Faculty development participants' experiences of working with change in clinical settings

Objectives: Many universities offer faculty development to support teachers in developing and improving clinical education in the health professions. Although research shows outcomes on individual levels after faculty development, little is known about its contribution to change within the organisation. To advance current faculty development and ensure that it can support wider educational change in healthcare organisations, a better understanding of educational change practices in these settings is needed. This study therefore explores the experiences of working with educational change in clinical workplaces from the perspective of clinical educators that have undergone faculty development training. The study adopts perspectives on change as influenced by context to include the impact from clinical workplaces on individuals' change work. Methods: A collective case study design with a multi-institutional approach was applied and individual interviews with 14 clinical educators from two universities, one in Sweden and one in South Africa, were conducted. Data were analysed separately before a cross-case analysis was performed,

with educational change in clinical workplaces from the perspective of clinical educators that have undergone faculty development training. The study adopts perspectives on change as influenced by context to include the impact from clinical workplaces on individuals' change work.
Methods: A collective case study design with a multi-institutional approach was applied and individual interviews with 14 clinical educators from two universities, one in Sweden and one in South Africa, were conducted. Data were analysed separately before a cross-case analysis was performed, synthesising the findings from both sites.
Findings: Participants shared experiences of having limited opportunities to work with educational change beyond their own individual teaching practices within their clinical workplaces. Also, participants appeared to refrain from leading change and rather pursued change on their own or relied on indirect approaches to change. They described several workplace aspects influencing their work, including the organisation and management of teaching, the resources and incentives for teaching and the attitudes and beliefs about teaching within the clinical community.
Conclusions: The study shows that clinical educators are part of communities and contexts that shape their approaches to educational change and influence which changes are feasible and which ones are not. It thus adds to the understanding of change as contextual and dynamic and contributes with implications for how to advance faculty development to better support change in practice.

| INTRODUCTION
Although health care settings constitute valuable learning environments for students in the health professions, they are at the same time challenging environments in terms of teaching and the strengthening thereof. 1 Faculty development is one of the primary initiatives to support clinical staff in managing these complex learning environments and to support educators in developing the quality of clinical education. 2 Although research shows impact on individual teaching behaviour and skills, change beyond the level of the individual teacher, such as on the level of the workgroup or organisation, remains largely unexplored. [2][3][4][5] Relatedly, little is known about how educational change unfolds in clinical workplaces and how this context influences opportunities for change. 2,6 Understanding these processes is critical to guide future faculty development efforts and enable that they reach their full potential in improving health professions education.
Traditionally, the field of medical education as well as that of faculty development have been dominated by rationalist theories of change based in notions of knowledge acquisition and transfer. 5,7,8 These models portray change as linear and predictable, moving unidirectionally from cause to effect. They often highlight the importance of a strong change leader and rely on general strategies with stepwise approaches that can be applied across settings. [9][10][11] However, critique has been levelled against these linear perspectives as they disregard the influence of social structures and local cultures within settings and as they reflect views on knowledge as acontextual and readily transferable.
Instead, alternative theories are being advocated, emphasising change as a complex, emerging and unpredictable process that is influenced by the context in which it takes place, including its culture, values and ways of working. 8,10 In relation to faculty development, this latter perspective reflects ideas that activities cannot result in change in practice through straightforward and linear transfer but that the extent to which participants can effect change relate to the setting in which they work. 5,12 These shifts in theoretical reasoning are supported by studies exploring educational change, suggesting it to depend on interactions between teachers and their workplaces. [13][14][15][16] For example, research highlights how social and organisational structures can influence teachers opportunities for change by offering support from leadership and peers as well as allowing access to resources such as time. 17,18 Although these inquiries offer important insights into educational change processes, some focus on faculty development within higher education and not within the health professions, 14,18 some do not focus on teachers in clinical settings 15 and yet others look at change in general and not in connection to faculty development. 17 This means that research into how teachers work with change and development of educational practices in clinical settings in relation to faculty development remains scarce, with a lack of understanding of what happens within the organisation following activities. As such, there are continuous calls for more studies in this area. 2,6,7 Moreover, the last decade has seen recurrent recommendations to advance the practice of faculty development so that it can better support change agency and educational leadership among participants as well as contribute to implementing wider educational change within organisations. 2,19,20 Nevertheless, until we increase our knowledge of how educational change unfolds in clinical systems following activities, we will have difficulties in renewing faculty development along these lines. In this study, we therefore aim to explore the experiences of working with educational change in clinical workplaces from the perspective of clinical educators that have undergone faculty development training.
Because previous research has explored effects of faculty development on individual levels, 2-4 we focus on teachers' experiences of working with change of teaching practices at levels of the workgroup or organisation. This can be referred to as second-order change, meaning that it involves and affects other people and shared practices, requiring adaptation at a deeper level within the organisation at large. 10 Further, this study adopts perspectives of change as dynamic and context dependent in efforts to explore the influence from clinical workplaces on faculty development participants' change work.

