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Research article Open Access

Published: 03 July 2018

A skill to be worked at: using social

learning theory to explore the
process of learning from role models
in clinical settings
Jo Horsburgh & Kate Ippolito 

BMC Medical Education  18, Article number: 156 (2018)

67k Accesses 40 Citations 55 Altmetric
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Abstract

Background
Role modelling is widely accepted as being a highly
influential teaching and learning method in medical
education but little attention is given to
understanding how students learn from role

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models. This study focuses on role modelling as an

active, dynamic process, involving observational
learning and aims to explore the process involved,
including strategies that learners and medical
teachers use to support this.

Methods
To gain insight into medical students’ and clinical
teachers’ understanding of learning through role
modelling, a qualitative, interpretative methodology
was adopted, using one-to-one semi-structured
interviews. Six final year medical students and five
clinical teachers were purposefully sampled and
interviewed. Interviews were audio recorded and
transcribed. The data were then analysed using
open and axial coding before codes were combined
to develop broader themes.

Results
Students could identify ways in which they learnt
from role models but acknowledged that this was
complex and haphazard. They described selectively
and consciously paying attention, using retention
strategies, reproducing observed behaviour and
being motivated to imitate. Students evidenced the
powerful impact of direct and vicarious
reinforcement. Clinical teachers reported using
strategies to help students learn, but these were not
always consciously or consistently applied or

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informed by teachers’ understanding of their

students’ cognitive processing.

Conclusion
Findings illustrate in what ways the process of
learning from role models in clinical settings is
challenging. They also support the relevancy and
usefulness of Bandura’s four stage social learning
model for understanding this process and
informing recommendations to make learning from
role modelling more systematic and effective.

Peer Review reports

Background

Learning from role models is widely accepted as

being an influential medical educational method,
especially during clinical rotations [1, 2]. Park et al.
argue that of all learning experiences exposure to
clinical environments and the role models present
there have ‘the greatest impact on professional
formation’ ([2], p.134). Despite this perceived value,
we would suggest that the term ‘role model’s’
common but vaguely defined usage [3], coupled
with limited awareness about the process of
learning from role models, lessens the value of this
construct as a way of explaining how medical

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students learn in clinical settings. The concept of

‘role model’ draws on two theoretical constructs.
First, the tendency of people to identify individuals
who hold a social position to which they themselves
aspire, in this context a successful senior medical
student or well-regarded consultant in a specialty of
interest. Second, the concept of modelling, or social
learning [4], which suggests that individuals pay
attention to role models because they believe they
can learn skills and accepted ways of behaving in a
particular context [5]. Although we see the
relevancy of both, our study is framed by the latter
because we perceive a need to critically examine the
active, dynamic process between role model and
observer, or teacher and learner.

Most previous studies in this area have focused on

what students learn from role models and there is
much consensus on the attributes of positive doctor
role models including excellent clinical knowledge
and skills, patient-centred approach and
humanistic behaviours such as empathy and
compassion [6, 7]. Our interest lies in further
examination of how students learn from role
models in order to maximise the conditions for this
type of learning. This builds on the work of Cruess
et al. [8] who proposed the idea of making explicit
the implicit reasons behind role models’ actions for
the benefit of both learners and role models. In

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addition, the BEME Guide no. 27 [9] highlighted

the importance of recognising the process of
learning from role models. In this paper we take an
exploratory approach to gain more insight into
medical students’ and clinical teachers’
understanding of how individuals learn through
behavioural observation and role modelling. Based
on this insight we will attempt to suggest ways to
improve learners’ and teachers’ understanding and
therefore the effectiveness of this method.

Bandura’s theory of social learning

Bandura’s theory of social learning [1] provides a
useful framework for us to consider how students
learn via observational learning and modelling. For
Bandura, learning takes place in a social setting via
observation, but it also involves cognitive processes;
that is, learners internalise and make sense of what
they see in order to reproduce the behaviour
themselves. Gibson argues that this involves ‘the
psychological matching of cognitive skills and
patterns of behaviour between a person and an
observing individual’ [3, 5]. Bandura proposed that
this type of learning involved four different stages –
attention, retention, reproduction and motivation.

The first stage is attention whereby learners need to

attend to the behaviour. They need to actually see
the behaviour that they want to reproduce or that

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others want them to reproduce. Secondly they need

to internalise and retain what they have seen. This
involves cognitive processes in which a learner
mentally rehearses the behaviour or actions that are
to be reproduced. Thirdly they need opportunity to
reproduce the behaviour by converting the
information obtained from attention and retention
processes into action. Finally learners need to be
motivated to enact or imitate the behaviour they
have observed. This motivation occurs via
reinforcement, of which Bandura proposes three
different types – direct reinforcement, vicarious
reinforcement and self-reinforcement.

