation.

…you always hear about the hierarchy system within the medical community…I was expecting that. I wasn’t really expecting some of the behaviours that I witnessed, especially at the start. (Participant B)

Participants also experienced the effect of the hierarchy through their ‘student status’, with a perceived inferiority within the workplace.

…[the supervisor] told me to do something…then the anaesthetist [would] be like ‘Oh why did you do that?’ and [then] the qualified AT would be like ‘Oh, you know, why did you do that’… I guess having a trainee’s an easy target… (Participant E)

Learning to survive with a derogatory view of being invisible

Participants recalled multiple events during their learning experiences that initially gave them a derogatory view of their new profession.

…where technicians see technicians and where everyone else sees technicians are different places on the scale. (Participant B)

…people think anaesthetic technicians just like pass over a tube and then sit down on their phones and then at extubation time they remove the tube and that’s all there is to it… (Participant A)

The lack of understanding about the AT role and a feeling of being undervalued ultimately led to a perception of being invisible.

…people don’t even know what we study, they wonder what we do… (Participant E)

Some anaesthetists like working solo most of the time…they talk to themselves and I’m invisible, I’m not there. (Participant D)

Learning to survive with a lost voice striving for acceptance

As students, participants felt they could not speak up because of their position in the hierarchy.

…feel[s] like you don’t have a voice, especially with qualified people. (Participant E)

They perceived themselves as being ‘lost’ during their training and seeking belonging and acceptance.

I didn’t really quite know where I belonged, and I wasn’t that comfortable with what I was because I wasn’t really anything. (Participant B)

This lack of belonging led participant C to question their role in the clinical environment.

If you’re in a place where you’re not accepted, well your self-worth will be crap…you think ‘why am I here?’. (Participant C)

These comments highlighted the importance of acceptance. Participants wanted to be recognised, but experienced moral conflict between professional standards and pressure to adhere to the team’s expectations. This intrinsic desire for acceptance dissipated once participants became registered ATs as they perceived themselves as being promoted within the hierarchy and thus receiving appropriate acceptance within the team.

…once you were qualified you got a new level of acceptance that you might not have got before. (Participant E)

Learning to survive by conforming

Participants described observing unprofessional behaviour in the operating theatre as students and can subconsciously accept aspects of such behaviour as the norm.

…there is a lot of behaviour that is tolerated…that wouldn’t be in other industries or other areas. (Participant B)

When you’re training…you just do what you’re told. (Participant E)

The need to conform appeared to be multifactorial, but the hierarchical setting in the clinical environment and the need for acceptance and job security were evident.

Learning to thrive

This theme comprised two subthemes: learning to thrive with support from the professional ‘family’ and learning to thrive by learning about each other.

Learning to thrive with support from the professional ‘family’

Participants described positive learning experiences in the clinical environment, including the influence of designated educators who supported them through their professional socialisation.

…they (educators) do teach you; they see you from having not done this kind of job to grow and prosper, and they’re always there to teach and discuss matters with…you end up building that rapport with them. (Participant A)

Designated educators were considered vital in rationalising negative observations that caused conflict for students, and essential for promoting best practice as future health professionals.

…my educator, I always run back to them, before any complaint or feedback from anyone…She pushed my level of professionalism to unexpected levels. (Participant D)

Participants indicated there was a time when students must ‘leave the nest’ and learn first-hand.

There are some technicians who think ‘ok, you’re not ready for this’, but they understood that I needed this for my learning…they are always there beside me or behind me if I needed anything or if ever I feel uncomfortable… (Participant C)

This highlighted that learning depended on understanding students’ needs and the shared responsibility of a community, especially as ATs learn in isolation from one another.

The ways for the new trainees to learn comes basically on the hands of the qualified ones…like the educators and the education programme, it’s in their hands on how to train good technicians for the future. (Participant C)

Learning to thrive by learning about each other

Participants recognised that interprofessional education (IPE) could improve interprofessional working relationships.

