Table 5.

Action points to support experiences of continuity and integration in LICs.

Bronfenbrenner’s system level	Components/Factors	Take-home	Action
Learner	The Learner	Students selected for LIC are often self-directed and relatively independent, valuing opportunities for autonomous hands-on learning	Make this clear to students, i.e., does this align with their approach to learning? Consider a session on self-directed learning, time management, etc. at orientation.
Microsystem (immediate environment)	Primary preceptor relationship	Preceptor selection is key. Preceptors were flexible, tailored learning to the learner. They scaffolded learning to extend comfort zones (zone of proximal development) (52). Preceptors got to know the learner as a person and were engaged in a mentoring relationship.	Carefully select preceptors and support through faculty development. Continuity of preceptorship key, e.g., if planning leave, this should be discussed at central and local level. Supporting open communication, e.g., to enable preceptors and learners to communicate if inter-personal differences to program leadership. Consider faculty development that explicitly outlines idea of scaffolded learning.
	Working with additional preceptors	Students value variation and working with a range of preceptors.	When establishing a LIC placement, it is important for the rest of the clinical team to be aware of their role and how they support (or not) a learner. The role of locums as teachers within LIC requires specific consideration. While these can be valuable learning opportunities, there is considerable variation in locum teaching interest. Consider the development of specific resources that can quickly orient locums to the concept of LIC and the role of the LIC learner for sites using locum physicians.
	Working with other professionals	Same as above	Same as above
	Personal relationships	Family and friends play a supportive or undermining role.	Make clear to learners how personal relationships are /are not supported through the program, e.g., housing, access to community recreation activities (see below).
Mesosystem (linkages and relationships between systems)	Working multiple settings	Working in different contexts helps learners understand how information and knowledge ‘flows’ across settings to support ‘contextual continuities’.	Ask learners to write a reflection on how working in different contexts in a local community helps foster their understanding of generalist practice.
	Exposure to patient continuity	Continuity of care is fostered by learners working in different settings.	Help students care for a cohort of obstetrical patients and patients with mental health issues can support their understanding of continuity of care.
	Social activities with preceptor and local team members	Social activities play a fundamental role in fostering student integration.	Make explicit to preceptors and teams. Consider ‘hosting’ /funding a ‘welcome’ event at the orientation of the student to the community.
	Community connections: Role of partner/family Recreational activities	Partner and family help integrate the learner and foster connection to the community	Have a ‘recreation’ activity list/engage a community member to help facilitate getting to know local resources and activities. Consider local gym/recreation pass.
Exosystem (indirect environment)	Factors may include: Lack of clinical resources Geographical isolation	Students learn in resource-strained environment Students felt disconnected with UME during their placement due to the geographic distance	Incorporate the physician advocacy role as an explicit learning objective relating to the rural healthcare environment. Ensure that students have clear ways to connect with UME and urban campus resources.
Macrosystem (social and cultural factors)	Socio-cultural factors: Accreditation requirements Supply and demand Models of compensation Professional remuneration Social accountability	LIC students acquired deeper understanding and awareness of the geopolitical, socioeconomic issues affecting rural Canada, which in turn impacted their sense of social accountability.	Preceptors should include these issues in teaching and conversation. Ensure that the connection between the LIC learning environment and social accountability is clearly reflected as a curriculum objective.
Chronosystem (changes over time)	Changes related to personal and professional conditions over time: Professional identity formation Preparation for future practice	Teaching and supervision will change over the course of the LIC to reflect developing professional identity and capacity for independence.	Support preceptors through faculty development, to adapt their approach to teaching and supervision over time with LIC learners, thereby supporting professional identity formation and readiness to transition to postgraduate training.