| METHODS
This study was designed from an interpretivist perspective, emphasising individuals' experiences and acknowledging the interaction between researcher and participant in meaning making where researchers actively contribute to the construction and interpretation of data. 21 Further, the study was inspired by case study research which focuses on exploration of complex issues in their real-life setting. Specifically, the collective case study design where several contexts are explored to reach deeper insights into the phenomenon under study 22 was used. Also, looking across sites allows exploration of change including contextual, organisational and systemic influences in the workplace, 2,7,23 and we therefore applied a multi-institutional design and included data from two medical schools in two different countries.

| Study sites
The study was conducted at two large, government-funded universities offering several programmes in health professions education

| Recruitment and participants
Participants were purposefully selected 24 using the following criteria:  The transcripts from each study site, constituting two data sets, were analysed using thematic analysis. 26 After repeated reading, A. E. coded all interviews, and authors K. B. L. and J. B. read and coded two interviews each, discussing codes with A. E. A. E. collated codes in preliminary sub-themes and themes before all authors discussed, reviewed and refined the preliminary themes and sub-themes. To enable comparison between study sites, we analysed each data set separately following this procedure and then followed with a crosscase analysis to compare findings between sites. 22 Although effort was made to identify differences, the cross-case analysis surfaced very limited differences between the data sets, and those that were identified were not substantive to the themes or aim of the study.
As such, the final step was to create, review and name themes and sub-themes covering the findings from both study sites. Consensus was reached through continuous discussion in the research team.
Disagreements generated review and further exploration of transcripts to anchor the analysis in the data, as well as deliberations on how team members backgrounds influenced interpretations made. To support the analysis, NVivo (QSR International Pty Ltd. Version 12) was used.

| Research team
The research team composed of researchers from both study sites,

| FINDINGS
Findings are presented in three overarching themes, of which two have related sub-themes. Participants experienced limited opportunities to work with educational change, seemed to refrain from leading change and described how this related to several workplace aspects. Within the clinical context, participants noted that they could work with small-scale change concerning administrative and structural aspects of the education, such as scheduling of students. However, as noted in the quote above, participants described difficulties in working with more extensive change which would require wider engagement and buy-in within the workplace community. This was evident at both study sites, and participants further experienced having little impact on the educational encounters taking place between students and clinicians in the workplace as well as difficulties to influence colleagues' teaching practices and assumptions, as described here:

| Refraining from leading change
In addition to the described limitations with conducting educational change in clinical workplaces, participants also did not seem to consider themselves as leaders of change. They reasoned that teaching was an individual activity where each clinician was free to choose how to teach based on own beliefs about teaching and learning, and as exemplified below, they did not regard changing or improving peers' teaching to be their responsibility. Second, participants described lacking resources and incentives for educational change work. As budgets for educational change were missing, any initiative requiring funding was unlikely to be pursued.

| DISCUSSION
In this study, we set out to explore the experience of working with educational change in clinical workplaces from the perspective of clinical educators that had undergone faculty development training. We specifically focused on change beyond levels of the individual educator, as this has been largely unexplored in previous literature. One of the major contributions is the finding that participants from different backgrounds at two institutions in different countries shared experiences of having limited opportunities to work with change beyond their individual teaching practices. Moreover, the study suggests that there were common issues across workplaces that influenced participants' opportunities to effect change. In the following discussion, we will first expand on participants' limited opportunities to work with change and further examine how this relate to several aspects in clinical settings. Then, we will address the implications following from the findings, both in terms of future faculty development practices, as well as how efforts could address the clinical settings in which change is to take place.

| Considerations and future research
The coherence between study sites and the shared experiences among participants from different specialties, workplaces and faculty development programmes added strength and credibility to the findings. It indicates that faculty development participants are having similar issues with instituting change and that there are key aspects across clinical workplaces which have important implications for educational change following faculty development. As such, the findings could be relevant for faculty developers and clinical educators in diverse settings. Future research could explicitly focus on national and institutional culture or identify cases displaying differences to explore how these influence change. It would also be worthwhile to explore programmes that have incorporated change management into their programming or focus on a specific programme to analyse relationships between programme design and participants' change work. This study was based on self-reported experiences of 14 participants, why more studies are needed which could also employ observations or include others in the workplace to gather useful information on the interplay between context and individuals and how that affect change in practice. Furthermore, all interviews were performed by one researcher (A. E.) who was familiar with one study site but not the other.
Although this may have impacted the interviews, we reasoned that her outside status in terms of not having any previous engagements with participants and not being a faculty developer would enable participants to freely express their experiences. Finally, recruitment of participants was difficult especially at the South African study site with many nonrepliers, possibly reflecting that the study was international and might have been considered external by those invited.

| CONCLUSION
We sought to better understand educational change practices in healthcare organisations in order to inform future faculty development.