…if you had more of an insight into what the other person does…then you’re not so in the dark and then you might not have a pessimistic outlook on what they do. (Participant A)

…it’s good to have [an] awareness of what they are doing…it’s pretty largely just technician-based training…there’s nothing that you actually work with other professions. (Participant E)

Participants had few opportunities to experience IPE in a hospital-based education model and suggested it would be advantageous for students to learn with, from and about other health professionals.

…you gain a bit more of an insight into what that experience was like for that person…that’s really helpful for everyone… (Participant B)

All participants noted the value of collaborative education, which aided their visibility in the hierarchy and acceptance within the group.

This was the first study to explore recent graduate ATs’ perspectives of professional socialisation and developing a professional identity in the complex perioperative practice setting. Their experiences were captured in three main themes: learning to behave, learning to survive and learning to thrive.

Learning to behave

Participants learned how to act professionally in the clinical environment rather than through their academic studies. Although unexpected, this was congruent with previous studies that revealed a disconnect between students’ observations and formal education [19–21]. Participants spoke of using some professionals in their work environment as role models, a problem if poor behaviours were shown. Therefore, other professionals’ values and behaviours formed a foundation for participants to ascertain what constituted correct behaviour. Participants’ pre-professional identity [22] and the clinical practice setting were major influences, especially as they lacked awareness of professional behaviour taught in their academic programme.

Learning to survive or ‘internalising observed behaviour to fit in’

Participants indicated student ATs lacked a voice and sometimes ‘conformed to survive’, possibly reflecting survival/destruction thought processes [23] given their ‘inferior’ student status. By conforming, students sought acceptance in the group [8]; however, this may also have given them a negative outlook of their profession [24]. Participants had experienced and observed behaviour that challenged their ability to act professionally and affected their ability to learn. Adapting behaviour based on observed poor practice may confer a sense of acceptance/belonging [25]. Belonging, which is also linked to positive learning experiences, may depend on the length of clinical placement [26]. However this contrasted with some study participants who despite spending up to three years in a single hospital, still experienced a lack of belonging.

Further professional socialisation challenges identified were the blurred professional role boundaries and hierarchy in the clinical environment. Participants experienced role conflicts with other health professions, which supported previous findings [27]. Professional conflict may arise when perceived role boundaries intersect [28]. Commitment to a profession’s ideology helps develop a strong professional identity [10, 29]. However, challenges such as intersecting role boundaries may influence the perception of a profession [10]. Student ATs work alongside multiple professions with distinct professional identities, and develop their professional identity as individuals, whereas students in other health professions develop their professional identity by learning with/directly from others in their own profession.

In contrast to other studies that described the relationship between professional socialisation and the formation of a strong professional identity [10, 12], this study uncovered the development of a perceived negative professional identity. This may be because the AT profession is perceived as having an ‘inferior’ qualification [30], similar to the nursing profession in relation to medicine [31]. Their hierarchical work environment means ATs may conform as subordinates to the dominant profession [32]. Subordinate groups may perceive themselves unfavourably based on behavioural norms/values influenced by the dominant group [31]. Therefore, student status impacted the development of participant professional identity. This highlights the importance of the clinical environment in learning professional values and behaviours, and to understand the impact of positive and negative behaviours on students’ perceptions.

Learning to thrive

Participants described the influence of supervisors and designated educators and emulated those who showed desirable attributes, but also recalled accepting negative behaviour as the norm, which supported previous findings [12, 33, 34]. Consistent with a previous study [35], participants recognised the value of IPE in improving educational and interpersonal experiences. Interestingly, the differences between participants’ experiences as students and as registered ATs were profound. Their ‘higher’ status conferred a new level of acceptance, meaning they re-found their voice.

The values and behaviours elicited by the professional socialisation process may support a strong professional identity. However, multiple strong professional identities merge in the perioperative environment and may cause conflict. Awareness of transdisciplinary working should therefore be embedded in educational philosophies to reflect shared knowledge and competencies among professions.