We wanted to better understand to what extent

learners and teachers are aware of and consciously
make use of the underlying cognitive processes
described by Bandura, even though they are
unlikely to be aware of his model, to maximise
learning from role modelling and what they think
creates barriers to this four-stage process. In
particular we wanted to investigate:

What are the processes occurring in clinical

settings that support learning from role
models and what hinders it?
What approaches do learners take to analyse,
evaluate and adopt or reject what they learn
through observation of and engagement with

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role models?
What strategies do role models consciously
apply to encourage their learners to learn in
this way?

Methods

A qualitative, interpretative methodology was

adopted, with one to one semi structured interviews
being conducted. Six final year medical students
(Anita, Mark, Pete, Emily, Jason and Liam), and
five clinical teachers (Shivani, Melanie, Iris, Stefan
and Abigail), identified here by pseudonyms, were
purposefully sampled on the basis that they would
provide rich insight into teaching and learning in
clinical settings [10] The clinical teachers were from
a variety of specialities and had a range of teaching
experience. The aim was not to achieve theoretical
saturation but to gain in-depth insight into 11
individuals’ unique experiences to better
understand how learners and teachers perceive and
make sense of learning from role modelling in
clinical settings [11]. The two interview guides
varied slightly between students and teachers to
take into account their differing roles. Although we
were aware of Bandura’s social learning theory and
anticipated it would help us to interpret our data his
four predetermined categories did not influence the
question design, which were deliberately broad,

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open questions that allowed interviewees to

describe the process of learning in a clinical context
in their own words (see Additional file 1). Interview
questions were not validated but were piloted for
understanding. Interviews were audio recorded and
transcribed. The data were analysed using open and
axial coding [12] which was completed by both
authors independently before codes were combined
to develop broader themes. For the purposes of this
paper we have adopted a theoretical data analysis
approach; identification of themes was guided by
our specific research questions and our theoretical
interest in the relevancy of Bandura’s four stage
model for analysing learning in the clinical setting.
This led to more detailed analysis of particular
aspects of the data rather than rich description of
all data collected [13] (see Table 1 below). Ethical
approval for this study was gained from the Medical
Education Ethics Committee at Imperial College,
London.

Table 1 Codes, themes and example

quotes from student and clinical teacher
interviews

Results

For the sake of clarity and to better explore the

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process of learning, in this paper we have chosen to

emphasise the learner experience and perspective,
with data from the clinical teachers used to enhance
and further illuminate the students’ viewpoints.
Table 1 shows the codes and themes derived from
analysis of the interview transcripts, illustrative
quotes for each of the themes, and the process from
Bandura’s theory that these relate to.

The students interviewed were able to identify ways

in which they learnt from role models but
acknowledged that this was a complex and
haphazard process.

Discussion

Having presented the codes, themes and illustrative

quotes from the interview transcripts, these will
now be discussed in further detail.

Attention
Being present and involved
Despite needing to be physically present and able to
see the action some students reported feeling in the
way like ‘lemons’ or ‘ghosts’, suggesting they needed
their participation to be legitimised. They described
that legitimacy as coming from being given a
specific role, such as taking a history from a patient.
Anita, for example, described being asked by a

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consultant to sit and chat with a patient whilst she

ate her breakfast. For the student this proved to be
a rich and memorable learning experience. This
purposeful role gave her an involved perspective
from which to observe and maintained her
attention. Lave and Wenger [14] refer to the way
that newcomers to a community of practice learn by
participating as legitimate peripheral
participation. But opportunities for legitimate
peripheral participation need to be created for
medical students and the value of this should not be
underestimated as the quotes from students’
demonstrated.

Teachers were also aware of this need to actively

involve students, particularly those less confident
ones, but due to time pressures this was not always
possible. Most teachers agreed that some role
models were easy to identify - what Abigail referred
to as ‘superstars’. But there was an
acknowledgement that other role models might be
more useful, particularly in the early stages.
Therefore, as has been found in other research [8]
signposting less obvious behaviours, such as at what
point and how junior doctors involve senior
colleagues was important.

