A conducive clinical learning environment in primary care as a wicked problem: A scoping review of enablers, obstacles, and strategies

Abstract

Background: The clinical learning environment (CLE) in primary care is increasingly recognised as critical to undergraduate medical education. However, its design and implementation are shaped by multiple interdependent factors, such as mentorship, autonomy, relationships and logistics, which make it a complex challenge.
Aim: This study aimed to map the literature on the contributing factors to conducive CLE for medical students in primary care settings, identify enablers and obstacles and strategies for improvement.
Setting: Primary care clinical learning environments, including community health centres, primary healthcare clinics, general practices, and district hospitals involved in undergraduate medical education.
Methods: A scoping review was conducted using the Joanna Briggs Institute methodology and the PRISMA-ScR (Preferred Reporting Items for Systematic reviews and Meta-Analyses extension for Scoping Reviews) checklist. Four databases were searched with no language or date restrictions. Articles were screened independently by two reviewers. Data were charted using Gruppen’s conceptual framework and thematically synthesised.
Results: A total of 34 articles were included. Common enablers included effective mentorship, student autonomy, positive interpersonal relationships, organisational alignment and supportive infrastructure. Obstacles included inadequate space, transport constraints, authoritarian teaching styles and a lack of student agency. Few articles proposed solutions, and many challenges were systemic and persistent. The CLE in primary care emerged as a wicked problem – a complex, context-sensitive issue involving multiple stakeholders without a definitive solution.
Conclusion: A conducive CLE in primary care requires coordinated, multilevel strategies that address both human and structural domains. Isolated interventions are unlikely to produce lasting change.
Contribution: This review highlights the CLE in primary care as a wicked problem and provides a framework for developing systemic, adaptive responses to support medical education in diverse contexts.