Professional socialisation also needs to be more prominent in the formal curriculum to help students rationalise observed experiences. Strategies to improve the educational environment are needed, including reinforcing the importance of role modelling professional behaviour across all health professions and increasing awareness of professional socialisation in the curriculum. Academic and clinical education facilitators should understand the need to advocate for professional behaviour and equip students with non-technical skills and attributes to enable them to cope with hierarchical pressures.

Strengths and limitations

This study highlighted various professional socialisation challenges encountered by recent graduate ATs in NZ clinical practice settings which should be further explored. Furthermore, the impact of an interprofessional identity merits exploration to clarify its potential in improving collaboration between perioperative professions.

This study had some limitations, such as small sample size. The participants had trained in different hospitals however, all participants had the same educational institution. This study did not explore aspects related to organisational socialisation that may contribute to professional identity development. Those who volunteered to participate in this study may have held strong views on the development of professional practice and may not represent the experiences of all recent graduates. Finally, despite emphasising the nature of this study as an academic project to fulfil the requirements of a Masters degree by the lead author, independent of their role as the new Programme Leader for the AT academic programme, participants may have refrained from full disclosure or biased their opinions toward perceived correct answers.

This study explored learning experiences in professional socialisation among recent graduate ATs. It emphasised the complexity of developing a professional identity through professional socialisation in the workplace. ATs in NZ have historically trained under an apprenticeship model, and students learn professional attitudes and behaviours in a hierarchical practice setting with competing professional identities meaning student ATs must navigate both positive and negative learning experiences. They may conform and incorporate poor behaviours to survive because of their ‘student status’. This study highlights that without an explicit curriculum which formally covers effective communication strategies and non-technical skills and attributes, students will seek validation from their seniors, potentially reinforcing poor institutionalised behaviours.

Emphasis should be placed on developing an inter-professional identity to promote collaboration. The present findings will inform educational strategies which can adopted by AT clinicians and training programmes, to develop positive learning environments.

anaesthetic technician

IPE

interprofessional education

New Zealand

Ethics approval and consent to participate

The need for ethics approval was waived by the Massey University Human Ethics Committee (MUHEC) processes. The Institutional Review Board for Massey University is MUHEC. All participation was voluntary, and all participants provided informed consent to participate in this study. All methods were performed in accordance with the relevant guidelines and regulations (e.g. Declaration of Helsinki and MUHEC).

Consent for publication

Not applicable.

Availability of data and materials

The data analysed in this study are not publicly available to preserve participants’ privacy. The lead author, Mike Smith, should be contacted if someone wants to request the data from this study.

Competing interests

The lead author, Mike Smith, at the time of this study was appointed as the Programme Leader for AT education. This study was undertaken as part of the requirements to fulfil a Masters degree and was independent of employment. The second author, Inga Hunter, has no competing interests.

Funding

Nil

Authors’ contributions

MS and IH designed the study. MS undertook the data collection and analysis. MS wrote the academic report as part of MS’s Masters study supervised by IH on which this manuscript is based. Both MS and IH wrote and reviewed manuscript drafts and agreed on the final version.

Acknowledgements

The authors would like to thank all participants for their enthusiasm and willingness to participate in this study. We also thank Audrey Holmes, MA, for editing drafts of this manuscript, funded by the lead author.

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Competing interest reported. The lead author, Mike Smith, at the time of this study was appointed as the Programme Leader for AT education. This study was undertaken as part of the requirements to fulfil a Masters degree and was independent of employment. The second author, Inga Hunter, has no competing interests.

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Professional socialisation in the clinical training environment of anaesthetic technicians’: A qualitative study

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Abstract

Background

Methods

Aim

Design

Study setting

Participants

Data collection

Data analysis

Ethical considerations

Results

Learning to behave by following role models

Learning to survive in a hierarchical environment

Learning to survive with a derogatory view of being invisible

Learning to survive with a lost voice striving for acceptance

Learning to survive by conforming

Learning to thrive by learning about each other

Discussion

Learning to behave

Learning to survive or ‘internalising observed behaviour to fit in’

Learning to thrive

Conclusion

Abbreviations

Declarations

References

Additional Declarations

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