Continuity of and exposure to role models

Barriers to paying attention included lack of

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continuous exposure to any one role model or

patient, meaning that students could not truly
analyse role model’s behaviours or evaluate the
impact of that behaviour on others. Attending to
patterns in role models’ practice takes time and for
some the short phases that tend to characterise
medical students’ clinical rotations made this
difficult.

Where role models had facilitated more continuous

observations of their practice the educational value
of this could be recognised by students. For some
students, their experience aligned well with Gioia
and Manz assertion that “if an observer is to learn
effectively from a model it is important for the
model to be credible, reasonably successful, clearly
display the behaviour to be learned, and otherwise
facilitate the attention process.” ([15]: 528).

Teachers also commented on the fragmented nature

of clinical rotations. Difficulty in identifying
patterns in behaviour and forming relationships
created by lack of continuous exposure to role
models seemed to be disruptive and demotivating
for both students and teachers. Being aware of these
challenges to attendance and opportunities to
observe was important. Faculty also needed to be
present in order for students to observe their
practice, although as Iris pointed out, clinical

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teachers were still role modelling even if absent.

Aligned values
The students reported paying close attention when
they observed a behaviour that aligned with their
views of what was important about being a doctor.
For Emily, the positive reactions she observed from
her role model’s patients were more important than
them having a long list of publications.

The artificial separation of scientific and medical

knowledge from skills and attitudes within medical
curricula can be confusing and students saw clinical
rotations as a place to learn how to bring these
elements of a doctor’s practice together, although
they found it difficult.

Retention
There is an enormous amount for a learner to take
on board when in a clinical setting and they cannot
possibly be expected to retain everything they
observe. In order to avoid becoming overwhelmed
learners seek cues to work out what is important to
retain and develop strategies for doing so.

Learning the language

Students spoke about comprehending and retaining
the unfamiliar clinical language that they heard
their role models use. This sometimes involved

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looking it up later or consulting peers.

Particularly useful role models deliberately helped

students to learn the language and develop the way
they communicated in the clinical setting.

Understanding thought processes

Students talked about how they valued their role
models giving insight into their thought processes
as this enabled them to understand the reasoning
behind the behaviours they were observing,
including coping with uncertainty, and helped them
to make sense of and retain the particular learning
point.

Liam, who like other students talked about the

importance of being able to relate to their role
models, attributed this relatability, in part, to him
and his role models thinking alike. This seems
connected to the point made earlier about the
attractiveness of aligned values between role
models and observers.

Meaningful reflection
Reflection is widely acknowledged as aiding
development, but how do learners make use of
reflection when learning from their role models?
Even though Jason claimed not to be ‘a fan of
formal reflection’ he had clearly developed a

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critically reflective approach to help him extract

personal value from what he had observed and
imitate aspects of it before deciding what to retain.

Stefan also talked about the importance of

authentic reflection and the role of teachers in
creating space and support for students to evaluate
what has been observed in clinical settings.

Writing it down
Liam described a particularly systematic approach
to aid retention and processing of what had been
observed, clearly guided by his role model.

Such strategies were encouraged and signposted by

teachers, with Melanie referring to use of an
advanced organiser [16] to help students
consciously retain what they observed. She
described an example in which she asked students
who were observing her on a busy labour ward to
write down a few things they noticed her doing or
questions she asked the patient and then,
importantly, got them to reflect on why they noticed
these specific things or why they thought them
important. Facilitating this metacognitive process,
whereby students are required to think about what
and how they are learning through observation,
may also enable teachers to reinforce or ‘correct’
important take away messages.

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Reproduction
Opportunity to practice
The opportunity for hands-on practice has been
reported as lacking from some clinical-based
learning experiences [17] In our study students
talked about being given the opportunity to put into
practice the behaviours and strategies that they had
observed in their role models. Some needed help to
recognise opportunities or to be given permission to
take advantage of opportunities and to participate
in a legitimate and meaningful way.

Giving students opportunity to legitimately

participate in the team may involve considering the
roles and expectations of the existing clinical team.

Most students recognised the need to be proactive

about identifying and creating their own
opportunities for practice and some had strategies
for arranging these.

Students’ also highlighted the value of being

supported by a role model to identify in advance, in
a systematic way, tasks and skills that they could
learn through modelling and observation with
opportunity for practice.

Feedback
When referring to opportunities to put into practice

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the techniques that they had observed, students

highlighted the value of feedback that both
reinforced desired behaviours and suggested
aspects for development, especially where it was
highly contextualised and immediate.

Shivani talked about making use of the student

perspective and adopting a more dialogic approach
to feedback [18] on what has been observed in way
that could offer suggestions for development for
both teachers and students.

Motivation
Feedback
Finally Bandura argued that if students are to learn
from and reproduce the behaviours that they
observe in their role models they need to be
motivated to do so. For many students this was a
question of direct reinforcement, whether this was a
self-regulated process involving perceptions of
‘wanting to please’ or further reinforced by direct,
positive feedback, including more independence.

Observing other’s responses - vicarious

reinforcement and punishment
Two further interesting and useful concepts from
Bandura’s social learning theory are vicarious
reinforcement and vicarious punishment. Bandura
proposed that when observing others we not only

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learn from their behaviour but also from the

reactions of other people to the role model’s
behaviour. This is potentially a very efficient way to
learn as it allows us to learn from others’ mistakes.
Our student interviewees identified a number of
examples of being vicariously reinforced or
punished and described how the reactions of
patients, colleagues or fellow students influenced
their decisions to reproduce behaviours they
observed. For example, Liam, who was vicariously
reinforced having closely observed this
paediatrician, chose to adopt his communication
technique as a result of the calming effect it
appeared to have on children.

Conversely an example of vicarious punishment

refers to what Jason considered to be brusque
treatment of a patient. He was vicariously punished
by the interaction between a role model and patient
and as a result talked about wanting to deliberately
avoid reproducing this behaviour in his own
practice because of the patient’s reaction.

Jason also highlighted barriers that interruptions in

exposure to patients and clinicians poses for
students wanting to convert observation into
practice. It appears to be important to create
opportunities for students to observe outcomes of
interactions (or for them to be discussed), as well as

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seeing the behaviour that led to them. Students

reported receiving mixed messages about
appropriate behaviour through vicarious
reinforcement. As Iris commented the less desirable
behaviours observed in clinical settings can have a
powerful influence, a view supported by Gibson [5],
who highlights the value of learning from negative
traits as well as positive aspects of role models.
Furthermore Bucher and Stelling [19] found, to
their surprise, that rather than identifying complete
roles models amongst their senior colleagues, as
had been assumed, medical students actively
identified specific attributes to emulate and to
reject, in a process of creating a vision of their ‘ideal
selves’. Clinical teachers recognised that students
made decisions about who were useful role models
on the basis of vicarious reinforcement. in the form
of successful clinical outcomes, and/or positive
reactions from patients and colleagues. Stefan
spoke about how students might use clinical
outcomes to judge the value of a particular
behaviour when deciding whether to adopt or adapt
them.

Reciprocating
Student also saw satisfaction and reward in being
part of the reciprocal role model cycle themselves
and referred regularly to the culture of peer support
in medical school.

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In terms of closing the reciprocal loop Liam, for

example, also talked about how he sent a letter,
email or card to his role models to thank them.

However, in general it is unclear how aware role

models are of the influence they have on those
observing them and indeed how they could be more
effective. Clinical teachers commented that they
seldom received direct feedback on the impact of
their role modelling but Shivani recalled that
students had commented on how she had interacted
with a patient thus highlighting for her the value
medical students derived from being able to closely
observe a role model in action. Feedback on how
role models have influenced those around them is
potentially an important of untapped source of
evaluation data.

Limitations
Whilst this paper has emphasised the benefits of
modelling and observational learning, students also
highlighted the limitations. This included that the
ability to imitate the actions of others and carry out
clinical tasks might not be accompanied by
underpinning clinical knowledge or rationale in the
mind of the learner.

Another limitation is created by the lack of

constructive alignment [20] between the formal

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undergraduate medical curricula, often with an

emphasis on gaining knowledge and exam-based
assessment, and the authentic, skills-based learning
in the clinical setting. This resulted in some learners
prioritising revision for their exams over taking the
opportunity to learn from observation in the clinical
setting.

Finally the unfamiliar and haphazard nature of

observational learning opportunities in the clinical
settings proved challenging for students to identify
and follow to their logical conclusion thus limiting
the learning process that Bandura describes. Even
when student interviewees described successful
learning having taken place it became apparent that
they were often not in control of, or even conscious
of, the process occurring, let alone able to guide
themselves through the four stages identified by
Bandura.

Conclusion

We acknowledge that the exploratory inquiry

presented here is a work in progress that does not
does not yet reflect the application of a finished
construct to an empirical study. However, this small
sample of medical students’ and clinical teachers’
insightful accounts of how observational learning
from role models happens, leads us to make the

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following tentative conclusions.

The way students and clinical teachers described

learning in this context can be aligned with the four
stage model set out by Bandura. That is,
participants clearly illustrated how they benefitted
from (and felt motivated by) being able to observe
or attend to the behaviours of their clinical teachers,
being helped to retain new understanding,
opportunities to practise the actions or behaviours
observed, as well as how they learnt through
vicarious reinforcement from seeing the reactions of
others. Barriers to learning identified can also be
analysed in terms of where these four stages could
not be carried out or were interrupted.

Although when asked student and teacher

participants demonstrated good understanding of
ways in which individuals learn from role
modelling,, all participants illustrated that learning
from role models in clinical settings is complex and
challenging and the processes they described as
supporting that learning were often fragmented and
inconsistent. Furthermore there appeared to be
limited awareness of underlying cognitive processes
supporting observational learning. Whilst some of
the clinical teachers interviewed did identify
methods that they used to enhance observational
learning in clinical settings, it could be argued from

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these findings that this could be done in a more

conscious and consistent way.. Whilst consistency is
not the ultimate goal in undergraduate learning
during clinical rotations and variety in approaches
to role modelling adds richness and authenticity to
the experience, we have given insight into how a
lack of structure can be problematic for students.
We believe that, the process of learning from role
models in clinical settings is a skill to be worked at.
Students in the study demonstrated different levels
of awareness and capacity in this regard, and some
suggested it would have been useful to be aware at
the beginning of their clinical rotations.

On the basis of our theoretically-informed analysis

we would like to suggest the explicit use of
Bandura’s model to develop a two pronged
approach to supporting students’ learning from role
modelling. Firstly, by introducing students to
Bandura’s four stage model and strategies outlined
above to inform development of their skills for
maximising their own learning at each stage and
their agency within the unfamiliar learning
environment. Secondly, by using it to develop
teachers’ understanding of how learning from
observation occurs and their ability to maximise
opportunities and create the conditions in the
environment that enable learners to:

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a) Closely and repeatedly observe role models’

actions and behaviours and patients and
colleagues’ responses to these behaviours.
b) Be given insight into the invisible thought
processes behind the behaviours they observe
c) Be given permission and structured
opportunity to reproduce and test out
observed behaviours in practice and reflect on
this.

By linking our exploration of learners’ and teachers’

understanding of how observational learning
happens in clinical settings with Bandura’s four
stage model we hope to have provided a feasible
and memorable framework to guide teachers and
students in making more effective use of modelling
and observational learning.

Abbreviations

BEME:
Best Evidence Medical Education

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Acknowledgments

The authors wish to acknowledge the support of the

Medical Education Research Unit and Educational
Development Unit, Imperial College, London. We
would also like to thank our staff and student
participants for their time and insight.

Availability of data and materials

There is no public availability to the interview
transcripts outside of the research team due to
reasons of confidentiality.

Author information

Authors and Affiliations

Educational Development Unit, Imperial
College London, Level 5, Sherfield Building,
Exhibition Road South Kensington, London,
SW7 2AZ, UK
Jo Horsburgh & Kate Ippolito
Department of Primary Care and Public
Health, Imperial College, London, UK

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Jo Horsburgh

Contributions
KI and JH designed the study, conducted the
interviews, analysed the data, drafted and revised
the manuscript. Both authors approved of the final
version.

Corresponding author
Correspondence to Jo Horsburgh.

Ethics declarations

Ethics approval and consent to participate

Ethical approval for this study was granted by
Imperial College Medical Education Ethics
Committee (ref 1314–23), Chelsea and Westminster
Hospital NHS Foundation Trust (ref C&W 15/079)
and was exempt from formal ethical approval by
London Northwest Healthcare Trust. All
participants provided informed written consent.

Competing interests
The authors declare that they have no competing
interests.

Publisher’s Note
Springer Nature remains neutral with regard to
jurisdictional claims in published maps and

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institutional affiliations.

Additional file

Additional file 1:
Interview schedule – interview questions for both
student and clinical teacher participants. (DOCX 13
kb)

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Cite this article

Horsburgh, J., Ippolito, K. A skill to be worked at: using
social learning theory to explore the process of learning
from role models in clinical settings. BMC Med Educ 18,
156 (2018). https://doi.org/10.1186/s12909-018-1251-x

Received Accepted Published

13 March 2017 01 June 2018 03 July 2018

DOI
https://doi.org/10.1186/s12909-018-1251-x

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Keywords
Role modelling Social learning theory

Clinical teaching Bandura Observation

Reinforcement

BMC Medical Education

ISSN: 1472-6920

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